NAILING VS. SINGLE PLATE
Surgical treatment of clavicle shaft fractures with an intramedullary nail or a single plate results in equivalent long-term clinical outcomes with similar complication rates. Plate fixation may be of benefit in the presence of fracture comminution.

Rationale

The literature (prospective and retrospective) generally supports that long-term clinical outcomes (> 1 year) are similar with the use of an intramedullary device versus single plate for fixation of displaced clavicular shaft fractures (Park 2020, Liu 2010, Zhang 2019, Anand 2021, Narsaria 2014). More comminution at the fracture site is however a clinical indication to use a clavicular plate, rather than an intramedullary device. The literature suggests better earlier clinical outcomes with the use of plates, presumably due to better stability early in the recovery phases after surgery (Anand 2021, Fuglesang 2018, van der Meijden 2015). The literature also suggests that hardware irritation/complications may be lower with the use of an intramedullary device when compared to a plate (Fuglesang 2018, Zhang 2019, Zehir 2016).

Benefits/Harms of Implementation

Benefits of these recommendations will potentially help surgeons avoid using an intramedullary device for a comminuted clavicular shaft fracture, when a better therapeutic choice would be a plate for clavicular shaft fracture with comminution. There are not potential clinical harms that could be created by following clinical recommendation of this guideline beyond the expected risks of surgical intervention.

Outcome Importance

Better clinical outcomes might be achieved by following this clinical guideline for the fixation of clavicular shaft fractures depending on fracture pattern simple versus comminuted).

Cost Effectiveness/Resource Utilization

At this time, the direct cost differences between intramedullary devices and plates for clavicular shaft fracture fixation are not known to this group. With respect to resource utilization, orthopedic surgeons would need clinical access to both intramedullary devices and plates for clavicular shaft fracture fixation. This might require more resources as hospitals would need to maintain inventories for both devices.

Acceptability

Clinically active orthopedic surgeons are probably more comfortable with plate fixation of clavicular shaft fractures at this time. Orthopedic surgeons may benefit from clinical training (sawbones, cadaver labs, etc.) to become more familiar with the use of intramedullary devices for clavicular shaft fracture fixation.

Feasibility

Clinical use of both intramedullary devices and plates is very reasonable for orthopedic surgeons who provide clinical surgical care for patients with clavicular shaft fractures.

Future Research

Future research would include more long-term clinical outcome data (need for hardware removal, complications related to surgical procedure, patient reported outcomes, etc.) beyond twelve months.