Clavicular fractures are common injuries and represent 10-15% of fractures in adults and 20-25% of fractures in children. They are usually regarded as non-complicated injuries. Middle third fractures account for 75-80%, distal third fractures for 15-20%, and proximal third fractures for approximately 5% of all clavicle fractures. Incidence ranges from 30-60 fractures per 100.000 inhabitants and year.
The goals of treatment are to restore normal anatomy, limit pain, and promote a quick return to activity or play. Different non-operative and operative treatment approaches are described in the literature and in practical use. Conservative (non-operative) management is the most common approach and includes immobilization in a figure-of-eight bandage or simple sling. Historically, figure-of-eight bandages have been used more commonly than arm slings. Operative management includes reduction with plate fixation or different techniques of intramedullary fixation. The widely accepted indications for operative treatment include neurovascular comprise and open fractures. Other indications for surgery are controversial.
The objective of this HTA report is to summarize the current evidence of efficacy and safety for the various treatment options, taking into account fracture type and other variables. We searched for systematic reviews and controlled studies, published between 1998 and 2008. Two systematic reviews of 2005 and 2008, respectively, as well as five randomized controlled trials and three cohort studies could be identified.
There is moderate evidence that operative treatment results in a lower rate of fracture non-union and improved patient-oriented outcome compared with non-operative treatment. But because union rates are generally high and there are complications (e.g. infection, hardware-associated pain) that are unique to surgical intervention, risks have to be considered and weighed before a treatment decision is taken. The most important risk factors for non-union are major displacement and fracture comminution. The evidence of efficacy is more convincing for plate fixation as compared to intramedullary fixation, which may be due to the use of different techniques and devices in the studies evaluating intramedullary fixation.
The HTA report presents evidence-based algorithms that may be useful for therapy decisions in clinical routine, as well as high-quality studies that are being conducted and whose results may have an important effect on the reevaluation of the different treatment modalities in the near future.