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

The balance between operative and nonoperative management of displaced midshaft clavicular fractures remains contested. We compared union, shoulder function and complications between the two in patients aged 16 years and over. We conducted a systematic review and meta-analysis reported to PRISMA 2020 (PROSPERO CRD42025644313). PubMed, MEDLINE, Web of Science and Google Scholar were searched to August 2026. Randomised trials comparing operative fixation with nonoperative management in patients aged 16 years or older were eligible. Binary outcomes were pooled as risk ratios (RR) and continuous outcomes as mean differences (MD) in random-effects models. Risk of bias (RoB 2) and certainty (GRADE) were assessed. Fifteen trials (1,713 patients) were included. Union was more likely after operative fixation (RR 1.12, 95% confidence interval (CI) 1.08 to 1.16; I² 27.4%) and malunion less frequent (RR 0.18, 95% CI 0.10 to 0.30). Neither the Constant-Murley (MD 3.83, 95% CI −0.51 to 8.16) nor the DASH score (−1.26, 95% CI −3.45 to 0.94) differed significantly, both intervals excluding the ten-point minimal clinically important difference (MCID). Infection affected 1.9% and implant irritation or removal 12.3% of operatively treated patients, with no nonoperative counterpart. No trial was at low risk of bias; certainty was moderate for union and low or very low elsewhere. Operative fixation increases union relative to nonoperative management and reduces malunion, but no clinically important functional difference was detected and it carries implant-related morbidity. It should be offered on nonunion and malunion risk, not expected function. Not applicable.