Operative care of clavicle fracture reduces complications, nonunion, and malunion
Operative versus non-operative treatment for clavicle fracture: a meta-analysisInt Orthop. 2013 Aug;37(8):1495-500
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5 randomized clinical trials and 3 controlled clinical trials (663 patients) were examined in this meta-analysis to determine if operative treatment provides better results than nonoperative treatment of clavicle fractures. The results from this meta-analysis suggest that operative care was associated with a reduced risk of non-union, malunion, and fewer neurological complications compared to nonoperative care. Statistical analysis of functional outcomes and long term adverse effects could not be completed due to incomplete reporting. However, qualitative assessment indicated that Constant Shoulder Scores and DASH scores were superior in the operative group.
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Were the criteria used for deciding which studies to include in the overview reported?
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Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
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Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
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Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
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Why was this study needed now?
Clavicle fractures are an exceedingly common injury in adults. Until recently these injuries tended to be treated through nonoperative means. However, recent research has indicated that operative care may potentially result in fewer nonunions, malunions, delayed unions and neurological complications, while providing superior functional outcomes. This meta-analysis and systematic review aims to provide an update to current assessments in the literature.
What was the principal research question?
Does operative treatment of a fractured clavicle provide better clinical and functional outcomes compared to nonoperative treatment involving a sling or bandage?
What were the important findings?
- 8 studies (I^2 = 0%) involving 566 patients indicated a reduced risk of nonunion for operative treatment compared to nonoperative (RR 0.12, 95 % CI 0.05-0.29) (p<0.0001).
- 6 homogeneous (I^2 = 0%) studies with 453 patients indicated a decreased risk of malunion in the operative treatment (RR 0.11, 95 % CI 0.04-0.29) (p<0.0001).
- 5 studies (I^2 = 29%) (337 patients) found no significant difference in the delayed union rates (RR 0.78, 95 % CI 0.31-1.95) (p=0.59).
- 7 studies (I^2 = 28%) (468 patients) showed fewer neurological complications associated with operative treatment (RR 0.45, 95 % CI 0.25-0.80) (p=0.008).
- A meta-analysis could not be competed on the CS and DASH scores due to incomplete reporting of standard deviation. A qualitative assessment of CS scores from 5 studies and DASH scores from 4 studies indicated superior results for operative treatment of clavicle fractures.
What should I remember most?
This meta-analysis supports operative measures for the treatment of a fractured clavicle based on reduced rates of nonunion, malunion and neurological complications. However, it should be noted that the functional outcomes examined (CS and DASH scores) were not included in the meta-analysis. Qualitative assessment of these outcomes indicated that operative treatment may provide superior function.
How will this affect the care of my patients?
Operative care of clavicle fractures effectively reduced the risks of non-union, malunion and neurological complications compared to non-operative treatment. Further research still needs to be conducted to identify specifically which types of clavicle fractures benefit the most from surgical fixation. Finally, treatment should be left to the discretion of the treating physician and patient preference.
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