In their meta-analysis of randomized controlled trials, McKee et al. offer a welcome and thorough analysis of the controversial topic of displaced midshaft clavicular fractures. McKee was the lead investigator on a prospective randomized clinical trial by the Canadian Orthopaedic Trauma Society (COTS) study that was published in January 2007 in JBJS and that is included in this analysis1. Since the publication of that study, it has been my observation that some surgeons have used the results of that study—specifically, that, overall, patients have improved function at all time periods of analysis—to justify the overutilization of internal fixation of displaced clavicular fractures. This manuscript thoroughly evaluates the six prospective randomized trials that are available for analysis. The summation of the data indicates, as McKee et al. note, that approximately 75% of all patients with a nonoperatively treated, 100% displaced midshaft clavicular fracture will have essentially normal motion, with full fracture union, normal strength, and normal outcome scores of the upper extremity, and that there is an overall minimal difference in function between operative and nonoperative groups as measured with use of Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Approximately 15% of patients with nonoperatively treated fractures will have a nonunion and 10% will have a symptomatic malunion.
It is not surprising that there is essentially no difference in the functional outcomes scores with use of the DASH or the Constant score for these two cohorts of patients. If 75% of nonoperatively treated patients heal with few or no symptoms, this large percentage will blunt any effects of the two treatment groups when considered on the whole. This manuscript can be utilized to give patients with a 100% displaced midshaft clavicular fracture the reasonable advice that they have a 75% chance of having no residual symptoms and normal shoulder function. We need to be able to better predict which patients are at risk of developing a nonunion and/or symptomatic malunion after this injury. In their 2007 paper, McKee et al. found that patients with a “droopy” shoulder may be the ones most likely to be at risk of developing symptoms from a midshaft clavicular fracture. Hopefully, further work will help define the patients who would truly benefit from early surgical intervention. McKee is to be congratulated for his part in the initial study and for his clear view of this timely topic.
Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.