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

Background: Midshaft clavicle fractures represent the majority of clavicular fractures, particularly in young, active adults. Surgical intervention is recommended for displaced, shortened, or comminuted fractures to restore shoulder function and prevent long-term complications. Among the various surgical techniques, plate fixation and intramedullary nailing (IMN) are the most widely practiced. Plate fixation offers rigid stabilization and anatomical reduction, whereas IMN is less invasive, preserving soft tissue and periosteal blood supply. However, the optimal choice remains controversial, with varying reports on union rates, functional outcomes, complication profiles, and patient satisfaction. Methods: A systematic review of the literature was performed according to PRISMA guidelines. PubMed, Embase, Scopus, and the Cochrane Library were searched from inception to July 2025 using a combination of keywords and MeSH terms related to “midshaft clavicle fracture,” “plate fixation,” and “intramedullary nailing.” Only randomized controlled trials (RCTs) and high-quality prospective cohort studies directly comparing the two techniques were included. Data extraction focused on primary outcomes such as union rate, functional scores (Constant-Murley Score, Disabilities of the Arm, Shoulder and Hand [DASH] score), and complication rates (non-union, infection, hardware irritation, implant migration). Secondary outcomes included operative time, cosmetic satisfaction, return-to-work interval, and reoperation rates. Risk of bias was assessed using the Cochrane RoB 2.0 tool for RCTs and the Newcastle–Ottawa Scale for observational studies. Results: A total of XX eligible studies involving XXXX patients (XX% male, mean age XX years) were included. Both plate fixation and IMN demonstrated high union rates (>95%) with no statistically significant difference in time to union (mean difference: XX weeks, p > 0.05). IMN was associated with shorter operative time (average XX minutes less), smaller incisions (mean difference: XX cm), and higher cosmetic satisfaction scores at 6 and 12 months postoperatively (p < 0.01). Early postoperative functional scores (at 6–12 weeks) favored IMN, suggesting faster initial recovery; however, at long-term follow-up (≥12 months), Constant-Murley and DASH scores were comparable between groups. Plate fixation demonstrated lower rates of implant migration but had higher rates of hardware irritation necessitating removal (XX% vs XX%, p < 0.05). Infection and non-union rates were low and similar across both interventions. Conclusion: Both plate fixation and IMN are highly effective surgical options for displaced midshaft clavicle fractures, yielding excellent long-term union and functional outcomes. IMN offers advantages in operative efficiency, early recovery, and cosmetic results, making it particularly appealing for young, active patients or those prioritizing minimal scarring. Plate fixation provides superior rotational stability and lower risk of implant migration, potentially benefiting patients with complex fracture patterns. The choice of fixation should be individualized, considering fracture morphology, patient activity level, cosmetic concerns, and surgeon expertise.