Surgical treatment options of displaced midshaft fractures of the clavicle in young adults: plate fixation versus intramedullary nailing

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Clin Shoulder Elb. 2024;27(4):447-453

Publication date (electronic) : 2024 November 8

doi : https://doi.org/10.5397/cise.2024.00605

Ji Un Kim¹, Ji Young Yoon², Hyung Jun Park³, Jung Ho Park^,3

¹Department of Orthopaedic Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea

²Department of Orthopaedic Surgery, National Police Hospital, Seoul, Korea

³Department of Orthopaedic Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea

Corresponding Author: Jung Ho Park Department of Orthopaedic Surgery, Korea University Ansan Hospital, Korea University College of Medicine,123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea Tel: +82-31-412-5049, Fax: 82-31-487-9502, E-mail: maria1004@naver.com

Received 2024 August 5; Revised 2024 September 19; Accepted 2024 September 24.

Abstract

INTRODUCTION

Clavicle fractures stand as one of the most prevalent injuries in orthopedic trauma, comprising 2.6% of all fractures and 5% of adult fractures [1,2], predominantly afflicting children and adolescents. However, there has been a notable increase in incidence among individuals older than 40 years due to increased participation in sports activities among young adults [3]. These fractures frequently result from sports-related incidents or motor vehicle collisions. Approximately 80% of clavicle fractures occur in the midshaft, with more than 70% of these cases exhibiting displacement [4].

Recent evidence indicating higher non-union rates and functional deficits has led to a shift from traditional surgery toward internal fixation as a viable treatment for midshaft clavicle fracture (MCFs) [3]. While most clavicle fractures occur in the middle third of the bone and are generally addressed conservatively, fractures in the midshaft display a posterosuperior angular displacement of the medial fragment, penetrating the trapezius muscle and encountering soft tissue interposition that prevents fragments from aligning naturally [5,6]. Especially among young, athletic populations, the patterns of clavicle fractures have become increasingly complex due to high-energy injuries like traffic accidents, falls, and sports-related incidents. These incidents heighten the probability of complications such as nonunion, mal-union, and re-fracture, contributing to suboptimal cosmetic and functional results and leading to an increasing trend in surgical interventions. As a result, recent studies have shown a paradigm shift toward operative treatment, with surgical methods such as plate fixation and intramedullary nailing (IMN) proving more effective due to higher non-union rates in non-operative treatments and better functional outcomes [4,7-10]. Despite the variety of fixation devices available, the optimal method remains debated, although the choice is primarily between plate fixation and IMN. Plate fixation offers immediate stability [6], but may result in scarring, irritation, infections, and implant failure [11].

Conversely, intramedullary nail fixation, while less invasive, raises concerns about radiation exposure, neurovascular damage, and potential migration. Meta-analyses comparing these methods yield conflicting conclusions, leaving clinicians uncertain in their choice of treatment. While techniques like IMN show promise in achieving stability with minimal invasiveness and rapid healing, plate fixation excels in stress shielding and ensuring stability for early recovery, particularly in managing displaced fractures [12]. This study hypothesizes that IMN will result in faster union times and fewer complications by relatively preserving the periosteum and reducing cosmetic problems in active young adults with MCFs.

This study aimed to compare internal fixation via open reduction and plate fixation (ORPF) against elastic stable IMN for displaced MCFs. The assessment will focus on union time, complications, and functional outcomes specifically within active young adult populations.

METHODS

This study was approved by the Institutional Review Board of the Ethics Committee of Korea University Medicine Center (No. 2023AS0358). Requirement for informed consent was waived by the Institutional Review Board because of the study retrospective design.

This retrospective cohort study involved analyses of medical records, postoperative clinical assessments, and comparative radiographs of patients who underwent surgical treatment for clavicle shaft fractures between April 2018 and April 2022. A total of 79 patients underwent surgery, with 39 analyzed in the present study. Patients treated surgically for displaced MCFs using plates and screws or elastic flexible titanium nails were assessed. The study was conducted at a single center by a consistent team of two shoulder specialists (JHP, JUK). Participants were selected based on specific inclusion and exclusion criteria. The study was conducted on patients younger than 60 years who had experienced displaced MCF treated with plate and screws or an intramedullary nail and were at least 12 months post-surgery. All patients had undergone implant removal after union. Displacement was characterized by an angle greater than 30º and shortening greater than 1.5 cm, while inclusion encompassed diaphyseal fractures falling within the Robinson classification type 2A2 or 2B1 [10,13,14]. Exclusion criteria included lateral third fractures (n=9), refracture (n=7), acromioclavicular injury (n=4), intra-articular fracture (n=1), open fracture (n=1), fractures associated with neurovascular injuries or additional shoulder lesions (n=6), infections (n=0), unreachable or unwilling patients (n=1), and severe comminuted fractures (AO Foundation/Orthopaedic Trauma Association fracture classification [AO/OTA classification] types C) (n=11).

