Displaced Midshaft Clavicle Fractures in Adolescents: Outcomes with Flexible Intramedullary Nail Fixation
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Published:
Aug 29, 2025
Keywords:
Clavicle fracture, intramedullary nail
Main Article Content
Abstract
Introduction: This study reports radiological and functional outcomes, surgical times, and intraoperative radiation exposure in patients aged 10–18 years with simple displaced midshaft clavicle fractures treated with flexible intramedullary nails, stratified by reduction type (open vs closed).
Materials and Methods: Retrospective analysis of prospectively collected electronic medical record data. Adolescents with acute, displaced, noncomminuted clavicular shaft fractures treated with flexible intramedullary nails and with 1-year follow-up were included.
Results: Sixteen patients were included (mean age, 14 years). Mean time from injury to surgery was 9.3 days. Seven patients required open reduction, mainly when delays exceeded 11 days. Procedures using closed reduction had longer intraoperative radiation exposure times. Fracture union occurred by 6 weeks. The Constant–Murley score improved from 83.35 at 6 weeks to 95.88 at 1 year. Osseous adaptation was observed in some patients, with an increase in clavicular diameter.
Conclusions: Flexible intramedullary nailing is an acceptable option for treating simple displaced midshaft clavicle fractures in adolescents. When time from injury exceeds 10 days, open reduction should be considered to reduce intraoperative radiation exposure.
Materials and Methods: Retrospective analysis of prospectively collected electronic medical record data. Adolescents with acute, displaced, noncomminuted clavicular shaft fractures treated with flexible intramedullary nails and with 1-year follow-up were included.
Results: Sixteen patients were included (mean age, 14 years). Mean time from injury to surgery was 9.3 days. Seven patients required open reduction, mainly when delays exceeded 11 days. Procedures using closed reduction had longer intraoperative radiation exposure times. Fracture union occurred by 6 weeks. The Constant–Murley score improved from 83.35 at 6 weeks to 95.88 at 1 year. Osseous adaptation was observed in some patients, with an increase in clavicular diameter.
Conclusions: Flexible intramedullary nailing is an acceptable option for treating simple displaced midshaft clavicle fractures in adolescents. When time from injury exceeds 10 days, open reduction should be considered to reduce intraoperative radiation exposure.
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How to Cite
Alfano, F., & Moya, D. (2025). Displaced Midshaft Clavicle Fractures in Adolescents: Outcomes with Flexible Intramedullary Nail Fixation. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(4), 335-343. https://doi.org/10.15417/issn.1852-7434.2025.90.4.2119
Section
Clinical Research
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References
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https://doi.org/10.1016/j.jhsa.2014.09.023
5. McGraw MA, Mehlman CT, Lindsell CJ, Kirby CL. Postnatal growth of the clavicle: birth to 18 years of age. J Pediatr Orthop 2009;29(8):937-43. https://doi.org/10.1097/BPO.0b013e3181c11992
6. Fanter NJ, Kenny RM, Baker CL 3rd, Baker CL Jr. Surgical treatment of clavicle fractures in the adolescent athlete. Sports Health 2015;7(2):137-41. https://doi.org/10.1177/1941738114566381
7. Rapp M, Prinz K, Kaiser M. Elastic stable intramedullary nailing for displaced pediatric clavicle midshaft fractures: a prospective study of the results and patient satisfaction in 24 children and adolescents aged 10 to 15 years. J Pediatr Orthop 2013;33(6):608-13. https://doi.org/10.1097/BPO.0b013e31829d1a76
