Clavicle fractures constitute approximately 2.6%–5% of all adult fractures and about 44% of shoulder girdle injuries, with midshaft fractures being the most frequent subtype, accounting for nearly 80% of all clavicle fractures (1,2). Traditionally, non-operative management has been the mainstay for midshaft clavicle fractures, particularly for undisplaced types. However, recent evidence indicates that displaced fractures treated conservatively may result in higher rates of nonunion, malunion, and unsatisfactory shoulder function, especially in active individuals (3,4).

Surgical intervention is increasingly preferred in displaced midshaft clavicle fractures to ensure anatomical alignment, early mobilization, and improved functional outcomes (5). Among the surgical options, plate fixation through open reduction and internal fixation (ORIF) and intramedullary nailing are widely accepted techniques. Plate fixation allows for rigid stabilization and accurate anatomic reduction but may involve extensive soft tissue dissection and hardware prominence (6,7). Conversely, intramedullary nailing is less invasive and offers better cosmetic outcomes with reduced surgical trauma, but concerns remain regarding implant migration and technical difficulty in maintaining reduction (8,9).

Several comparative studies have attempted to evaluate the relative efficacy of these two approaches in terms of union rate, shoulder function, and complication profile, yet the findings remain inconclusive (10,11). Functional recovery, often measured using the Constant-Murley and DASH scores, plays a critical role in determining the quality of life and return to activity for patients post-intervention (12).

This study aims to provide a prospective comparative evaluation of functional outcomes, union times, and complications associated with plate fixation and intramedullary nailing in the treatment of displaced midshaft clavicle fractures, thereby contributing to the growing body of literature guiding optimal surgical decision-making.

This prospective cohort study was conducted over a period of 18 months in the Department of Orthopaedics, Sree Gokulam Medical College. A total of 60 adult patients, aged between 18 and 60 years, presenting with acute, displaced midshaft clavicle fractures (Robinson type 2B) were enrolled based on defined inclusion and exclusion criteria. Written informed consent was obtained from all participants.

Inclusion criteria included:

• Age between 18 and 60 years
• Displaced midshaft clavicle fracture confirmed by radiographs
• Injury less than 2 weeks old
• Willingness for surgery and follow-up

Exclusion criteria were:

• Pathological fractures
• Open fractures
• Fractures associated with neurovascular injury
• Previous clavicle surgery
• Patients medically unfit for surgery

Participants were randomly allocated into two groups of 30 each using a computer-generated sequence.

• Group A underwent open reduction and internal fixation (ORIF) with pre-contoured locking compression plates.
• Group B received intramedullary fixation using titanium elastic nails (TENs) via a minimally invasive technique.

All surgeries were performed under general anesthesia by experienced orthopedic surgeons. Postoperative protocols included standardized analgesia, immobilization with an arm sling for two weeks, followed by a supervised physiotherapy regimen. Radiological assessments were done at 6 weeks, 3 months, and 6 months to evaluate fracture union.

Outcome measures included:

• Functional assessment using the Constant-Murley Shoulder Score and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 6 weeks, 3 months, and 6 months.
• Radiological union defined as the presence of bridging callus in at least three cortices on standard radiographs.
• Complications such as infection, hardware irritation, nonunion, or implant migration were also recorded.

Statistical analysis was performed using SPSS version 25.0. Quantitative data were expressed as mean ± standard deviation and analyzed using the independent t-test. Categorical data were compared using the Chi-square test. A p-value of less than 0.05 was considered statistically significant.

A total of 60 patients (45 males and 15 females) with displaced midshaft clavicle fractures were enrolled and equally distributed into two groups (n=30 each). The mean age of patients in Group A (plate fixation) was 34.7 ± 9.3 years, while in Group B (intramedullary nailing), it was 35.1 ± 10.1 years, with no statistically significant difference (p = 0.81).

