Anatomical plating versus titanium elastic nailing for displaced midshaft clavicle fractures: a prospective comparative study

Ashish Philip, Shishir Murugharaj Suranigi, Lingaraj ., Kanagasabai Rengasamy, Syed Najimudeen


Background: Plate fixation has become the standard operative method for fixing displaced midshaft clavicle fractures. Over the years, TENS has also gained lot of attention due to its minimal invasive nature, smaller scar and reduced operative time. The purpose of this study was to compare the functional outcome of middle third displaced clavicle fractures treated either by plate or intra medullary TENS fixation using Constant Murley score and disability of the arm, shoulder and hand score.

Methods: A prospective randomised study was conducted from January 2010 to September 2016 at our institute on patients with displaced midshaft clavicle fractures. A total of 56 patients (TENS; n=25, plating; n=31), classified according to orthopaedic trauma association classification underwent midshaft clavicle fixation. They were followed-up for a minimum period of 1 year.

Results: Length of the scar in the TENS group was significantly smaller when compared to the incision in the plating group (1.86±1.23 and 11.01±3.29 cms respectively, p<0.001). The Constant shoulder score measured at the end of 1 year was 90.77±9.01 for the TENS group and 92.63±6.04 for the plating group, not significant statistically (p=0.269). The mean DASH score was also not significantly different (p=0.552) between the TENS group and the plating group, at 6.01±11.09 and 6.32±10.33 respectively.

Conclusions: In comparison with plate fixation, the nailing procedure is less invasive, requires smaller incisions and has a shorter duration of hospital stay with no statistically significant difference in terms of functional outcome. Hence, TENS technique is recommended for the fixation of displaced mid-shaft non-/minimal comminuted clavicular fractures, especially for young individuals and can be used as an alternative to plate fixation.



Middle one-third clavicle fractures, Clavicle plating, Intramedullary clavicle nailing, Titanium elastic nailing system

Full Text:



Schiffer G, Faymonville C, Skouras E, Andermahr J, Jubel A . Midclavicular fracture:not just a trivial injury. Dtsch Arztebl Int. 2010;107(41):711-7.

Hill JM, Mcguire MH, Crosby LA. Closed treatment of displaced middle third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79(4): 537-9.

Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M. Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review. Int Orthop. 2012;36(3):579-85.

Assobhi JE. Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures. J Orthop Traumatol. 2011;12(4):185-92.

Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2012;21(3):423-9.

Kettler M, Schieker M, Braunstein V, Konig M, Mutschler W. Flexible intramedullary nailing for stabilization of displaced midshaft clavicle fractures: technique and results in 87 patients. Acta Orthop. 2007;78(3):424-9.

Strauss EJ, Egol KA, France MA, Koval KJ, Zuckerman JD. Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures. J Shoulder Elbow Surg. 2007;16(3):280-4.

Frigg A, Rillmann P, Perren T, Gerber M, Ryf C. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications. Am J Sports Med. 2009;37(2):352-9.

Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214(1):160-4.

Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH, the upper extremity collaborative group. Am J Ind Med. 1996;29(6):602-8.

Shishir SM, Lingaraj, Ashish PZ, Kanagasabai R, Syed N, James JG. Antegrade flexible intramedullary nailing for fixation of displaced midshaft clavicle fractures. IOSR J Dent Med Sci. 2014;13(4):29-37.

Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R, Somville J. Plate fixation of middle-third fractures of the clavicle in the semi-professional athlete. Acta Orthop Belg. 2005;71(1):17-21.

Wijdicks FJ, Van der Meijden OA, Millett PJ, Verleisdonk EJ, Houwert RM. Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg. 2012;132(5): 617-25.

Liu PC, Chien SH, Chen JC, Hsieh CH, Chou PH, Lu CC. Minimally invasive fixation of displaced midclavicular fractures with titanium elastic nails. J Orthop Trauma. 2010;24(4):217-23.

Kleweno CP, Jawa A, Wells JH, O’Brien TG, Higgins LD, Harris MB, et al. Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation. J Shoulder Elbow Surg Am. 2011;20(7): 1114-7.

Böhme J, Bonk A, Bacher G, Wilharm A, Hoffmann R, Josten C. Current treatment concepts for mid-shaft fractures of the clavicle-results of a prospective multicentre study. Z Orthop Unfall. 2011;149(1):68-76.

Chen YF, Wei HF, Zhang C, Zeng BF, Zhang CQ, Xue JF, et al. Retrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures. J Shoulder Elbow Surg. 2012;21(4):495-501.

Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res. 2008;90(11):1495-8.

Wang J, Meng XH, Guo ZM, Wu YH, Zhao JG. Interventions for treating displaced midshaft clavicular fractures: a Bayesian network meta-analysis of randomized controlled trials. Medicine. 2015;94(11):e595.

Zeng L, Wei H, Liu Y, Zhang W, Pan Y, Zhang W, et al. Titanium elastic nail (TEN) versus reconstruction plate repair of midshaft clavicular fractures: A finite element study. PLoS One. 2015;10 (5):126-31.

McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone joint Surg Am. 2003;85(5):790-7.

Ledger M, Leeks N, Ackland T, Wang A. Short malunions of the clavicle: an anatomic and functional study. J Shoulder Elbow Surg. 2005;14 (4):349-54.

Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005;76(4):496-502.

Schulz J, Moor M, Roocroft J, Bastrom TP, Pennock AT. Functional and radiographic outcomes of non-operative treatment of displaced adolescent clavicle fractures. J Bone Joint Surg Am. 2013;95(13):1159-65.

Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elbow Surg. 2006;15(2):191-4.

McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88 (1):35-40.

Bostman O, Manninen M, PIihlajamak H. Complications of plate fixation in fresh, displaced midclavicular fractures. J Trauma. 1997;43(5):778-83.

Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. Current concepts review. J Bone Joint Surg Am. 2009;91(2):447-60.

Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2012;21(3):423-9.

Houwert RM, Wijdicks FJ, Steins Bisschop C, Verleisdonk EJ, Kruyt M. Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review. Int Orthop. 2012; 36 (3):579-85.