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9. Suppan CA, Bae DS, Donohue KS, Miller PE, Kocher MS, Heyworth BE. Trends in the volume of operative
treatment of midshaft clavicle fractures in children and adolescents: a retrospective, 12-year, single-institution
analysis. J Pediatr Orthop B 2016;25(4):305-9. https://doi.org/10.1097/BPB.0000000000000301
10. Pandya N, Namdari S, Hosalkar H. Displaced clavicle fractures in adolescents: facts, controversies, and current
trends. J Am Acad Orthop Surg 2012;20(8):498-505. https://doi.org/10.5435/JAAOS-20-08-498
11. Wang X-H, Cheng L, Guo W-J, Li A-B, Cheng G-J, Lei T, et al. Plate versus intramedullary fixation care of displaced midshaft clavicular fractures a meta-analysis of prospective randomized controlled trials. Medicine
(Baltimore) 2015;94(41):21792. https://doi.org/10.1097/MD.0000000000001792
12. Luo TD, Ashraf A, Larson AN, Stans AA, Shaughnessy WJ, McIntosh AL. Complications in the treatment of
adolescent clavicle fractures. Orthopedics 2015;38(4):287-91. https://doi.org/10.3928/01477447-20150402-56
13. Eisenstein ED, Misenhimer JJ, Kotb A, Thabet AM, Abdelgawad AA. Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series. J Clin Orthop Trauma 2018;9(Suppl 1):S97-S102. https://doi.org/10.1016/j.jcot.2017.06.019
14. Bae DS, Shah AS, Kalish LA, Kwon JY, Waters PM. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop 2013;33(5):544-50. https://doi.org/10.1097/BPO.0b013e3182857d9e
15. Masnovi ME, Mehlman CT, Eismann EA, Matey DA. Pediatric refracture rates after angulated and completely
displaced clavicle shaft fractures. J Orthop Trauma 2014;28(11):648-52. https://doi.org/10.1097/BOT.0000000000000135
16. Mehlman CT, Yihua G, Bochang C, Zhigang W. Operative treatment of completely displaced clavicle shaft fractures in children. J Pediatr Orthop 2009;29(8):851-5. https://doi.org/10.1097/BPO.0b013e3181c29c9c
17. Namdari S, Ganley TJ, Baldwin K, Rendon Sampson N, Hosalkar H, Nikci V, et al. Fixation of displaced midshaft
clavicle fractures in skeletally immature patients. J Pediatr Orthop 2011;31:507-11. https://doi.org/10.1097/BPO.0b013e318220ba48
18. Robinson C. Fractures of the clavicle in the adult. J Bone Joint Surg Br 1998;80(3):476-84. https://doi.org/10.1302/0301-620x.80b3.0800476
19. Wylie JD, Beckmann JT, Granger E, Tashjian RZ. Functional outcomes assessment in shoulder surgery. World J
Orthop 2014;5:623-33. https://doi.org/10.5312/wjo.v5.i5.623
20. 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. https://doi.org/10.1177/0363546508328103
21. Frye BM, Rye S, McDonough EB, Bal GJ. Operative treatment of adolescent clavicle fractures with an intramedullary clavicle pin. J Pediatr Orthop 2012;32(4):334-9. https://doi.org/10.1097/BPO.0b013e31825611da
22. La Salvia JC, Reis de Moraes P, Ammar TY, Schwartsmann CR. Fluoroscopy duration in orthopedic surgery. Rev
Bras Ortop 2011;46(2):136-8. https://doi.org/10.1016/S2255-4971(15)30228-7
23. Barry T. Radiation exposure to an orthopaedic surgeon. Clin Orthop Relat Res 1984;(182):160-4. PMID: 6692610
24. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond) 2005;55(6):498-500. https://doi.org/10.1093/occmed/kqi048
25. Hoogervorst P, van Dam T, Verdonschot N, Hannink G. Functional outcomes and complications of intramedullary fixation devices for midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskelet Disord 2020;21(1):395. https://doi.org/10.1186/s12891-020-03256-8
26. Jubel A, Andermahr J, Faymonville C, Binnebösel M, Prokop A, Rehm KE. [Reconstruction of shoulder-girdle
symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage]. Chirurg
2002;73(10):978-81. [En alemán] https://doi.org/10.1007/s00104-002-0544-z
27. 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;78:424-9.
