Abstract
There is no consensus on the optimal treatment for mid-shaft clavicular fracture. We conducted a meta-analysis to compare the effectiveness of non-operative treatment, plate fixation, and intramedullary pin fixation in terms of the Constant-Murley Score (CMS) for treatment of mid-shaft clavicular fracture. Comprehensive search of the Embase, Cochrane Library and PubMed was conducted to retrieve relevant randomized controlled trials (RCTs). A random-effect network meta-analysis was conducted within a Bayesian framework using Markov Chain Monte Carlo (MCMC) in OpenBUGS 3.2.2. Differences in CMS among the three treatments analyzed were evaluated with weighted mean difference (WMD) and surface under the cumulative ranking curves (SUCRA). Eleven studies met our inclusion criteria and were included in our network meta-analysis. Our results revealed that in terms of CMS followed-up for six months, the efficacies of plate fixation and intramedullary pin fixation were higher than non-operative treatment (plate fixation: WMD = 4.70, 95% CI = 1.21 ∼ 7.83; intramedullary pin fixation: WMD = 6.71, 95% CI = 3.20 ∼ 10.39), and intramedullary pin fixation had better efficacy than plate fixation, had better efficacy. However, no differences were found between the efficacies of the three treatments in pairwise comparisons with respect to CMS followed-up for six weeks, three months, 12 months and 24 months. In addition, the cluster analysis showed that intramedullary pin fixation had the best efficacy for patients with mid-shaft CF, followed by plate fixation and non-operative treatment. These analyses suggest intramedullary pin fixation may be the optimal therapeutic approach for mid-shaft clavicular fracture patients.
Highlights
The clavicle, located directly above the first rib, is one of the most commonly fractured bones, accounting for about 3%~5% of all fractures [1]
The results indicated that the efficacy of non-operative treatment for mid-shaft Clavicular fracture (CF) was relatively poor compared with plate fixation in terms of ConstantMurley Score (CMS) followed-up for six weeks (WMD = −9.70, 95% CI = −17.65 ~ −1.75) while no difference was found for the efficacies in comparison between plate fixation and intramedullary pin fixation (WMD = −2.00, 95% CI = −10.67 ~ 6.68) (Supplementary Figure 1A)
As for the CMS followed-up for three months, our results showed no difference in the direct paired comparisons of non-operative treatment vs. plate fixation and plate fixation vs. intramedullary pin fixation (WMD = −1.89, 95% CI = −4.37 ~ 0.59; weighted mean difference (WMD) = −1.86, 95% CI = −4.40 ~ 0.67, respectively) (Supplementary Figure 1B)
Summary
The clavicle, located directly above the first rib, is one of the most commonly fractured bones, accounting for about 3%~5% of all fractures [1]. Clavicular fracture (CF) generally occurs in the mid-shaft (81%), while lateral (17%) together with medial fractures (2%) are less frequently [2]. Mid-shaft CF results from falls, sport injuries and motor vehicle accidents. The main reasons for mid-shaft CF are falling onto outstretched hands, a direct hit to the clavicle, and direct falls on the shoulder [5]. Serious complications can occur in mid-shaft CF patients after treatment, including nonunion or re-fracture along with malunion, which further results in chronic pain, weakness, decreased range of motion and cosmetic deformity [4]. Identifying the most efficacious and safest approach for mid-shaft CF treatment would help increase the likelihood of optimal restoration of shoulder stability and function for patients [7]
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