Conservative vs surgical treatment of midshaft clavicular fractures: a systematic review

Purpose: This systematic review aimed to evaluate the effectiveness of surgical versus conservative management in terms of union rates, functional outcomes and complications. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomised controlled trials published between January 2017 and November 2023 were sourced from MEDLINE, Embase, PubMed and Cochrane databases. Outcomes assessed included union rates, functional scores and complications. Results: Six trials, involving 579 patients with midshaft clavicle fractures, met the inclusion criteria. The union rate was higher in the surgical group (93.3-100%) compared to the conservative group (82-94%). Time to union was significantly shorter for surgical management in two out of three studies reporting this outcome. Shoulder scores revealed short-term improvements in surgical groups but no significant differences at 12 months or longer. Complication rates were comparable: hardware irritation was more frequent in surgical groups, while non-union was more prevalent in conservative management. Only two studies found a statistically significant difference in union rates favouring surgery. Conclusion: Surgical management offers higher union rates and faster recovery but does not demonstrate significant long-term advantages in functional outcomes compared to conservative treatment. Complication rates are similar, with distinct profiles. Clinicians should prioritise patient-centred decision-making, considering individual preferences and clinical contexts, as operative intervention may not significantly enhance long-term outcomes. Further research should perform subgroup analyses to refine management strategies.