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Operative Versus Nonoperative Treatment of Pediatric and Adolescent Clavicular Fractures

A Systematic Review and Critical Analysis

Scott, Meredith L., BS1; Baldwin, Keith D., MD, MSPT, MPH2; Mistovich, R. Justin, MD3

doi: 10.2106/JBJS.RVW.18.00043
Evidence-Based Systematic Reviews

Background: The optimal treatment of displaced middle-third clavicular fractures in pediatric and adolescent patients remains controversial. Furthermore, risk factors for the failure of nonoperative treatment have not been clearly defined. Therefore, we designed a systematic review and critical analysis to assess appropriate Grades of Recommendation for evidence-based treatment of middle-third clavicular fractures in the pediatric and adolescent populations.

Methods: We performed a systematic review following a search of the PubMed, Embase, and Cochrane databases that was conducted in May 2017. The search terms were clavicle, clavic*, and fracture. Our specific PubMed search was (“clavicle”[MeSH] OR clavic*) AND (“fracture”[MeSH] OR fracture*). The results were filtered for English language and subjects ≤18 years of age. There was no chronological limit on the results. The results were then assessed for relevance via a stepwise approach by first screening titles, then abstracts, and, finally, full text. The levels of evidence were determined for studies that met the inclusion criteria. The findings were summarized, and Grades of Recommendation were assigned by consensus.

Results: Our search returned 3,615 studies. Of these, 215 were potentially relevant. Studies that did not meet our inclusion criteria were removed by consensus. One hundred and nineteen full-text articles were then assessed. Of these, 19 met the inclusion criteria. Overall, patients with both operative and nonoperative treatment of displaced middle-third clavicular fractures have good functional outcomes, with Grade-B supporting evidence. There is Grade-B evidence that operative treatment results in a high complication rate. Both plating and nailing have a high likelihood of requiring implant removal, with Grade-B evidence. There is conflicting evidence regarding the effect of both nonoperative and operative treatment on patient cosmesis following displaced fractures. There is Grade-B evidence that nonunions of pediatric clavicular fractures are exceptionally rare, regardless of treatment strategy. Nonoperatively treated displaced fractures have conflicting evidence regarding any adverse effect displacement may have on functional status.

Conclusions: Existing literature does not clearly delineate appropriate indications for nonoperative care or relative indications for operative intervention. Further studies are needed to guide treatment and promote better informed consent.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1University of Toledo College of Medicine and Life Sciences, Toledo, Ohio

2The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

3Case Western Reserve University School of Medicine, Cleveland, Ohio

E-mail address for R.J. Mistovich:

Investigation performed at Case Western Reserve University School of Medicine, Cleveland, Ohio

Disclosure: No external funds were received in support of this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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