A systematic review of plate versus intramedullary fixation in the treatment of midshaft clavicle fractures

Abstract

The best method of fixation for clavicle fractures is not known. The purpose of this review was to examine the evidence comparing plate and intramedullary fixation for midshaft clavicle fractures. A search of MEDLINE in September 2011 identified five papers that compared plate and intramedullary fixation, and fulfilled our eligibility criteria, consisting of; one randomised controlled trial, two quasi-randomised controlled trials, and two retrospective studies. Level of evidence was assessed using the Scottish Intercollegiate Guidelines Network guidance and the Cochrane Bone, Joint and Muscle Trauma Group’s quality assessment tool. No attempt at meta-analysis was made due to the heterogeneity of the study populations and interventions. We found no difference between intramedullary fixation and plate fixation. There was a trend towards a lower complication rate with intramedullary fixation. On the basis of the available evidence, we would advocate both techniques for the treatment of midshaft clavicle fractures.

Keywords

Clavicle fracture fixation internal intramedullary

Introduction

Clavicle fractures in adults make up 2.6 to 10% of all fractures and the majority of these (81%) are midshaft clavicle fractures.^1,2 These fractures have traditionally been treated non-operatively; recently, several authors have challenged this due to published non or mal union rates as high as 15.1%.^3,4 This figure includes non-displaced and minimally displaced fractures. The fixation of acute clavicular fractures is therefore likely to become more commonplace.

There are multiple techniques for operative fixation of midshaft clavicle fractures including various forms of plating and intramedullary (IM) devices.¹

IM nailing has the theoretical advantage of a smaller scar, no periosteal stripping, preservation of the soft tissue envelope, and, potentially, less soft tissue irritation.^2,5,6 Early complications of hardware migration^7–9 appear to have been solved with the introduction of locking IM devices.^5,6 However, in biomechanical studies, IM devices offer less stability than plates.¹⁰

It is unclear which method is best and the purpose of this review is to examine the evidence to determine if one technique is superior to the other.

Methods

A MEDLINE search was conducted on 29 September 2011. The search strategy can be found in Table 1. Studies that compared IM techniques to plating for acute midshaft clavicle fractures in adults were included. Exclusion criteria were studies that only examine delayed on non-unions; studies not reporting a shoulder-specific outcome measure or complications; studies not in the English language; and studies published over 10 years ago. We used the shoulder-specific outcome score as our primary outcome measure.

Table 1.

OVID search strategy (Medline).

1. clavicle.mp. or Clavicle/

2. collar bone.mp.

3. Bone Nails/ or Fracture Fixation, Intramedullary/or intramedullary nail.mp

4. IM nail.mp. or Fracture Fixation, Internal/

5. ORIF.mp. or Fracture Fixation/

6. elastic nail.mp

7. flexible nail.mp

8. 3 or 4 or 5 or 6 or 7

9. 1 or 2

10. 8 and 9

11. limit 10 to (english language and “all adult (19 plus years)” and last 10 years)

The title and abstracts of returned papers were screened, with the full text of relevant articles then reviewed. A citation search was also performed. A data extraction form was used to summarise the data from each paper. Reporting standards were assessed using the CONSORT¹¹ or STROBE¹² guidelines (as appropriate to study design), and quality grading and assessment using the SIGN guidance¹³ and the Cochrane Bone, Joint and Muscle Trauma Group’s quality assessment tool.¹⁴ Two independent reviewers performed each stage of the review, with any difference in opinion settled by discussion with the third author.

There was a large amount of variation in study populations and in interventions used, and therefore meta-analysis was not performed.

Results

We identified four papers that satisfied our eligibility criteria form our initial search (Figure 1). Two of these papers included patients that had non-unions^2,6; however, it was agreed to include them as the vast majority of patients in these studies had acute clavicle fractures, and the number of prospective studies were limited. One further paper was identified through a citation search.¹⁵ Of the papers, four compared IM devices to plating,^2,5,6,16 and one compared IM devices to plating and conservative treatment.¹⁵

Figure 1.

Flowchart of papers excluded.

Quality assessment

Table 2 summarises the quality assessment and reporting standards. Two prospective quasi-randomised studies demonstrated middle-level evidence (2b); however, deviations from study protocols, non-dependant assessing of participants, and no blinding of allocation upon entry to the study are significant limitations in the study design.^2,6

Table 2.

