Clavicle surgery raises union rates but adds implant complications, meta-analysis finds

Operative fixation of displaced midshaft clavicle fractures increases the likelihood of the bone healing and reduces malunion compared with nonoperative management, but it does not deliver a clinically meaningful improvement in shoulder function and carries its own burden of hardware-related complications. That is the conclusion of a systematic review and meta-analysis published in BMC Musculoskeletal Disorders, which pooled data from fifteen randomised trials involving 1,713 patients aged 16 years or older.

The review, reported according to PRISMA 2020 guidelines and registered with PROSPERO under CRD42025644313, addressed a question that has divided orthopaedic surgeons for years: when a collarbone breaks in its middle section and the fragments are displaced, does plating the bone beat simply letting it heal in a sling? The researchers searched PubMed, MEDLINE, Web of Science and Google Scholar for randomised trials comparing operative fixation with nonoperative care, with literature coverage extending to August 2026.

Binary outcomes were pooled as risk ratios and continuous outcomes as mean differences in random-effects models, and the team assessed risk of bias with the RoB 2 tool and certainty of evidence with GRADE. Union was more likely after surgery, with a risk ratio of 1.12 (95% confidence interval 1.08 to 1.16) and low heterogeneity between trials, indicated by an I² of 27.4%. Malunion was markedly less frequent in the operative group, with a risk ratio of 0.18 (95% confidence interval 0.10 to 0.30).

Function told a different story. Neither the Constant-Murley score, a widely used measure of shoulder function, nor the DASH score, which captures disability of the arm, shoulder and hand, differed significantly between the two treatments. The mean difference for the Constant-Murley score was 3.83 points (95% confidence interval −0.51 to 8.16), and for the DASH score it was −1.26 points (95% confidence interval −3.45 to 0.94).

Complications split sharply along treatment lines. Infection affected 1.9% of operatively treated patients, and implant irritation or the need for implant removal affected 12.3%, with no nonoperative counterpart for either event.

The certainty of the evidence behind these estimates was uneven. No trial included in the meta-analysis was judged to be at low risk of bias, and GRADE ratings were moderate for union but low or very low for the remaining outcomes. That grading matters for interpretation: the union advantage is the most robust finding, while estimates for function and complications rest on weaker foundations and should be read with corresponding caution.

The authors draw a practical conclusion from the pattern of results. Operative fixation should be offered on the basis of nonunion and malunion risk, not on the expectation of better function. For patients at high risk of the bone failing to unite or uniting in a shortened, angulated position, surgery demonstrably shifts those risks downward.

For clinicians counselling patients, the numbers offer a concrete framework. Function scores, the outcomes patients often care about most, were statistically indistinguishable between groups.

The study is a systematic review and meta-analysis of randomised trials, so its conclusions are bounded by the quality of the underlying trials, none of which was at low risk of bias, and by the moderate to very low certainty ratings across most outcomes. Within those limits, the analysis provides the clearest available summary of the trade-off: operative fixation of displaced midshaft clavicle fractures buys union and avoids malunion, at the cost of hardware complications, without a clinically important functional payoff.

Subject of Research: Operative versus nonoperative management of displaced midshaft clavicle fractures

Article Title: Comparing the outcomes of operative versus nonoperative management for midshaft clavicle fractures: a systematic review and meta-analysis

Article References: Bawazir, M. S., Balamesh, A. A., Alshammari, M. M., Alhadrami, A. T., Almuwaysi, A. A., Almutairi, R. N., Zarei, E. W. E., Alenezi, S. S., Mobarki, H. J., Alomrani, A. A., Alnahdi, M. A., & Altuwairqi, A. A. (2026). Comparing the outcomes of operative versus nonoperative management for midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. https://doi.org/10.1186/s12891-026-10601-w

Image Credits: AI Generated

DOI: 10.1186/s12891-026-10601-w

Keywords: clavicle fracture, midshaft clavicle fracture, operative fixation, nonoperative management, systematic review, meta-analysis, malunion, nonunion risk, shoulder function, implant complications, orthopaedic surgery, randomised trials