Are displaced distal clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review

Abstract

Background: Management of displaced distal clavicle fractures remains a topic of discussion because of notoriously high nonunion rates, but there is little documented in the literature as to what effect this may have on patient-reported function. The aim of this systematic review was to look at nonoperative management following displaced distal clavicle fractures to determine union rates, complications, and patient-reported outcome measures. Methods: A review of the online databases MEDLINE and Embase was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies that included a cohort of nonoperatively managed displaced distal clavicle fractures and reported on union rate, complications, and patient-reported functional scores were included. Results: Eleven studies were eligible for inclusion (2 randomized controlled trials, 1 prospective noncomparative cohort study, 5 retrospective comparative cohort studies, and 3 case series) with a total of 779 patients included in this review. Average union rate was 63.2% (22.2%-94.4%) in nonoperatively managed patients, compared with 96.3% (87.9%-100%) in operatively managed patients. The Constant-Murley score and Disabilities of the Arm, Shoulder, and Hand questionnaire were the most frequently used outcome measure tools. No study demonstrated any significant difference in any outcome measure when comparing nonoperative with operative treatment. Complication rate (including nonunion) in nonoperatively managed patients was 45.1%, with 11.1% requiring delayed surgery. Average complication rate in the operatively managed groups was 41.2%, with 40.1% requiring a second operation. Conclusion: Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. Decision making must take into account patient factors and expectations to provide high-quality, individualized care.