Just Put the Clavicle in a Sling - Not Any More

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More patients are having operative repair for displaced midshaft clavicle fractures.  This meta-analysis of 6 RCTs found that the rate of nonunion was markedly reduced and final functional outcome was also improved (though not as strikingly) with operative management.

Why does this matter?
For us in the ED, the adage has always been that most clavicle fractures do not need repair.  These new studies challenge that notion.  Though the authors conclude, "there is not enough evidence to support routine operative treatment," it demands we have an informed discussion with the patient that surgery is an option and refer them for follow up.

Just put 'em in a sling?
This was a meta-analysis of 6 RCTs comparing operative vs. non-op management of displaced midshaft clavicle fractures.  Risk of nonunion was dramatically decreased in operative patients, RR 0.14.  Functional outcome at one year was also improved with surgery, as measured by the Constant score and DASH score.  The Constant score factors in pain.  Most studies also showed an early functional improvement with surgery, but the timing and methods of measurement were different between studies and could not be grouped into this meta-analysis.  Interestingly, a new RCT, not included in this meta-analysis and published in the same issue of JBJS, found decreased non-union in the surgery group but no difference in DASH score at any time point from 6 weeks to a year.  Bottom line for me - after reading this, I think I would rather have surgery.  But Thomas says he wouldn't, after reviewing this.  Hence, the need to have an open dialogue with your patient.

Source
Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials.  J Bone Joint Surg Am. 2017 Jun 21;99(12):1051-1057. doi: 10.2106/JBJS.16.01068.

Peer reviewed by Thomas Davis, MD.

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