Functional Outcome

The Constant-Murley Shoulder Score was assessed at 6 weeks, 3 months, and 6 months. At 6 weeks, the mean score was 64.8 ± 6.5 in Group A and 62.3 ± 7.2 in Group B (p = 0.14). At 3 months, the scores were 78.2 ± 5.4 and 75.9 ± 6.0 in Groups A and B respectively (p = 0.09). At 6 months, Group A recorded a significantly higher mean score (91.4 ± 5.2) compared to Group B (88.1 ± 6.7) (p = 0.045) (Table 1).

The DASH scores followed a similar trend. At 6 months, the mean DASH score in Group A was 8.3 ± 2.4, while in Group B it was 10.6 ± 3.1, reflecting better subjective outcomes in the plating group (p = 0.038) (Table 1).

Table 1: Comparison of Functional Outcomes Between Groups A and B

*Statistically significant; p < 0.05

Union Time and Complications

Radiographic union was achieved in all patients within 16 weeks. The average union time was 11.2 ± 1.8 weeks in Group A and 10.7 ± 2.1 weeks in Group B, with no statistically significant difference (p = 0.22) (Table 2).

Complication rates were comparable between the two groups. In Group A, 4 patients (13.3%) experienced complications, including minor wound infections (n=2) and hardware irritation (n=2). In Group B, complications were noted in 3 patients (10%)—2 cases of nail migration and 1 of skin irritation (Table 2).

Table 2: Comparison of Union Time and Complications

These findings suggest that although both methods were effective in achieving union, plate fixation resulted in marginally better functional outcomes at mid-term follow-up with a similar rate of complications and healing time (Tables 1 and 2).

Midshaft clavicle fractures are prevalent injuries, particularly in young adults involved in high-energy trauma. While non-operative treatment has been the traditional choice for displaced fractures, recent literature supports surgical intervention in specific cases to achieve optimal alignment, reduce malunion, and facilitate early functional recovery (1,2). This prospective cohort study compared the outcomes of open reduction and internal fixation (ORIF) using plates versus intramedullary (IM) nailing in the treatment of displaced midshaft clavicle fractures.

Our findings revealed that both techniques led to satisfactory outcomes in terms of fracture union and complication rates. However, patients treated with plating demonstrated marginally superior shoulder function and lower disability scores at the 6-month follow-up. These findings are consistent with reports from prior studies that noted improved shoulder strength and range of motion following ORIF compared to IM nailing (3,4).

The Constant-Murley and DASH scores are validated tools for assessing shoulder function and upper limb disability, respectively (5,6). In our study, Group A (plating) consistently scored higher on the Constant scale and lower on the DASH scale compared to Group B (nailing), particularly at the final follow-up. These differences, though statistically significant, may not be clinically substantial in all cases but still indicate better subjective and objective function with plate fixation. Similar trends have been observed in multicenter randomized trials and meta-analyses (7,8).

Union times did not differ significantly between groups in our cohort, which aligns with findings from studies demonstrating comparable healing durations between ORIF and IM fixation (9,10). Some studies have suggested a slightly quicker union with IM devices due to limited soft tissue dissection and preservation of periosteal blood supply (11), though our data did not reflect such a difference.

Complication rates in our study were similar in both groups and were primarily minor, including superficial infections and hardware irritation in the plating group and nail migration or skin irritation in the nailing group. The overall rate was lower than some previously published data, possibly due to standardized surgical techniques and diligent postoperative care (12,13).

Cosmetic satisfaction, although not formally evaluated in our study, has been reported to be higher with IM nailing due to smaller incisions and less hardware prominence (14). However, the increased risk of implant migration and difficulty in achieving stable fixation in comminuted fractures often limit its use to simple fracture patterns (15).

Limitations of this study include the relatively small sample size and short follow-up duration, which may not fully capture long-term complications or functional decline. Future studies with larger cohorts and extended follow-up are warranted to validate these findings and establish definitive treatment algorithms.

In conclusion, while both plate fixation and intramedullary nailing are effective surgical options for midshaft clavicle fractures, plating provides marginally better functional recovery in the mid-term with comparable union and complication profiles. Individual patient factors, fracture characteristics, and surgeon experience should guide the choice of surgical approach.

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