Operative Versus Non-operative Management of Mid-diaphyseal Clavicle Fractures in the Skeletally Immature Population: A Systematic Review and Meta-analysis

Abstract

Purpose The purpose of this study is to compare the outcomes and complications of operative vs non-operative management of mid-diaphyseal clavicle fractures in the skeletally immature population. Recent Findings Traditionally, skeletally immature clavicle fractures have been managed non-operatively. However, there has been an increasing trend towards operative management with a lack of evidence indicating its effectiveness. Methods Two reviewers searched three online databases (MEDLINE, EMBASE and PubMed), independently and in duplicates, for literature comparing the outcomes and complications of operative versus non-operative management in skeletally-immature patients (defined as birth to 18 years of age) with a middiaphyseal clavicle fracture. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Results Seven studies, containing 522 skeletally immature patients (with 528 mid-diaphyseal clavicle fractures) with an age range of 8 to 18 years, with 148 patients undergoing operative management and 380 patients undergoing non-operative management, were included. Across the 6 studies that reported gender (N = 444), there were 335 males and 109 females. Patients were followed up from 2 weeks to 3.7 years across five studies (N = 201 patients) that reported follow-up time. There was no significant difference in the time to achieve union (p = 0.1), the time to return to activity (p = 0.09), and the overall complication rate (p = 0.50) between the operative and the non-operative groups. Summary There is no significant difference between operative and non-operative management of skeletally immature middiaphyseal clavicle fractures. Clinical equipoise exists to study this further by means of a prospective, randomized, blinded control trial. Level of Evidence Level IV, systematic review and meta-analysis of level II, III, and IV.

Intermediate-Term Outcomes Following Operative and Nonoperative Management of Midshaft Clavicle Fractures in Children and Adolescents

“…The lack of nonunions in this cohort is consistent with the low rate reported in these meta-analyses (nonunion rates of <1% to 2% for nonoperative management and <1% to 3% for operative management 7 , 8 ). The refracture rates of 5% in the operatively treated group and 3% in the nonoperatively treated group are in keeping with previously reported rates of 0% to 8.7% 7 , 8 . Our implant removal rate of 19% is in keeping with the previously reported rate of 15% 7 .…”

“…Although Constant scores were significantly higher in operatively treated patients, all patients demonstrated favorable scores compared with the general, uninjured population. In their meta-analysis of 7 studies, Nawar et al reported no difference in time to union, return to activity, or complications between operative and nonoperative management, concluding that there is no significant difference between operative and nonoperative management in the skeletally immature population 8 . The lack of nonunions in this cohort is consistent with the low rate reported in these meta-analyses (nonunion rates of <1% to 2% for nonoperative management and <1% to 3% for operative management 7 , 8 ).…”

“…In their meta-analysis of 7 studies, Nawar et al reported no difference in time to union, return to activity, or complications between operative and nonoperative management, concluding that there is no significant difference between operative and nonoperative management in the skeletally immature population 8 . The lack of nonunions in this cohort is consistent with the low rate reported in these meta-analyses (nonunion rates of <1% to 2% for nonoperative management and <1% to 3% for operative management 7 , 8 ). The refracture rates of 5% in the operatively treated group and 3% in the nonoperatively treated group are in keeping with previously reported rates of 0% to 8.7% 7 , 8 .…”

“…Gao et al reported faster union, earlier return to sports, a higher Constant score, higher rates of complication, and a high rate of secondary surgical procedures with operative management 7 . In contrast, Nawar et al reported no difference in time to union, return to activity, or complications between operative and nonoperative management 8 . Both meta-analyses concluded that excellent outcomes followed both operative and nonoperative management.…”

“…Recent meta-analyses identified a nonunion rate in patients <19 years of age of <1% to 2% for nonoperative management and <1% to 3% for operative management 7 , 8 . Gao et al reported faster union, earlier return to sports, a higher Constant score, higher rates of complication, and a high rate of secondary surgical procedures with operative management 7 .…”