ISOLATED DISPLACED MIDSHAFT FRACTURE: OPERATIVE VS. NON-OPERATIVE TREATMENT [ADULT]

For those with displaced, mid shaft clavicle fractures, the exact amount of displacement and shortening to warrant consideration are not well-defined in the majority of studies. The referral to the guidelines of the COTS study 2007 are often discussed with displacement defined as no cortical contact between the two fragments.  The studies which compared operative treatment with plate fixation versus non-operative treatment found an increased union rate with operative plate fixation (Ban 2021, Tamaoki 2017, COTS 2007). Additional studies that evaluated elastic stable intramedullary nailing (ESIN) also supported operative treatment for displaced midshaft clavicle fractures. The union rate not only was higher for operative treatment, but time to union was also faster (Chen 2011, Smekal 2009, Smekal 2011). There were superior functional outcomes earlier in the operatively treated group. For active patients and those who need to return to work with a displaced, midshaft clavicle fracture, operative fixation should be strongly considered.

Benefits/Harms of Implementation

Plate fixation and intramedullary nailing lead to higher union rates in adult patients.  With any operative treatment, there is increased risk of infection and implant failure.  The infection rates in all of the studies were low. There is increased need for surgery due to nonunion in the non-operatively treated group. There is increased need for reoperation for plate or EISN removal in the operatively treated group due to irritation and/or prominence of implant. Neither operative nor non-operative treatment was found to be superior in terms of cosmesis. At long-term follow-up, similar functional outcomes can be expected.

Outcome Importance

For displaced and shortened clavicle fractures, operative treatment with plate fixation was found to provide the best outcomes in terms of union rate.

Cost Effectiveness/Resource Utilization

Surgical fixation costs more in terms of overall costs and increased costs in the post operative period due to procedure costs for implant removal. With the need for operative conversion in non-operatively treated fractures to promote union, the delay in definitive management may affect the time to return to work and have economic consequences for the patient.

Acceptability

Operative stabilization of displaced and/or comminuted mid shaft clavicle fractures is an acceptable treatment. There are more studies comparing plate fixation, but in comparing operative versus non-operative treatment, regardless of the type of implant, the union rate was superior and time to union was faster compared to non-operative treatment.

Feasibility

Operative treatment with a plate or intramedullary nailing can lead to a high union rate. The familiarity with plate fixation is the most likely reason for the greater number of studies analyzing this technique.

Future Research

Consistency in reporting the definition of displaced clavicle fractures in randomized studies should be sought. Mid- and long-term outcome studies would provide information on value of treatment over time in the adult population. Improved understanding or prediction of which patients are most likely to fail nonoperative or operative treatment will be useful to further tailor clinical decision-making. The determination of when non-operative treatment should be converted to operative stabilization would be useful in shared decision-making processes. It appears functional outcomes are similar at one year with either operative or non-operative treatment.