title: Surgical versus conservative interventions for treating fractures of the middle third of the clavicle.
abstract: BACKGROUND
  Clavicle fractures are common, accounting for 2.6% to 4% of all fractures. Eighty per cent of clavicle fractures are located in the middle third of the clavicle. Although treatment of these fractures is usually non-surgical, displaced clavicle fractures may be considered for surgical treatment because of their greater risk of non-union.
  
  
  OBJECTIVE
  To assess the effects (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures.
  
  
  METHODS
  We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2012), Cochrane Central Register of Controlled Trials (CENTRAL; in The Cochrane Library 2012, Issue 11), MEDLINE (1966 to December 2012), EMBASE (1980 to 2012 Week 40), LILACS (1982 to December 2012), and trial registries (December 2012). No language or publication restrictions were applied.
  
  
  METHODS
  Randomised and quasi-randomised controlled trials evaluating surgical versus conservative interventions for treating middle third of the clavicle fractures were considered. The primary outcomes were shoulder function or disability, pain and treatment failure (defined as the number of participants who had been given a non-routine secondary surgical intervention (excluding hardware removal) for symptomatic non-union, malunion or other complications).
  
  
  METHODS
  At least two review authors selected eligible trials, independently assessed risk of bias and cross-checked data. Where appropriate, results of comparable trials were pooled.
  
  
  RESULTS
  We included eight trials involving 555 participants with middle third clavicle fractures. Four studies compared plate fixation with wearing a sling and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage. Almost all trials had design features that carry a high risk of bias, thus limiting the strength of their findings.Low-quality evidence from seven trials (429 participants) showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not result in a significant improvement in upper arm function at one year of more follow-up: standardised mean difference 0.46, 95% confidence interval (CI) CI -0.06 to 0.98. This corresponds to an absolute mean improvement of 3.2 points in favour of surgery (0.4 points worse to 7 points improvement) on the 100-point Constant score; this is neither clinically nor statistically significant. Low-quality evidence from seven trials (437 participants) indicates a marginal difference in the incidence of treatment failure between surgery (9/232, 3.9%) and conservative treatment (24/205, 11.7%) (risk ratio 0.38, 95% CI 0.15 to 0.99). However, this was dominated by the results of the largest trial, which had an unusually high number of symptomatic malunions in the conservative treatment group. One trial providing pain results at one-year follow-up found no difference between the two groups. No trials reported on quality of life.No significant difference between groups was noted in the pooled results for adverse events but separate analyses by type of adverse events showed that wound infection and/or dehiscence (data from three trials) and secondary surgery due to hardware complications (data from five trials) occurred only in the surgical group. Skin and nerve problems were also more common after surgical treatment, although the difference between the two groups was not statistically significant (data from four trials). Conversely, stiffness or restriction of shoulder movement was more common after conservative treatment (data from three trials).
  
  
  CONCLUSIONS
  Limited evidence is available from randomised controlled trials on the relative effectiveness of surgical versus conservative treatment for acute middle third clavicle fractures. Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.
authors.affiliation: Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo, São Paulo, Brazil. mariolenza@yahoo.com.br.
authors.forename: Mário
authors.initials: M
authors.lastname: Lenza
authors.forename: Rachelle
authors.initials: R
authors.lastname: Buchbinder
authors.forename: Renea V
authors.initials: RV
authors.lastname: Johnston
authors.forename: João Carlos
authors.initials: JC
authors.lastname: Belloti
authors.forename: Flávio
authors.initials: F
authors.lastname: Faloppa
mesh_terms: D001458:Bandages; D002968:Clavicle / Q000293:injuries*; D005592:Fracture Fixation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D050723:Fractures, Bone / Q000601:surgery / Q000628:therapy*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D013165:Splints; D016896:Treatment Outcome