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Operative Versus Nonoperative Care of Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Clinical Trials
Robbin C. McKee1; Daniel B. Whelan, MD, FRCS(C)1; Emil H. Schemitsch, MD, FRCS(C)1; Michael D. McKee, MD, FRCS(C)1
1 Division of Orthopaedics, Department of Surgery, St. Michael’s Hospital and the University of Toronto, 800 – 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for M.D. McKee: McKeeM@smh.ca
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Investigation performed at St. Michael’s Hospital and the University of Toronto, Toronto, Ontario, Canada

This article was chosen to appear electronically on March 14, 2012, in advance of publication in a regularly scheduled issue.

A commentary by William T. Obremskey, MD, MPH, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her 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. No author has had any other relationships, or has 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.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Apr 18;94(8):675-684. doi: 10.2106/JBJS.J.01364
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Recent studies have suggested benefits following primary operative fixation of substantially displaced midshaft fractures of the clavicle. We reviewed randomized clinical trials of operative versus nonoperative treatment of these fractures, and pooled the functional outcome and complication rates to arrive at summary estimates of these outcomes.


A systematic review of the literature was performed to identify studies of randomized clinical trials comparing operative versus nonoperative care for displaced midshaft clavicular fractures.


Six studies (n = 412 patients, mean Detsky score = 15.3) were included. The nonunion rate was higher in the nonoperatively treated patients (twenty-nine of 200) than it was in patients treated operatively (three of 212) (p = 0.001). The rate of symptomatic malunion was higher in the nonoperative group (seventeen of 200) than it was in the operative group (0 of 212) (p < 0.001).


Operative treatment provided a significantly lower rate of nonunion and symptomatic malunion and an earlier functional return compared with nonoperative treatment. However, there is little evidence at present to show that the long-term functional outcome of operative intervention is significantly superior to nonoperative care.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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