Optimal operative choice for displaced midshaft clavicle fractures in adolescents: a comparative study of intramedullary flexible nails and plating

Abstract Background: Traditionally, operative treatment for displaced midshaft clavicle fractures in adolescents has been achieved by a plate and screws. However, a minimally invasive trend in most of the surgeries has led the pediatric orthopedic surgeons to use elastic stable intramedullary nail (ESIN) for displaced midshaft clavicle fractures. This study aims to compare the clinical outcomes of adolescent patients who were surgically treated with the (ESIN) and plate for displaced midshaft clavicle fractures.Methods: A total of 73 patients, aged between 10 years and 14 years, with displaced midshaft clavicle fractures were treated surgically from January 2014 to January 2018. Patients were categorized into two groups, ESIN (n = 45; male 27, female 18) and plate (n = 28; male17, female 11) according to surgical technique. The preoperative data, including baseline information of the patients, radiographic parameters, and types of surgical procedure, were collected from the hospital database. The postoperative data, including clinical outcome and complications, were collected during the follow-up visit. Clinical outcome was evaluated using the American Shoulder and Elbow Surgeons (ASES).Results: The average age of the patients in the ESIN group was 12.2±1.5 years, and that in the Plate group was 12.2±1.4 years. There was a significantly less operative time, reduced estimated blood loss (EBL), shortened hospital stay and smaller incision for ESIN group as compared to the Plate group (P<0.01). The rate of scar concern was much higher in plate (14/28, 50%) than ESIN (2/45, 4.4%) , (P <0.01). There was no statistically significant difference in shoulder function between the ESIN group (94.5±2.8) and the Plate group (95.1±2.7), P = 0.36. In all the cases, implant removal was performed between 4 and 12 months postoperatively, and the ESIN group had significantly less operative time, EBL and shortened hospital stay as compared to the plate for implant removal (P<0.01).Conclusion: Both the ESIN and Plate are safe and effective treatment methods for displaced midshaft clavicle fractures in adolescents. The ESIN is superior to plate in terms of shorter operative time, less intraoperative radiation exposure, shorter hospital stay, less scar concern and easier implant removals. However, ESIN for heavier kids remain cautious.