Functional outcomes of nonoperative versus operative management of displaced fractures of the middle one-third clavicle in adults: A systematic review.

Introduction: Clavicular injuries represent 2.6% of all bone fractures, with the most common site being the middle one-third. The functional outcome of nonoperative versus operative management is still debated. Aim: To primarily compare the operative versus nonoperative management of displaced middle one-third fractures of the clavicle in adults with regard to functional outcome. And to compare the rate and type of complications as a secondary objective. Methods: An electronic medical database search was conducted to perform this systematic review. The records were pooled and reviewed according to the defined inclusion and exclusion criteria, and a critical assessment was performed. Data was extracted from eligible records, tabulated, and interpreted. Results: A total of 5 studies met the inclusion, exclusion, and quality assessment criteria. The data were then grouped according to defined time points during follow-up. The functional outcome of patients who underwent surgery were found to be greater than those who underwent conservative treatment at most time points. The overall complication rate was higher in the nonoperative group. The incidence of nonunion and malunion were greater in the nonoperative group, while hardware-related problems were greater in the operative group. Conclusion: Operative intervention was found to have a superior functional outcome at different time points during treatment. It had a lower overall complication rate. However, it introduces its own set of surgery and hardware related problems. We suggest a shared decision making approach where most eligible patients would undergo primary fixation according to their needs, while the rest would try nonoperative management and only progress to operative management based on an early predictive model or on treatment failure.