Operative vs nonoperative management of displaced midshaft clavicle fractures: A systematic review

Table 1 Randomized and comparative studies evaluating operative vs nonoperative management of adult displaced midshaft clavicle fractures

Study	Year	Design	Sample size, n for op/non-op among (n = 1615)	Loss to follow-up	Intervention vs comparator	Key outcomes (follow-up)
Jubel et al[13]	2005	CCT	53/53	None reported	ESIN vs sling	Better early pain reduction and ROM with ESIN; excellent functional results (12 months)
Canadian Orthopaedic Trauma Society[6]	2007	RCT	67/65	Op: 5 lost; non-op: 7 lost	Plate fixation vs sling	Nonunion 2% vs 15%; better early DASH/Constant scores (12 months)
Smekal et al[15]	2009	RCT	30/30	Op: 2 lost; non-op: 1 lost	ESIN vs sling	0 nonunions (Op) vs 3 (non-op); better early function with ESIN
Ferran et al[16]	2010	RCT	17/15	0 lost	Locked IM nail vs plate	100% union in both groups; no significant difference (12 months)
Kulshrestha et al[14]	2011	Prospective study	73/68	Op: 3 lost; non-op: 5 lost	Plate fixation vs sling	Significantly lower nonunion rate and better functional scores in operative group (18 months)
Mirzatolooei[21]	2011	RCT	32/30	Op: 1 lost; non-op: 2 lost	Plate/ESIN vs bandage	Nonunion 0% vs 13%; significantly better Constant scores with surgery at 12 months
Virtanen et al[7]	2012	RCT	30/30	Op: 2 lost non-op: 0 lost	Plate fixation vs sling	Nonunion 0% vs 24%; similar function at 12 months
Robinson et al[5]	2013	RCT	100/100	Op: 4 lost non-op: 6 lost	Plate fixation vs sling	Nonunion 1% vs 16%; cosmetic satisfaction better (12 months)
Mukherjee et al[17]	2014	Prospective study	34 (Op)	2 lost	Plate fixation	100% union; early return to function; no major complications (single-arm series)
Ahrens et al[8]	2017	RCT	154/147	Op: 8 lost; non-op: 11 lost	Plate fixation vs sling	Lower nonunion; improved early function; reoperation common (12 months)
Bhardwaj et al[19]	2018	Prospective study	36/33	Op: 1 lost; non-op: 2 lost	Plate fixation vs sling	Faster union (15.6 weeks vs 22.8 weeks); better Constant scores at 24 months; 6% nonunion in conservative group
Qvist et al[9]	2018	RCT	75/71	Op: 3 lost; non-op: 4 lost	Plate fixation vs nonoperative management	Faster early recovery; higher union rate; functional outcomes comparable by 6-12 months
Pathak et al[18]	2019	RCT	42/42	0 lost	Plate vs figure-of-eight	Faster union with surgery (12.4 weeks vs 14.3 weeks); better early ASES scores; no difference at 12 months
Ma et al[20]	2020	Retrospective cohort	45/38	0 lost	Plate fixation vs sling	Op: 100% union; non-op: 89.5% union. Better function in Op group
Han et al[22]	2024	Retrospective cohort	50/55	0 lost	Plate fixation vs nonoperative management	Union 98% (Op) vs 87% (non-op); faster union (2.4 months vs 3.7 months) and return to work with surgery

ASES: American Shoulder and Elbow Surgeons; CCT: Controlled clinical trial; DASH: Disabilities of the Arm, Shoulder and Hand; ESIN: Elastic stable intramedullary nailing; IM: Intramedullary; RCT: Randomized controlled trial; ROM: Range of motion.