Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

Fractures are an important public health burden. The age-standardized annual fracture incidence in England has been reported to be as high as 3.6% [1] with great variation dependent on how and from which population it is estimated [1‐3]. Years lived with disability due to fractures are estimated to be around 22 million, most of which are long-term disability [4], and the total UK annual hospital costs associated with incident hip fractures in older adults alone are around £1.1 billion [5].

Surgery is the preferred treatment of most displaced fractures, but evidence from recent years suggests that non-surgical treatment might serve as an effective alternative for selected fractures, potentially associated with fewer adverse events and lower costs [6‐9].

Fractures of the clavicula, humerus, radius, ulna, metacarpals, femur, and ankle are some of the most common fractures [2, 3]. However, a comprehensive overview of the benefits (e.g., improvements in pain, function, and quality of life) and harms (e.g., serious adverse events) of surgical and non-surgical treatment of these and other fractures is missing. A better understanding of the benefits and harms of these treatments for each of the most common fractures separately would serve as an important basis for shared decision-making about treatment of fractures in clinical practice.

We therefore aimed in this systematic review and meta-analysis to determine the benefits and harms of surgical compared with non-surgical treatments for acute, traumatic, skeletal fractures in adults. We extend existing knowledge [6‐9] by including more recent trials and by including and analyzing outcomes on patient-reported pain, physical function, quality of life, and SAE on each type of fracture separately.

This report conforms to the PRISMA statement [10]. The study followed the published guidelines on systematic reviews from the Cochrane Collaboration [11] and it was pre-registered with PROSPERO (CRD42015020805). In the PROSPERO-registration, two systematic reviews are described, the other being a systematic review of surgical vs. non-surgical treatment of non-fracture musculoskeletal conditions, which will be reported in a subsequent publication.

The large inconsistency and often missing reporting of SAEs and death in the included trials represent a limitation of our study. The lack of consensus in terms and definitions of complications after treatment of fractures calls for the development and validation of a core set of complications [81]. Another potential limitation of this study relates to our selection of outcomes, as 39 trials were excluded due to insufficient data. Some of the trials had selected composite scores of, e.g., pain and function or other outcomes like time to healing of the fracture, while others did not report data that could be included in meta-analyses, e.g., by reporting pain evaluated on a 5-point Likert scale. For feasibility reasons, we excluded trials that were not in languages understood by any of the authors, which could be a potential bias. However, as only two trials were excluded based on this criterion, the expected impact on the results is considered minimal. Finally, from a clinical point of view, it is common to decide on whether to recommend surgery or not based not only on the fracture type, but also on patient characteristics such as age, work status, and symptom severity. In pragmatic trials, patients are more commonly included without accounting for patient characteristics, which thereby can potentially affect the generalizability of the results from the individual meta-analyses of this study [63].

Although our results could indicate that non-surgical treatment is as effective as surgical treatment for several traumatic fractures in adults, including displaced midshaft clavicular, proximal humeral, scaphoid waist, and thoracolumbar traumatic compression fractures, serious caveats relating to the number of patients studied, heterogeneity and study methodology question the confidence in such a suggestion. First, only 7/19 fracture types had been scrutinized in at least 2 trials with at least 100 patients totally. Second, few and underpowered studies for some fracture types might be part of the explanation for our findings [82], as a previous study found a mean overall study power (1-beta) among 117 trials of traumatic skeletal fractures of 25% [83]. Third, none of the included trials were associated with a low risk of bias for benefits, and only 2/44 (5%) trials were associated with a low risk of bias for SAEs, confirming a previous study summarizing orthopedic trials [82]. In fact, 17/52 (33%) of the trials with data on benefits were associated with a high risk of bias. Finally, the studied fracture types only represent selected types of fractures in selected types of patients. For some fractures (e.g., clavicular and stable lateral malleolar fractures), the natural history of healing without surgical treatment has a good prognosis [84‐86]. However, in older persons with lower expectations of function with, e.g., a distal radius or malleolar fracture and more osteoporotic bone, the expected beneficial effect from surgical treatment is typically less than in younger more physically active patients. Thus, some of the studies included represent fracture types suspected to have limited benefits in terms of pain, function, and quality of life from surgical treatment. Other fracture types more obviously in need of surgery (displaced lower arm or hip fractures) is less likely to be subjected to randomization to non-surgical treatment; often termed parachute trials [87]. Despite the mentioned limitations of the SAE reporting, some interesting findings are worth mentioning as our study presents the first overview of SAEs across RCTs of different fractures. While the risk of SAEs was lower from surgical treatment in displaced midshaft clavicular fracture, it was higher in distal radius fractures, and no difference was present for the other six comparisons with the estimated relative risk of SAEs distributed relatively even on both sides of the “no difference in risk” line, dependent on the fracture type. Importantly, most of the findings were based on 2-3 studies, including few patients, precluding any firm conclusions. However, our results do suggest that for some of the more often studied fracture types, like displaced midshaft clavicular fractures, distal radius fractures in older patients, proximal humerus fractures, and traumatic thoraco-lumbar compression fractures, non-surgical treatment might serve as an equally effective and safe treatment as surgical treatment.

Only 20% of the most commonly performed orthopedic procedures, including surgery for fractures, are supported by at least one low risk of bias trial [88]. A search of trials of surgical and non-surgical treatment of fractures in the WHO International Clinical Trials Registry Platform [89] indicates that several ongoing trials will provide data to help build the evidence base for optimal treatment of fractures. Our study is a call to action for more low-risk-of-bias trials powered to detect any difference in benefits and harms between surgical and non-surgical treatment of the most common traumatic skeletal fractures in adults. Although such studies are known to be challenging [90], they are crucial to improve the clinical care of the patients.

Of 12 fracture types with data from more than one trial, only two demonstrated a difference in function in favor of surgery (moderate effect for displaced intraarticular calcaneal fractures, although affected by a large heterogeneity, and small effect for distal radial fractures), but with greater risk of harms after surgery for radial fractures. We found no difference in effect for displaced midshaft clavicular fractures, proximal humeral fractures, scaphoid waist, and thoracolumbar traumatic compression fractures, while surgery for clavicular fractures was associated with a reduced risk of SAE. Our results also highlight the current paucity of high-quality randomized trials for other common fracture types and a considerable heterogeneity for some of the estimates and risk of bias in a large proportion of available trials.