Temporal Trends in the Management of Midshaft Clavicle Fractures: A Systematic Review.

Midshaft clavicle fractures are among the most common shoulder girdle injuries and have traditionally been managed conservatively. Over the past two decades, evidence comparing operative and non-operative approaches has expanded, and this systematic review aimed to evaluate functional outcomes, union rates, complications, and temporal trends in management between 2005 and 2025. A comprehensive literature search was performed across PubMed, Embase, CINAHL, Web of Science, the Cochrane Library, and Ovid MEDLINE for studies published during this period. Randomised controlled trials (RCTs), cohort studies, comparative observational studies, and systematic reviews or meta-analyses directly comparing operative and non-operative management in adults were included. Two reviewers independently screened titles, abstracts, and full texts in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality was assessed using the Cochrane Risk of Bias 2 (RoB-2) tool for RCTs and the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool for non-randomised studies. Grey literature and non-peer-reviewed reports were excluded to ensure methodological rigour. A total of 28 studies met the inclusion criteria (15 RCTs and 13 cohort or observational studies), enrolling 3,094 patients. Additional systematic reviews and meta-analyses were examined to contextualise and support primary findings. The mean age ranged from 20 to 45 years, with a 70-80% male predominance. Road traffic accidents and sports injuries were the most frequent mechanisms, and follow-up duration ranged from 6 to 53 months. Operative management (n = 1,572) primarily involved plate fixation, whereas non-operative care (n = 1,522) utilised slings or figure-of-eight harnesses. Surgical fixation was consistently associated with shorter union times (16-18 vs. 24-30 weeks) and lower rates of non-union (0.8-2.4% vs. 11-23%) and malunion (0-4.5%, occurring only in conservative groups). Early and intermediate functional outcomes generally favoured surgery, but long-term results often converged with conservative treatment. Conservative management avoided implant-related complications but showed higher risks of non-union and malunion, whereas surgical complications were more frequent (16-40%), most commonly hardware irritation or infection. A temporal trend was observed - earlier studies (2007-2015) strongly supported surgical fixation, while more recent evidence (2020-2025) emphasises selective indications and shared decision-making. Overall, evidence from 2005 to 2025 demonstrates a clear temporal evolution in the management of midshaft clavicle fractures. Surgical fixation provides faster recovery, earlier union, and lower non-union and malunion rates, particularly in young, active patients with displaced fractures. However, long-term functional outcomes frequently align with conservative care, which remains appropriate for low-demand patients. Current findings highlight the importance of an individualised, patient-centred approach informed by fracture pattern, activity level, and patient preference.