ICYMI: Clavicle Fracture Guideline — Strengths and Soft Spots

What’s the Claim?

The AAOS released its clinical practice guideline on the treatment of clavicle fractures last year, and it was summarized a couple months ago in JAAOS. Here are its four main recommendations, with the big one first:

• 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 guidance on 10 other topics (some of them interesting), but because the evidence in support of those was so limited, we’re not covering them.

How’s It Stack Up?

The process behind the guideline was well done, and the topics it covers are real-world relevant to practicing surgeons — so much so that we shared this with CORRelations Fractures & Trauma readers last month but did not want to take a chance that anyone caring for these patients would miss it, thus this ICYMI post.

There are no competing society-level guidelines that we know of (and the AAOS guideline was endorsed both by OTA and ASES). Best-practice statements and decision tools for nonspecialists are out there, but as far as we know, this AAOS guideline is one of a kind.

What’s Our Take?

We're sharing this guideline because it's important you know about it, both medically and medicolegally. If the lawyers know about it — and they do — you should, too. And for the most part, it’s really good stuff.

Our main concern about this guideline was that it overestimated the benefit of surgery and underestimated the potential harms. The portion about surgical versus nonoperative management, for example, did not mention how large the difference was in patient-reported outcomes favoring surgery, how often complications occurred, or how frequently patients underwent unplanned reoperations to remove plates. Those seem important.

A recent and very-well-done network meta-analysis of randomized trials on the topic provided some helpful context on those very points:

• The “improvements” in patient-reported outcomes scores associated with surgery were likely too small to be considered important by patients
• The vast majority of patients heal without surgery, so to avoid one nonunion, one has to expose 10 patients to major surgery (number needed to treat = 10)
• All of those patients treated surgically are at risk for complications of that surgery, and many will have a second operation to remove the hardware

On the topic of whether or not to operate, we found the message of that network meta-analysis (which is freely available in full-text form) more balanced than that of the AAOS’ new guideline, but both are practical and helpful.

Finally, CORRelations' advisor in Arthroscopy/Sports, Brian Gilmer, MD, pointed out that sports medicine specialists may tilt toward surgery for these injuries because they treat an especially active and demanding patient population, so much so that many even fix these fractures in adolescents. Here's a quote on exactly that point from the guideline:

In adolescent patients with displaced midshaft clavicle fractures, operative treatment may offer no benefit compared to non-operative treatment. Operative treatment is associated with similar union rates and substantial reoperation rates for implant removal.

Food for thought.

Source

American Academy of Orthopaedic Surgeons Treatment of Clavicle Fractures Evidence-Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons; 2022.