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Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients

A Systematic Review and Meta-Analysis

Gao, Burke MD*; Dwivedi, Shashank MD*; Patel, Shyam A. MD*; Nwizu, Chibuikem ScB*; Cruz, Aristides I. Jr. MD, MBA*,†

doi: 10.1097/BOT.0000000000001580
Review Article

Objectives: The purpose of this study was to systematically review and quantitatively analyze outcomes in operative versus nonoperative management of displaced midshaft clavicle fractures in pediatric and adolescent patients.

Data Sources: Using the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic searches of PubMed and EMBASE were conducted to identify English-language studies reporting outcomes in displaced pediatric midshaft clavicle fractures from 1997 to 2018.

Study Selection: Studies that reported on outcomes of operative and/or nonoperative treatment of displaced midshaft clavicle fractures in patients younger than 19 years were included.

Data Extraction: Patient and treatment characteristics, union rates, time to union, time to return to activity, patient-reported outcome measures, and complications were extracted.

Data Synthesis: All extracted data were recorded and qualitatively compared. QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand) scores and Constant scores were pooled using random-effects modeling and compared among studies, which adequately reported data for hypothesis testing.

Conclusions: Three thousand eight hundred ten articles were identified, and 12 met inclusion criteria. These studies encompassed 497 patients with an average age of 14.1 years (8–18 years, range). Both operative and nonoperative management of displaced midshaft clavicle fractures in this population provide excellent rates of union and patient-reported outcome measures. Compared with nonoperative management, operative management yielded faster return to activity, superior Constant scores, and equal QuickDASH scores. Operative management had higher complication rates and complications that required secondary operative treatment (mostly related to implant prominence).

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

*Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI; and

Department of Orthopaedic Surgery, Hasbro Children's Hospital, Providence, RI.

Reprints: Aristides I. Cruz, MD, MBA, Department of Orthopaedics, Warren Alpert Medical School at Brown University, 1 Kettle Point Avenue, East Providence, RI 02914 (e-mail:

A. I. Cruz is a member of the POSNA (Pediatric Orthopaedic Society of North America) Advocacy Committee and QSVI Sports Committee. The remaining authors report no conflict of interest.

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Accepted June 20, 2019

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