Operative and nonoperative treatment of clavicle fractures in adults

Kaisa J Virtanen, Antti O V Malmivaara, Ville M Remes, Mika P Paavola, Kaisa J Virtanen, Antti O V Malmivaara, Ville M Remes, Mika P Paavola

Abstract

Background and purpose: Traditionally, clavicle fractures have been treated nonoperatively. However, many recent studies have concentrated on the results of operative treatment. We assessed and compared the outcomes of operative and nonoperative treatment for acute clavicle fractures in adults.

Methods: We performed a systematic search of the medical literature from 1966 until the end of March 2011. We included randomized controlled trials and controlled clinical trials comparing operative and nonoperative treatment and studies comparing different operative and nonoperative treatments. We required that there should be at least 30 adult patients and a follow-up of at least 6 months in each individual trial. We used the GRADE method to assess the quality of evidence.

Results: 6 randomized controlled trials (n = 631) and 7 controlled clinical trials (n = 559) were included. There was moderate-quality evidence (i.e. of grade B) (1) that surgery has considerable effectiveness on better function and less disability at short follow-up, (2) of similar risk of relatively mild complications after operative or nonoperative treatment, (3) that delayed union and nonunion were more common in patients who were treated nonoperatively than in those treated operatively, and (4) that the osteosynthesis method had no effect on the incidence of delayed union or nonunion. Only 1 controlled clinical trial was found on lateral clavicle fractures with very limited (grade D) evidence.

Interpretation: Patients treated operatively have slightly better function and less disability than those treated nonoperatively at short follow-up, but then the effectiveness diminishes and is weak at 6 months. The different operative techniques may not differ in effectiveness or in adverse effects, but the evidence is very limited or conflicting. Surgery could be considered for active patients who require recovery to the previous level of activity in the shortest possible time.

Figures

Figure.
Figure.
Flow chart illustrating number of trials evaluated at each stage in the systematic review of clavicle fractures. a Studies are assessed to originate from the same patient population. Results are reported from the recent (2011) study, thus the final number of studies was 13.

References

    1. Allman F LJ. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg (Am) 1967;49:774–84.
    1. Bohme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C. Current treatment concepts for mid-shaft fractures of the clavicle - results of a prospective multicentre study. Z Orthop Unfall. 2011;149:68–76.
    1. COTS Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg (Am) 2007;89:1–10.
    1. Ferran NA, Hodgson P, Vannet N, Williams R, Evans RO. Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial. J Shoulder Elbow Surg. 2010;19:783–9.
    1. Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 2009;34:1929–41.
    1. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11.
    1. Hoofwijk AG, van der Werken C. Conservative treatment of clavicular fractures. Z Unfallchir Versicherungsmed Berufskr. 1988;81:151–6.
    1. Hsu TL, Hsu SK, Chen HM, Wang ST. Comparison of hook plate and tension band wire in the treatment of distal clavicle fractures. Orthopedics. 2010;33:879.
    1. Jubel A, Andermahr J, Prokop A, Lee JI, Schiffer G, Rehm KE. Treatment of mid-clavicular fractures in adults. Early results after rucksack bandage or elastic stable intramedullary nailing. Unfallchirurg. 2005;108:707–14.
    1. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop. 2009;38:341–5.
    1. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Orthop Trauma. 2011;25:31–8.
    1. Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis (Suppl 3) 2007;66:iii40–1.
    1. Lee YS, Lin CC, Huang CR, Chen CN, Liao WY. Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate. Orthopedics. 2007;30:959–64.
    1. Lee YS, Huang HL, Lo TY, Hsieh YF, Huang CR. Surgical treatment of midclavicular fractures: a prospective comparison of Knowles pinning and plate fixation. Int Orthop. 2008;32:541–5.
    1. Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Cochrane Database Syst Rev. 2009a. Conservative interventions for treating middle third clavicle fractures in adolescents and adults; p. CD007121.
    1. Lenza M, Belloti JC, Gomes Dos Santos JB, Matsumoto MH, Faloppa F. Cochrane Database Syst Rev. 2009b. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle; p. CD007428.
    1. Loke YK, Price D, Herxheimer A. John Wiley & Sons; Chichester, England: 2006. Cochrane Handbook for systematic reviews of interventions.
    1. Neer CS. Nonunion of the clavicle. J Am Med Assoc. 1960;172:1006–11.
    1. Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop. 1994;300:127–32.
    1. Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury. 2000;31:353–8.
    1. Pai HT, Lee YS, Cheng CY. Surgical treatment of midclavicular fractures in the elderly: a comparison of locking and nonlocking plates. Orthopedics. 2009;32(4):257.
    1. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11:452–6.
    1. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg (Br) 1998;80:476–84.
    1. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623–32.
    1. Shen JW, Tong PJ, Qu HB. A three-dimensional reconstruction plate for displaced midshaft fractures of the clavicle. J Bone Joint Surg (Br) 2008;90:1495–8.
    1. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23:106–12.
    1. Smekal V, Irenberger A, El Attal R, Oberladstaetter J, Krappinger D, Kralinger F. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients. Injury. 2011;42:324–9.
    1. Tubach F, Dougados M, Falissard B, Baron G, Logeart I, Ravaud P. Feeling good rather than feeling better matters more to patients. Arthritis Rheum. 2006;55:526–30.
    1. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma. 2005;19:504–7.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe