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World J Orthop. Sep 18, 2026; 17(9): 124549
Published online Sep 18, 2026. doi: 10.5312/wjo.124549
Operative vs nonoperative management of displaced midshaft clavicle fractures: A systematic review
Abdulaziz Ahmed Munshi, Abdulaziz Ahmed Abdulaziz, Husam Hasan Tamim, Ghamid Abdulsattar Alghamdi, Abdalrashid Faisal Halawani, Abdullah Hesham Alsawaf, Ahmad Abdulrahman Alghamdi, Abdulellah Ismail Alqurashi, Meshal Yahya Altowairqi, Khalid Ahmad Alnofeay
Abdulaziz Ahmed Munshi, Faculty of Medicine, Umm A-Qura University, Mecca 21955, Saudi Arabia
Abdulaziz Ahmed Abdulaziz, Department of Orthopedic Surgery, King Faisal Medical Complex, Taif 26522, Saudi Arabia
Husam Hasan Tamim, Department of Orthopedic Surgery, Security Forces Hospital, Makkah 24251, Saudi Arabia
Ghamid Abdulsattar Alghamdi, Department of Orthopedic Surgery, King Abdulaziz University Hospital, Jeddah 21589, Saudi Arabia
Abdalrashid Faisal Halawani, Khalid Ahmad Alnofeay, Department of Orthopedic Surgery, King Faisal Hospital, Makkah 24236, Saudi Arabia
Abdullah Hesham Alsawaf, Department of Orthopedic Surgery, King Fahad General Hospital, Jeddah 23325, Saudi Arabia
Ahmad Abdulrahman Alghamdi, Department of Orthopedic Surgery, Ministry of Health, East Jeddah Hospital, Jeddah 22253, Saudi Arabia
Abdulellah Ismail Alqurashi, Department of Orthopedic Surgery, AlNoor Specialist Hospital, Makkah 24241, Saudi Arabia
Meshal Yahya Altowairqi, Department of Orthopedic Surgery, King Abdulaziz Specialist Hospital, Taif 26521, Saudi Arabia
Co-corresponding authors: Abdulaziz Ahmed Munshi and Abdulaziz Ahmed Abdulaziz.
Author contributions: Munshi AA and Abdulaziz AA contributed to the study conception and design; Alghamdi AA, Altowairqi MY, and Tamim HH performed the data acquisition and extraction; Alsawaf AH and Halawani AF conducted the data selection and quality assessment; Munshi AA and Abdulaziz AA drafted the manuscript; Alqurashi AI, Alghamdi GA, and Alnofeay KA critically revised the manuscript for important intellectual content; Alnofeay KA provided overall supervision for the study; all authors have read and approved the final manuscript. We respectfully submit this rationale to justify designating Munshi AA and Abdulaziz AA as co-corresponding authors for manuscript. Both authors played equal, distinct, and indispensable leadership roles throughout the entire lifecycle of this systematic review. Munshi AA led the conceptual framework, protocol registration with PROSPERO, and the structural synthesis of the manuscript. Concurrently, Abdulaziz AA directed the comprehensive data matrix verification, quality and risk-of-bias assessments, and the detailed qualitative subgroup stratifications. Given the multi-center collaboration across different clinical institutions within the region, dual corresponding authorship ensures seamless administrative continuity, timely oversight during peer review, and long-term accountability for data integrity. Both authors contributed equally to drafting and revising the final manuscript, and both share full responsibility for the scientific rigor, transparency, and post-publication inquiry management for this study.
AI contribution statement: The authors declare that no artificial intelligence tools were utilized to conceptualize, analyze, or draft the scientific core of this study. The manuscript was subjected to professional medical editing by Filipodia Editing to optimize English syntax and academic readability in accordance with standard international publishing guidelines.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Abdulaziz Ahmed Munshi, MD, Faculty of Medicine, Umm A-Qura University, Al-Abdiyyah, Mecca 21955, Saudi Arabia.
abdulaziza.munshi@gmail.com
Received: June 18, 2026
Revised: July 17, 2026
Accepted: August 14, 2026
Published online: September 18, 2026
Processing time: 83 Days and 21.7 Hours
BACKGROUND
The optimal management of displaced midshaft clavicle fractures in adults remains controversial, with ongoing debate regarding the long-term superiority of operative fixation over nonoperative care.
AIM
To compare operative vs nonoperative outcomes, union rates, and complications in adults with displaced midshaft clavicle fractures.
METHODS
A systematic review was conducted in accordance with PRISMA 2009 guidelines and registered on PROSPERO (CRD420261328668). PubMed, EMBASE, Scopus, and Web of Science were searched for randomized controlled trials and comparative studies published from January 2000 to June 2026. Eligible studies included adults with acute displaced midshaft fractures and reported union rates and/or functional outcomes, including Disabilities of the Arm, Shoulder and Hand and Constant scores.
RESULTS
A total of 15 studies involving 1615 patients were included. Operative fixation was associated with significantly lower nonunion rates (0%-5%) compared with nonoperative treatment (6%-24%). Although early functional scores were superior in the surgical group, these differences generally diminished by 12 months of follow-up in most studies. Surgical complications were primarily hardware-related, with reported rates of up to 27%, whereas nonoperative treatment was associated with higher rates of symptomatic malunion and nonunion.
CONCLUSION
Operative fixation significantly reduces the risk of nonunion and accelerates functional recovery in adults with displaced midshaft clavicle fractures. However, long-term functional outcomes remain equivalent to those observed with nonoperative management.
Core Tip: This systematic review of level I evidence evaluated operative fixation vs nonoperative management for displaced midshaft clavicle fractures in 1615 patients. Our findings demonstrate that while surgery significantly reduces the risk of nonunion and facilitates earlier functional recovery, long-term functional outcomes at 1 year are generally comparable between operative and nonoperative management. These results emphasize the need for individualized, patient-centered decision-making, particularly for active adults who prioritize a rapid return to function.
