Over the years, treatment of midshaft clavicle fractures has evolved. A 2007 publication with level 1 evidence comparing operative versus nonoperative treatment of midshaft clavicle fractures affected clinical decision-making, as the trial observed improved functional outcome scores and decreased rates of malunion and nonunion with open reduction and internal fixation (ORIF). Interest and literature regarding the topic expanded. A recent PubMed search yielded 3,563 articles. Since 2010, more than 100 articles have been published per year. With any new level 1 evidence, some practitioners jump on the bandwagon. But the question remains: Is ORIF of midshaft clavicle fractures the better treatment option?

Here, trauma and sports medicine physicians comment on the recent meta-analysis by Guerra et al., which concluded that operative treatment was superior.

Lisa K. Cannada, MD, FAAOS, is an orthopaedic traumatologist, member of the AAOS Now Editorial Board, and member of the diversity content workgroup. She can be reached at cannada.lisa@gmail.com.

Management of midshaft clavicle fractures: a trauma surgeon’s perspective 

As the treatment for midshaft clavicle fractures remains controversial, Guerra et al., attempted to answer this clinical question by performing a meta-analysis of randomized, controlled trials (RCTs) comparing surgery to nonoperative treatment in “displaced” midshaft clavicle fractures.

After a lengthy literature search and comprehensive review, they found 14 articles that addressed this question with RCTs using PRISMA and GRADE guidelines. They concluded that “Surgery provided a better result compared to nonoperative treatment.” Only two articles examined the use of intramedullary devices, so no conclusion was reached with the use of those implants relative to plates. The authors went on to state that “long-term” outcomes were better, time to union was faster, and nonunion rates were lower with surgery (16.5 percent versus 1.4 percent). However, “long-term” outcomes (based on the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores) were defined as only greater than nine months, and, as the authors admitted, the small differences in outcome scores may have been statistically significant, but they did not approach clinical significance based on prior studies on the topic.

One can only wonder what the outcomes would be at two years or longer. Furthermore, the lower outcome scores at nine months may be biased by the high nonunion rate (110 patients with nonunion, of whom 78 patients elected to have additional surgery). Assuming the 78 patients who had additional surgery for nonunion had longer follow-up, they may have had improved outcome scores, as late reconstruction is a reliable and reproducible surgery with high satisfaction.

Only three papers addressed the time to return to previous activities/work. The authors found that earlier return to activities failed to reach a significant difference, thus questioning the value of earlier time to union. It also may be that the “earlier time to union” could be difficult to determine when radiographs are taken at four- to six-week intervals or more, considering the difference was noted to be only 5.1 weeks. Not surprisingly, when complications were assessed, and hardware removal was included, the surgical group had a higher complication rate (31.0 percent versus 20.5 percent) and a higher risk of additional surgery (17 percent versus 13 percent).

To the authors’ credit, they did acknowledge that the question still remains to be answered and that more data are needed. So, what is the correct treatment for the displaced midshaft clavicle?

In my opinion, the answer reflects more on the art of medicine and less on the science. Each patient should be evaluated, and, if possible, involved in treatment decision-making. The decision boils down to the risk-benefit ratio, which varies from one patient to another. Although good scientific data support a higher nonunion rate with closed treatment, the costs of operative care may be a big factor for a patient.

For example, consider two healthy college students with displaced midshaft clavicle fractures. One is a starting shortstop for the school’s softball team and has insurance, whereas the other is in the speech and debate club and has no insurance. The softball player wishes to get back on the field and understands that the likelihood of healing is much higher with surgery. For her, cost is not a factor, so she elects surgery. The other student is much more concerned about the cost and is willing to accept the higher risk of nonunion, understanding that it would not affect her position in the speech and debate club. If it does not heal, she then will face the decision again to consider surgery.

This is just one example; many other variables exist that are individual to each patient. In a multitrauma situation, the need for mobilization may be improved with fixation, and the shared decision may be to fix the fracture. Patients with significant comorbidities may elect to avoid the risks of surgery. A professional cyclist who desires to get back on a bike might elect surgery, whereas an accountant who plays chess may decide to accept the risks of nonoperative treatment.

Ultimately, without a clear “best” approach to treatment, a collective decision between the physician and patient may indeed be the best approach—at least today.

Kyle J. Jeray, MD, FAAOS, is chairman of the Orthopedic Department at Prisma Health in Greenville, S.C. He practices orthopaedic trauma and is a member of the Orthopaedic Trauma Association and AAOS, where he has been involved with the Leadership Fellows Program as a participant and mentor.