[Ortho] Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials

[Alexander Chelnokov]

J Bone Joint Surg Am. 2017 Jun 21;99(12):1051-1057. doi: 
10.2106/JBJS.16.01068.

Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft 
Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials.


Woltz S(1), Krijnen P, Schipper IB.

Author information:

(1)1Department of Trauma Surgery, Leiden
University Medical Center, Leiden, the
Netherlands.

BACKGROUND: The aim was to analyze whether patients with a displaced 
midshaft clavicular fracture are best managed with plate fixation or 
nonoperative treatment with respect to nonunion, secondary operations, 
and functional outcome,
by evaluating all available randomized controlled trials (RCTs) on this 
subject.

METHODS: A systematic search of electronic databases (PubMed, MEDLINE, 
Embase, and Web of Science) was performed to identify RCTs comparing 
nonoperative treatment with plate fixation for displaced midshaft 
clavicular fractures. Risk
of bias of the studies was assessed. Outcomes evaluated were nonunion, 
shoulder function (Constant score and Disabilities of the Arm, Shoulder 
and Hand [DASH] score), and secondary operations.

RESULTS: Six RCTs (614 patients) were included. The risk of nonunion was 
lower in the operatively treated patients (relative risk [RR] = 0.14, 
95% confidence interval [CI] = 0.06 to 0.32). One-third of the patients 
with a nonunion did not receive further treatment. Secondary operations 
for adverse events were performed less often in the operatively treated 
patients (RR = 0.42, 95% CI = 0.25 to
0.71). When plate removal operations were also included, a secondary 
operation was performed in 17.6% in the operative group and 16.6% in the 
nonoperative group (RR = 1.01, 95% CI = 0.64 to 1.59). Constant and DASH 
scores after 1 year were
somewhat better after plate fixation, with mean differences of 4.4 
points (95% CI, 0.9 to 7.9 points) and 5.1 points (95% CI, 0.1 to 10.1 
points), respectively.

CONCLUSIONS: Plate fixation significantly reduces the risk of nonunion, 
but does not have a clinically relevant advantage regarding final 
functional outcome.

Secondary operations are common after both treatments. Overall, there is 
not enough evidence to support routine operative treatment for all 
patients with a displaced midshaft clavicular fracture.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for 
a complete description of levels of evidence.



DOI: 10.2106/JBJS.16.01068

PMID: 28632595
Alexander Chelnokov