Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Demonstrates Fewer Union Complications but Similar Patient-reported Outcomes Compared to Nonoperative Management: A Cohort Study with Mean 3.4 Year Follow-Up

Purpose: Although open reduction and internal fixation (ORIF) is the gold standard treatment for displaced midshaft clavicle fractures, recent studies have advocated for nonoperative management, citing high rates of reoperation associated with operative intervention. However, no studies have compared nonoperative management to ORIF with dual-plate fixation, which may be associated with lower rates of reoperation compared to single-plate fixation. The purpose of this study was to compare the complications and patient-reported outcomes of dual mini-fragment plate fixation to nonoperative management for displaced midshaft clavicle fractures.

Methods: This was a retrospective cohort study of patients who presented with a displaced midshaft clavicle fracture and underwent either nonoperative management or dual mini-fragment plate fixation from 2010-2021 with minimum 12-month follow-up. The primary outcomes were union complications including non-union, delayed union, and symptomatic malunion. Secondary outcomes were patient-reported outcomes including visual analog pain scale (VAS) and subjective shoulder value (SSV). A multivariate logistic regression model was utilized to determine the relationship between treatment and union complications.

Results: One hundred and eleven patients were identified (mean age 41.6 ± 16.7 years) with average follow-up of 3.4 years. Of these, 62 underwent dual-plate fixation and 49 underwent nonoperative management with no differences in demographics or fracture characteristics. There were 0 non-unions, 1 delayed union, 0 symptomatic malunions, and 1 re-operation in the dual plating cohort compared to 4 non-unions (p=0.035), 1 delayed union (p=1.00), and 3 symptomatic malunions (p=0.083) in the nonoperative cohort. Patients who underwent nonoperative management were over 14 times more likely to develop a union complication (β=14.3; p=0.019). There were no differences between the dual plating and nonoperative cohort with regards to VAS (1.2 ± 2.2 vs 1.5 ± 2.4; p=0.559) and SSV (90 ± 16 vs 92 ± 15; p=0.671).

Conclusion: While both dual mini-fragment plate fixation and nonoperative management of displaced midshaft clavicle fractures demonstrate similarly excellent patient-reported pain and functional outcomes, dual-plate fixation has a 14-fold lower risk of union complications.