ISOLATED DISPLACED MIDSHAFT FRACTURE: OPERATIVE VS. NON-OPERATIVE TREATMENT[ADOLESCENT ≤18 YEARS]

Two low-quality studies (Swarup 2011, Riiser 2021) comparing operative and non-operative treatment of clavicle fracture in adolescent patients (≤ 18 years old) met inclusion criteria. Both studies found no significant difference in patient reported outcomes between operative and non-operatively treated patients. Swarup (2021) found no significant difference between groups in QuickDASH, Numerical Rating Scales for pain, UCLA Activity Scale, PROMIS Pain Interference, and PROMIS Physical Function Upper Extremity, and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Eight of forty-three operatively treated patients required implant removal (Swarup 2011). Conducting a similar comparison, Riiser (2021) found no significant difference in QuickDASH or Oxford Shoulder Score. However, they did find that non-operative treatment was favored for cosmetic outcomes, pain, and patient satisfaction (Riiser 2021). 

Benefits/Harms of Implementation

The decision for surgery in an adolescent patient should be based upon a shared decision-making model with the understanding that there is no difference in outcome measures once the fracture has healed. Surgery should be reserved for select cases in the older adolescents.

Outcome Importance

It is important to understand surgical treatment with a plate or intramedullary nail does not confer an advantage in functional outcomes. Displaced, midshaft clavicle fractures in adolescents heal regardless of what treatment method is chosen as no non-unions were reported in the two studies (Swarup 2021, Riiser 2021).

Cost Effectiveness/Resource Utilization

Operative treatment has a higher need for implant removal, thus increasing health care costs and the risks associated with additional surgery.

Acceptability

Families and patients need to be counseled they can expect similar functional results with surgery or without surgery and the studies favor a trend toward non-operative treatment providing a more favorable cosmetic result.

Feasibility

Guidelines regarding treatment risks and outcomes provide surgeons with information to help counsel patients and their families. No specific treatment recommendations are provided as similar outcomes are demonstrated regardless of how they are treated.

Future Research

Due to the low number of studies on this topic, there is need for future research to provide best evidence to guide decision making. Research should be directed towards the older adolescents, age 14 –18.