AAOS’s Practice Guideline on Clavicle Fractures Is A Bit Too Enthused About Surgery

Missing were any estimates of effect size or the frequency and severity of complications

What’s the Claim?

The AAOS released its clinical practice guideline on the treatment of clavicle fractures last year, and it was recently summarized in JAAOS. Here are its four main recommendations, leading with the biggie:

  • Surgical treatment of displaced midshaft clavicle fractures in adults results in higher union rates and better early patient-reported outcomes than nonoperative treatment, but both approaches are potentially useful as they don't differ in terms of long-term patient-reported outcomes. Evidence quality: High
  • Low-intensity pulsed ultrasound should not be used for nonoperative management of acute midshaft clavicle fractures (because it doesn’t decrease the risk of nonunion or accelerate union). Evidence quality: Moderate
  • Lateral locking plates may have fewer complications and better functional outcomes than hook plates for lateral clavicle fractures in adults. Evidence quality: Moderate
  • No difference between IM nails and single plate fixation in terms of long-term clinical outcomes or complications, but plates may be advantageous if comminution is present. Evidence quality: Moderate

The guideline also provided 10 other bits of guidance on a range of topics (some of them interesting), but because the evidence in support of those was so limited, we’re not listing them here.

How’s It Stack Up?

It’s a well-done guideline in terms of the process used, and the topics are real-world relevant to practicing surgeons. There are no competing society-level guidelines that we know of (and the AAOS guideline was endorsed both by OTA and ASES). Best-practices statements and decision tools for nonspecialists are out there, but as far as we know, this guideline is one of a kind.

What’s Our Take?