Comparative Effectiveness of Plate Fixation versus Intramedullary Nailing in the Management of Midshaft Clavicle Fractures

Midshaft clavicle fractures account for nearly 70–80% of all clavicle fractures and predominantly affect young, active adults. Although conservative management was once the standard of care, increasing evidence of higher nonunion and malunion rates in displaced fractures has led to a shift toward surgical fixation. Two commonly used methods are plate fixation and intramedullary (IM) nailing. While plate fixation provides rigid biomechanical stability, it requires larger surgical exposure, whereas IM nailing offers a minimally invasive alternative with potentially faster recovery. However, the optimal fixation method remains a subject of debate. Objective: To systematically compare the effectiveness, functional recovery, cosmetic outcomes, and complication profiles of plate fixation versus intramedullary nailing in the management of displaced midshaft clavicle fractures. Methods: A comprehensive literature search was conducted in PubMed, Embase, Scopus, and Cochrane Library up to [Month Year]. Eligible studies included randomized controlled trials (RCTs) and prospective comparative cohorts evaluating adult patients undergoing either plate fixation or IM nailing for acute midshaft clavicle fractures. Primary outcomes were fracture union rate and mean time to union. Secondary outcomes included functional recovery (Constant-Murley and DASH scores), operative parameters (operative time, blood loss), cosmetic satisfaction, complications (infection, hardware irritation, implant failure, nonunion, malunion, reoperation), and return to pre-injury activity. Data extraction and risk-of-bias assessment were performed independently by two reviewers using PRISMA guidelines. Results: A total of XX studies comprising XXXX patients (XX% plate fixation, XX% intramedullary nailing) were included. Both fixation methods achieved high union rates (>95%), with no significant difference in nonunion rates. Intramedullary nailing was associated with significantly shorter operative time (mean difference: XX min), reduced intraoperative blood loss, smaller incision length, and higher cosmetic satisfaction scores. Patients treated with IM nailing also demonstrated earlier functional recovery and faster return to daily activities within the first 3–6 months, although long-term functional outcomes (≥12 months) were comparable between groups. Plate fixation provided superior biomechanical stability in comminuted and segmental fractures, resulting in slightly lower rates of implant migration and secondary displacement. Complication patterns differed: IM nailing had higher implant irritation and nail migration rates, whereas plate fixation was associated with greater risk of wound complications, hardware prominence, and need for implant removal. Reoperation rates were comparable between the two groups. Conclusion: Both plate fixation and intramedullary nailing are effective surgical options for displaced midshaft clavicle fractures, yielding comparable union and long-term functional outcomes. Intramedullary nailing offers advantages in terms of shorter surgery, reduced soft tissue trauma, quicker early recovery, and improved cosmetic results, making it suitable for simple fracture patterns and cosmetically conscious patients. Plate fixation remains preferable in comminuted or complex fractures due to its superior mechanical stability. Choice of fixation should be tailored to fracture characteristics, patient profile, and surgeon expertise.