Surgical interventions for treating acute fractures or non‐union of the middle third of the clavicle
Abstract
Background
This review covers two conditions. These are acute fractures and non‐union resulting from failed fracture healing. Clavicle or collarbone fractures account for around 4% of all fractures. While treatment of these fractures is usually non‐operative, some types of fractures, as well as non‐union of the middle third of the clavicle, are often treated surgically.
Objectives
To evaluate the effectiveness of different methods of surgical treatment for acute fracture or non‐union of the middle third of the clavicle.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1966 to December 2008), EMBASE (1988 to December 2008), LILACS (1982 to December 2008), trial registries and reference lists of articles. No language or publication restrictions were applied.
Selection criteria
Randomised and quasi‐randomised controlled trials evaluating any surgical intervention for treating people with fractures or non‐union of the middle third of the clavicle were considered. The primary outcomes were pain, treatment failure and health‐related quality of life or shoulder function.
Data collection and analysis
Two authors independently selected eligible trials and three authors assessed methodological quality and cross‐checked data extraction. There was no pooling of data.
Main results
Data from three small trials, each testing a different comparison, were included. Two trials had design features that carry a high risk of bias, limiting the strength of their findings. Low‐contact dynamic compression plates appeared to be associated with significantly better upper‐limb function throughout the year following surgery, earlier fracture union and return to work, and a reduced incidence of implant‐associated symptoms when compared with a standard dynamic compression plate in 36 adults with symptomatic non‐union of the middle third of the clavicle. One study (69 participants) compared the Knowles pin versus a plate for treating middle third clavicle fractures or non‐union. Knowles pins appeared to be associated with lower pain levels and use of post‐operative analgesics, reduced incidence of implant‐associated symptoms, and shorter operation time and hospital stay. One study (133 participants) found that a three‐dimensional technique for fixation with a reconstruction plate was associated with a significantly lower incidence of symptomatic delayed union than a standard superior position surgical approach.
Authors' conclusions
There is limited evidence, from single trials only, regarding the effectiveness of different methods of surgical fixation of fractures and non‐union of the middle third of the clavicle.
PICOs
Plain language summary
Surgical interventions for treating fractures and non‐union of the collarbone
Collarbone or middle third of the clavicle fractures are a very common injury and account for up to 4% of all fractures. Although the majority of acute fractures can be treated conservatively, such as using a sling, there are some types of fracture that need to be surgically treated. Non‐union of the collarbone, which results from failed fracture healing, is usually treated surgically when associated with pain and functional impairment.
This review set out to evaluate the effects, primarily on pain and long‐term function, of different methods for surgically treating collarbone fractures and non‐union.
Three small studies, two of which had methodological limitations that may affect the reliability of their findings, were included in this review. One poor quality trial that involved 36 participants compared two types of plates for treating non‐union of fractures of the middle third of the clavicle. The trial found that participants treated with a low‐contact dynamic compression plate reported a better quality of life in the year after surgery and returned to work earlier than those patients treated with a standard dynamic compression plate. The second trial, which was also of poor quality, concluded that there were advantages in using intramedullary nail fixation compared with plate fixation in 69 people with either acute fractures or non‐union. The third trial, involving 133 participants, was well conducted but did not include enough participants to be conclusive. It compared two different techniques for placement of plates to fix displaced clavicle fractures. This trial found that a technique in which the plate is contoured in three dimensions before fixation to the clavicle gave better results than placing the plate along the upper surface of the clavicle.
Evidence regarding the effectiveness of different methods of surgical interventions for treating fracture and non‐union of the collarbone is limited and further studies are justified.
