Conservative interventions for treating middle third clavicle fractures in adolescents and adults
Abstract
Background
Clavicle (collarbone) fractures account for around 4% of all fractures. Most (76%) clavicle fractures involve the middle‐third section of the clavicle. Treatment of these fractures is usually non‐surgical (conservative). Commonly used treatments are arm slings, strapping and figure‐of‐eight bandages.
This is an update of a Cochrane review first published in 2009 and updated in 2014.
Objectives
To evaluate the effects (benefits and harms) of different methods for conservative (non‐operative) treatment for acute (treated soon after injury) middle third clavicle fractures in adolescents and adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE (from 1966), Embase (from 1980), LILACS (from 1982), trial registers, orthopaedic proceedings and reference lists of articles. We applied no language or publication restrictions. The date of the last search was 5 January 2016.
Selection criteria
Randomised and quasi‐randomised controlled trials testing conservative interventions for treating adolescents and adults with acute middle third clavicle fractures. The primary outcomes were shoulder function or disability, pain and treatment failure.
Data collection and analysis
For this update, two review authors selected eligible trials, independently assessed risk of bias and cross‐checked data extraction. We calculated risk ratios and 95% confidence intervals for dichotomous variables, and mean differences and 95% confidence intervals for continuous variables. There was very limited pooling of data.
Main results
We included four trials in this review with 416 participants, who were aged 14 years or above. One new trial was included in this update.
Very low quality evidence was available from three trials (296 participants) that compared the figure‐of‐eight bandage with an arm sling for treating acute middle third clavicle fractures. The three trials were underpowered and compromised by poor methodology. Shoulder function was assessed in different ways in the three trials (data for 51, 61 and 152 participants); each trial provided very low quality evidence of similar shoulder function in the two groups. Pooled data from two trials (203 participants) showed no clinical difference between groups after two weeks in pain (visual analogue scale: 0 (no pain) to 10 (worst pain); mean difference (MD) 0.43, 95% confidence interval (CI) ‐0.35 to 1.21; I² = 74%; very low quality evidence). A third trial (61 participants) provided very low quality evidence based on a non‐validated scoring system of more pain and discomfort during the course of treatment in the figure‐of‐eight group. Treatment failure, measured in terms of subsequent surgery, was not reported in two trials; the third trial (152 participants) reported one participant in the arm sling group had surgery for secondary plexus nerve palsy. There was very low quality evidence from one trial (148 participants) of little difference in time to clinical fracture healing (MD 0.2 weeks, 95% CI ‐0.11 to 0.51); data from four non‐symptomatic non‐unions in the figure‐of‐eight group were not included. The very low evidence quality data for individual adverse outcomes (poor cosmetic appearance; change in allocated treatment due to pain and discomfort, worsened fracture position on healing; shortening > 15 mm; non‐symptomatic non‐union and permanent pain) did not confirm a difference between the two groups. There was no clear between group difference in the time to return to school or work activities (MD ‐0.12 weeks, 95% CI ‐0.69 to 0.45; 176 participants; very low quality evidence).
Moderate quality evidence was available from one trial (120 participants; reporting data for 101 participants), which evaluated therapeutic ultrasound. This trial was at low risk of bias but was underpowered and did not report on shoulder function or quality of life. The trial found no evidence of a difference between low‐intensity pulsed ultrasound and placebo in pain, treatment failure (subsequent surgery: 6/52 versus 5/49; RR 1.13, 95% CI 0.37 to 3.47), the time to clinical fracture healing (MD ‐0.32 days, 95% CI ‐5.85 to 5.21), adverse events (one case of skin irritation was reported in each group) or time to resume previous activities.
Authors' conclusions
The current evidence available from randomised controlled trials is insufficient to determine which methods of conservative treatment are the most appropriate for acute middle third clavicle fractures in adolescents and adults. Further research is warranted.
PICOs
Plain language summary
Non‐surgical interventions for treating a broken collarbone in adolescents and adults
Background and aims
A broken collarbone (clavicle fracture) is a common injury, particularly in adolescents, and accounts for up to 4% of all fractures. Most collarbone fractures occur in the middle‐third section. These fractures are frequently treated with conservative treatments that do not involve surgery. Common conservative treatments are arm slings, strapping and figure‐of‐eight bandages.
This review aimed to evaluate the effects of different conservative treatments for treating collarbone fractures in adolescents and adults without surgery. The main outcomes we were interested in were long‐term function and pain.
Search results
We searched the scientific literature up to January 2016 and found four relevant studies with a total of 416 participants. The four small studies had methodological limitations that may affect the reliability of their findings. The types of conservative treatments evaluated were figure‐of‐bandage versus arm sling in three trials and therapeutic ultrasound versus sham treatment (placebo) in one trial.
Key results
The three studies (296 participants) comparing the figure‐of‐eight bandage versus an arm sling found similar shoulder function in the two groups at the end of follow‐up. Although data from two studies did not show a difference in pain at two weeks after injury, the third study reported more pain and discomfort in people in the figure‐of‐eight bandage group. One participant was recorded as having surgery for a complication. None of the three studies found differences in time for fracture healing, adverse outcomes or time to return to school or work activities.
The fourth study compared therapeutic ultrasound with sham treatment in 120 people with clavicle fractures. It found no difference in outcome, including the time for fracture healing, between the two groups.
Conclusions and quality of evidence
The evidence from the three studies that compared figure‐of‐eight bandage with arm sling was very low quality and so we cannot rely on it to draw conclusions about how collarbone fractures should be treated. We considered the evidence from one study that compared therapeutic ultrasound versus sham treatment to be moderate quality as the study was well conducted but it was not big enough to be conclusive.
Overall, there was not enough evidence to draw conclusions about the best methods of conservative treatment for these fractures.
