Comparing the outcomes of operative versus nonoperative management for midshaft clavicle fractures: a systematic review and meta-analysis
BMC Musculoskeletal Disorders · 30 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
Displaced midshaft clavicle fractures are a common trauma and exam topic, and this review suggests surgery is chosen to prevent nonunion and malunion rather than to improve final shoulder function.
The evidence
This systematic review pooled 15 randomised trials (1,713 patients aged 16 and older) comparing surgical fixation (plate or intramedullary nail) with sling or brace treatment for displaced midshaft clavicle fractures. Surgery made union about 12% more likely (risk ratio 1.12, 95% CI 1.08 to 1.16) and cut malunion sharply (RR 0.18). Shoulder function scores (Constant-Murley and DASH) did not differ meaningfully, and about 1 in 8 operated patients had implant irritation or removal.
Fracture union: Risk ratio 1.12 (95% CI 1.08 to 1.16; ratio). The interval favours the first group; the size of the benefit needs clinical interpretation.
Why this rigour score?
Meta-analysis of RCTsDesign starting point: 60.8
Raised the score
- Prospectively registered+5.1
- Pools randomised trials+5.1
Lowered the score
No negative adjustments recorded.
Methods at a glance
Recorded assessment- Comprehensive literature searchMet
- Risk of bias assessedMet
- Bias considered in synthesisMet
- Publication bias assessedMet
- Study exclusions justifiedMet
- Prospective registrationMet
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 60.8
- Compared against current standard of care
- +3.4
- Prospectively registered
- +5.1
- Pools randomised trials
- +5.1
- Comprehensive literature search
- +3.4
- Risk of bias assessed in the included studies
- +3.4
- Risk of bias carried into the synthesis
- +2.5
- Excluded studies listed and justified
- +1.7
- Publication bias assessed
- +2.5
- Final rigour score rounded
- 88 / 100
Study design sets the starting point and a ceiling of 96. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.Which patient and fracture features (for example shortening, comminution, smoking, high functional demand) would push you to recommend fixation, given that surgery mainly reduces nonunion and malunion rather than improving function?
2.How would you counsel a young adult with a displaced midshaft clavicle fracture about the trade-off between a lower nonunion risk and a roughly one-in-eight chance of implant irritation or removal?
Original publication title
Comparing the outcomes of operative versus nonoperative management for midshaft clavicle fractures: a systematic review and meta-analysis