Summary of reporting and quality assessment.

Study	Ferran⁹	Lee et al.⁸	Lui	Lee et al.²	Thyagarajan et al.¹¹
Level of evidence (SIGN)	1b	2b	3b	2b	4
Cochrane quality assessment	16	11	14	12	7
CONSORT score	28	16	N/A	17	N/A
STROBE score	N/A	N/A	18	N/A	10

Data extraction

A table summarising these papers can be found below (Table 3).

Lee et al.² – Surgical treatment of midclavicular fractures: a prospective comparison of knowles pinning and plate fixation.

A quasi randomised design to compare Knowles pins with plating. All fracture types were included. Three patients with non-unions are also included. The authors report no difference in shoulder-specific outcome score.

Lee et al.⁸ – Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate.

A prospective quasi-randomised trial examining Knowles pins and plating (dynamic compression plate (DCP)) in patients over 50 years. All fracture types are included, including non-displaced fractures. They find no difference in Constant Score.

Liu et al.¹⁰ – Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures.

A retrospective matched parallel case series including severely displaced fractures; however, open fractures and severely comminuted fractures were excluded. The authors report no difference in Constant Score.

Ferran et al.⁹ – Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial.

A randomised controlled trial including isolated midshaft fractures that were displaced and shortened; however, the authors excluded comminuted fractures that extended laterally. The authors found no difference in Constant or Oxford shoulder scores.

Thyagarajan et al.¹¹ – Treatment of mid-shaft clavicle fractures: a comparative study.

A retrospective parallel case series including only fractures that had 100% displacement and over 2 cm shortening. The authors found no difference in Constant score.

Discussion

We found no difference in shoulder-specific outcome measures between IM nailing and plating of acute clavicle fracture.

There are some limitations to our search strategy. One database was searched, our results were limited to this century, and proceedings were not examined. However, Medline is the largest medical database and most likely to contain the information needed. A review of references revealed one more study. Given the small number of trials directly comparing plate and IM fixation, we included studies that had heterogeneity in the study population (e.g. including patients with non-union). Although this altered the study population, the number of patients was small and the benefit of including larger numbers was felt to outweigh the disadvantage.

There is limited evidence that there is no difference in shoulder-specific outcome measures in midshaft clavicle fractures treated with IM fixation or plate fixation. There is a trend in these studies towards lower complication rates in the IM group; however, the limited number of prospective, randomised trials examining this issue, combined with the different implants used, means it is difficult to ascertain a difference in complication rates. We conclude, therefore, that there is no evidence of a difference between plating and IM nailing for midshaft clavicle fractures, and would advocate both in the treatment of midshaft clavicle fractures dependant on surgeon and patient preference.

Table 3.

Data extraction forms (significant results (p < 0.05) in bold).

Study	Ferran		Lee 2007		Thyagarajan		Lui		Lee – Elderly
Design	RCT		Prospective quasi-randomised trial		Retrospective parallel case series		Retrospective matched parallel case series		Prospective quasi-randomised trail
Treatment	Rockwood Pin	LCDCP	Rockwood	ESIN	Knowles pin	DCP	LCP	Knowles pin	DCP	LC-DCP
Number	17	15	17	51	32	30	59	32	30	17
Follow up	12.4 months		12 months		6		17.7 months		30 months
Outcome measures
Constant Score	92.1 ± 6	88.7 ± 9.1	98	87 ± 5	85	84	88 ± 5	85	84	94
DASH	N/A	N\A	N/A	14 ± 4	N/A	N/A	13 ± 4	N/A	N/A	N/A
Oxford Score	45.2 ± 2.3	44.7 ± 3.4	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Time to union	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Blood loss	N/A	N/A	N/A	67 ± 37	N/A	N/A	128 ± 49	N/A	N/A	N/A
Operative time	N/A	N/A	N/A	73 ± 26	36	64	76 ± 23	36	64	N/A
Complications
Soft tissue irritation	1	0	0	N/A	4	12	N/A	4	12	6
Scar numbness	2	1	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Superficial wound infection	0	3	2	3 (6%)	0	1	6 (10%)	0	1	2
Metalwork removal	17 (100%)	8 (53%)	0	4	20	22	12	20	22	2
Non-union	0	0	0	5	0	1	6	0	1	1

Note: Dynamic Compression Plate (DCP); Low Contact Dynamic Compression Plate (LCDCP).

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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