Treating fracture of the clavicle

Historically, one of the few golden rules of orthopedics was that midshaft clavicle fractures did not need surgical repair. Literature published predominantly within the last 10 years has challenged this accepted wisdom, and the pendulum has swung toward surgical treatment. With any major shift in medical practice, it is appropriate to continue to evaluate the practice. A rigorous systematic review and meta-analysis recently published in CMAJ Open found that rates of complications of surgery and unplanned secondary operations were high, regardless of the treatment approach used.1 It would seem, on the surface, that current evidence does not support routine fixation for displaced midshaft clavicle fractures. A closer look at the linked study reveals that all of the included trials that compared operative with nonoperative treatment had an uncertain to high risk of bias and were of low overall quality. Although complication and reoperation rates were similar between surgical and nonsurgical groups, the type of complication and reasons for reoperation were different, something that is equally - and perhaps more - relevant than merely the number of complications. The authors found that the most common adverse effect of surgical management was the development of irritation from metal fixation hardware, necessitating removal, whereas the most common cause of secondary operation after nonoperative treatment was symptomatic nonunion. Symptomatic hardware is typically a nuisance to patients, whereas symptomatic nonunion has been shown to be debilitating.2 Furthermore, the surgical solution to irritating hardware is simple; the solution to nonunion is frequently far more difficult than surgery for the acute fracture, and with results that have been previously shown to be inferior to acute fixation.3 Although the focus of the linked study was on complications and reoperations, the article highlighted indications for surgery as an important issue. It shows that the absolute indications for surgical intervention for midshaft fracture of the clavicle are still unknown. It is clear that most patients with midshaft clavicle fractures treated conservatively will heal and "do well"; however, some do not. Although it seems that displacement alone is not a strong enough predictor of a poor outcome for it to be considered a clear risk factor, it is one of the important factors. A key inference from the linked study is that there is still more work to do in the search for the o