Both groups received general anesthesia. In the ORPF group, a Synthes precast blocked LCP plate (DePuy Synthes) was used. The procedure involved an upper, horizontal incision; muscle fascia opening; and superior plate fixation with at least three screws in each main fragment under the principle of stability. In the IMN group, a medial entry point into the clavicle was made through a 1 cm anterior horizontal incision. A flexible 2.5 mm or 3.0 mm Titanium Elastic Nail (TEN) System (DePuy Synthes), sized according to the medullary canal, was used for fixation. The groups followed a similar rehabilitation protocol. Immobilization was maintained for at least 4 weeks post-surgery in both groups, with no difference in the duration of immobilization between the ORPF and IMN groups.

Radiography in anteroposterior view was conducted on the day of evaluation, including both clavicles. Length and angulation of the clavicle were evaluated by two shoulder specialists (JHP, JUK). Clinical outcomes include time to fracture union and healing confirmed by radiological investigations and risk ratios of complication rates including mal-union, non-union, chronic neuropathy, and skin problems such as skin numbness, irritation, and protrusion by the end of the study follow-up. The functional outcome is the ranges of motion of the shoulder joint.

To identify significant differences in functional outcomes between the two interventions, appropriate parametric (Student t-test and Welch's t-test) and non-parametric tests (Fisher's exact test) were conducted using the SPSS software package version 21.0 (IBM Corp.). P-values <0.05 were considered significant.

RESULTS

In this retrospective cohort study, we compared the radiologic and clinical outcomes of 39 patients with MCFs treated with either ORPF group (n=29) or IMN group (n=10). There were no significant demographic differences between the two groups (Table 1). The mean age of the patients was 33.1 years, and the age difference between the groups was not significant (P=0.11). The majority of the patients in both groups was male.

Table 1.

Demographics and clinical characteristics of patients treated with plate vs. nail for mid-shaft clavicle fractures

In terms of fracture pattern, AO-OTA Type A fractures were present in 19 patients (65.5%) in the ORPF group and in 4 patients (40%) in the IMN group. AO-OTA Type B fractures were present in 10 patients (34.5%) in the ORPF group and in 6 patients (60%) in the IMN group. The difference in fracture pattern between the groups was not significant (P=0.77). Also, the difference in injury mechanism between the groups was not significant (P=0.57).

The time elapsed from the onset of injury to treatment was significantly different between the two groups (P<0.01) (Table 1). There was a significant difference in the mean follow-up periods between the ORPF group (16.5 months) and the IMN group (12.2 months) (P<0.01) (Table 2). However, The difference in range of motion between the groups was not significant (all P>0.05) (Table 3). Surgical duration was significantly shorter in the IMN group compared to the ORPF group. The mean surgery time for the IMN group was 55.3 minutes, while that for the ORPF group was 64.2 minutes, a statistically significant difference (P=0.04).

Table 2.

Comparative outcomes and complications of patients treated with plate vs. nail for mid-shaft clavicle fractures

Table 3.

Ranges of shoulder motions in patients treated with plate vs. nail for mid-shaft clavicle fractures

Major complications, which include nonunion, malunion, shortening, angulation, and infection, were observed in 3 patients from the ORPF group, with all 3 cases experiencing nonunion. No such complications were reported in the IMN group. The majority of patients in both groups achieved union, with 90.0% in the ORPF group and 100.0% in the IMN group. This difference was not statistically significant (P=0.08). The time to union was significantly different between the two groups (P<0.01), with the ORPF group averaging 23.1 weeks and the IMN group averaging 20.8 weeks. Nonunion was observed in 3 patients (10.3%) from the ORPF group (Fig. 1) but none from the IMN group (P=0.08) (Fig. 2).

Fig. 1.

A 22-year-old woman with a right-sided displaced mid-shaft clavicle fracture underwent plate fixation. (A) The preoperative radiograph shows a midclavicular fracture (Robinson 2B1). (B) A radiograph at 1 year postoperative shows successful union of the fracture with the implanted plate and screw. (C) After implant removal, the radiograph shows achieved union. (D) A radiograph obtained 4 weeks after hardware removal shows a new onset fracture at a different site due to hardware removal.

Fig. 2.

A 24-year-old man with a left-sided displaced mid-shaft clavicle fracture underwent intramedullary nailing. (A) The preoperative radiograph shows a midclavicular fracture (Robinson 2B1). (B) A radiograph at 1 year postoperative shows successful union of the fracture with the nail. (C) After implant removal, the radiograph shows persistent union.

No cases of wound dehiscence were observed in either group. However, skin irritation was significantly more common in the ORPF group (55.2%) compared to the IMN group (P<0.01). Skin numbness was reported in 10 patients (34.5%) from the ORPF group and 1 patient (10%) from the IMN group (P=0.08). Revision surgery due to implant failures was required in 3 patients (10.3%) from the ORPF group but none from the IMN group (P=0.08).

DISCUSSION

This study aimed to compare the optimal fixation strategy for unstable MCFs in young adults. Both methods were effective in returning patients to their pre-injury functional levels. However, IMN, with its lower rates of skin problems and implant failure, appears to be the preferred method for MCFs in young adults. Our results indicate that nails were more frequently used in younger patients and those with a shorter time onset, although there was no significant difference. This trend aligns with existing research, which suggests that plates are more effective for anatomical alignment and stability [15,16]. Consequently, plates were often chosen for relatively older patients or those with a longer duration from trauma to surgery (P<0.01), in whom the stability of bone union might be compromised.

In a national population-based survey, age 45–64 years was an independent risk group for clavicle fractures [17]. Within this bracket, the incidence stood at 37.5/100,000 person-years, significantly higher than in all other age cohorts except teenagers [18]. This trend was linked to the prevalent active lifestyles within this demographic. Echoing previous research that identified a bimodal age peak in MCFs among both adolescents and active young adults, our study sought to compare and analyze the two predominant surgical treatments—plate fixation (ORPF group) and intramedullary nailing (IMN group)—within these age groups. The mean time to union was 23.1±1.7 weeks for the ORPF group and 20.8±1.2 weeks for the IMN group, with a significant difference (P<0.01). This indicates that the IMN group experienced a shorter healing period compared to the ORPF group.

In our study, the ORPF group demonstrated an overall complication rate of 10%, consistent with findings from similar studies [15,16,19]. Previous studies on the clinical outcomes of plate fixation have reported complications such as nonunion, malunion (pseudoarthrosis, shortening, angulation), infections, paresthesia at incision sites, injuries to neurovascular structures, skin irritations and discomfort due to the presence of implants, and refracture following implant removal [15,19]. Incisional numbness has been reported at a prevalence of 41.7% of ORPF cases [20]. Our study showed similar results, with 10 patients (34.5%) in the ORPF group and 1 patient (10%) in the IMN group experiencing incisional numbness.

According to a previous systematic review, infection rates in plate treatment were less than 10% in nine analyzed articles, lower than in prior articles [21]. Within our study, we observed that skin irritation was present in 55.2% (n=16) of the cases in the ORPF group. However, we did not encounter infections such as skin erosion leading to deep infection post-plate exposure. On the other hand, the IMN group exhibited a lower overall complication rate of 0.0% compared to the ORPF group. The principal drawbacks of nail utilization include radiographic malunion and superficial wound infection [22]. Biomechanically, IMN can result in poor anti-rotation and anti-shortening forces, which may lead to reduced rotational stability and potential for malunion [23]. Complications such as medial perforations, lateral penetrations, elastic nail breakage, and dislocation have also been reported [24].

Traditionally, IM nailing after closed reduction is recommended for simple fractures, whereas plate fixation is preferred for comminuted cases, enabling faster recovery and better clinical outcomes with reduced implant removal [13]. Previous studies have shown that patients treated with nails reported higher satisfaction due to smaller scars compared to those who underwent plate treatment [25]. According to meta-analysis, intramedullary nailing and plating provide equivalent long-term functional outcomes. However, plating may lead to higher risk of treatment failure and non-operative complications [26]. Similarly, in our study, at a mean follow-up of 1 year, the healing rate was 100% in the IMN group and 90.0% in the ORPF group, but this difference was not significant (P=0.08). Our results indicated a higher need for revision surgery in the ORPF group compared to the IMN group.

Our study, being retrospective in nature, had varying follow-up times for the groups, which complicated comparative evaluations. The study relied on medical records for data collection, which may be subject to information bias. The number of patients was relatively small, limiting the generalizability of the results. Moreover, this study was conducted at a single center, so the results may differ in other regions or population groups. Last, we did not provide clinical outcome scores, but we aimed to compensate for this by offering detailed radiologic outcomes, complication rates, and range of motion. To gain conclusive insights into the optimal surgical treatments for these prevalent and impactful orthopedic fractures, it is crucial to conduct age-matched prospective studies with long-term follow-up.

CONCLUSIONS

Both ORPF and IMN restore pre-injury functional levels in patients with MCFs. IMN presents advantages in certain aspects like higher healing rate and fewer revision surgeries compared to the ORPF group. Additionally, IMN was associated with lower rates of incisional numbness. Therefore, IMN is recommended as the preferred treatment method for MCF in young adults due to its superior outcomes.

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