https://doi.org/10.1080/17453670710014022
28. Lu CC, Liu PC, Huang SH, Hsieh CH, Tien YC, Chien SH. Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures. Orthopedics 2014;37:e377-83. https://doi.org/10.3928/01477447-20140401-60
29. Hulsmans MHJ, van Heijl M, Frima H, van der Meijden OAJ, van den Berg HR, van der Veen AH, et al. Predicting
suitability of intramedullary fixation for displaced midshaft clavicle fractures. Eur J Trauma Emerg Surg 2018;44(4):581-7. https://doi.org/10.1007/s00068-017-0848-9
30. van der Meijden OA, Houwert RM, Hulsmans M, Wijdicks F-JG, Dijkgraaf MGW, Meylaerts SAG, et al. Operative
treatment of dislocated midshaft clavicular fractures: Plate or intramedullary nail fixation? A randomized controlled trial. J Bone Joint Surg Am 2015;97:613-9. https://doi.org/10.2106/JBJS.N.00449
2. Kubiak R, Slongo T. Operative treatment of clavicle fractures in children: a review of 21 years. J Pediatr Orthop
2002;22(6):736-9. PMID: 12409898
3. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative versus nonoperative treatment of midshaft clavicle
fractures in adolescents. J Pediatr Orthop 2010;30(4):307-12. https://doi.org/10.1097/BPO.0b013e3181db3227
4. Assafiri I, Sraj S. Adolescent displaced midshaft clavicle fracture. J Hand Surg Am 2015;40(1):145-7.
https://doi.org/10.1016/j.jhsa.2014.09.023
5. McGraw MA, Mehlman CT, Lindsell CJ, Kirby CL. Postnatal growth of the clavicle: birth to 18 years of age. J Pediatr Orthop 2009;29(8):937-43. https://doi.org/10.1097/BPO.0b013e3181c11992
6. Fanter NJ, Kenny RM, Baker CL 3rd, Baker CL Jr. Surgical treatment of clavicle fractures in the adolescent athlete. Sports Health 2015;7(2):137-41. https://doi.org/10.1177/1941738114566381
7. Rapp M, Prinz K, Kaiser M. Elastic stable intramedullary nailing for displaced pediatric clavicle midshaft fractures: a prospective study of the results and patient satisfaction in 24 children and adolescents aged 10 to 15 years. J Pediatr Orthop 2013;33(6):608-13. https://doi.org/10.1097/BPO.0b013e31829d1a76
8. Carry P, Koonce R, Pan Z, Polousky JD. A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members. J Pediatr Orthop 2011;31(1):44-9. https://doi.org/10.1097/BPO.0b013e3181ff67ce
9. Suppan CA, Bae DS, Donohue KS, Miller PE, Kocher MS, Heyworth BE. Trends in the volume of operative
treatment of midshaft clavicle fractures in children and adolescents: a retrospective, 12-year, single-institution
analysis. J Pediatr Orthop B 2016;25(4):305-9. https://doi.org/10.1097/BPB.0000000000000301
10. Pandya N, Namdari S, Hosalkar H. Displaced clavicle fractures in adolescents: facts, controversies, and current
trends. J Am Acad Orthop Surg 2012;20(8):498-505. https://doi.org/10.5435/JAAOS-20-08-498
11. Wang X-H, Cheng L, Guo W-J, Li A-B, Cheng G-J, Lei T, et al. Plate versus intramedullary fixation care of displaced midshaft clavicular fractures a meta-analysis of prospective randomized controlled trials. Medicine
(Baltimore) 2015;94(41):21792. https://doi.org/10.1097/MD.0000000000001792
12. Luo TD, Ashraf A, Larson AN, Stans AA, Shaughnessy WJ, McIntosh AL. Complications in the treatment of
adolescent clavicle fractures. Orthopedics 2015;38(4):287-91. https://doi.org/10.3928/01477447-20150402-56
13. Eisenstein ED, Misenhimer JJ, Kotb A, Thabet AM, Abdelgawad AA. Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series. J Clin Orthop Trauma 2018;9(Suppl 1):S97-S102. https://doi.org/10.1016/j.jcot.2017.06.019
14. Bae DS, Shah AS, Kalish LA, Kwon JY, Waters PM. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop 2013;33(5):544-50. https://doi.org/10.1097/BPO.0b013e3182857d9e
15. Masnovi ME, Mehlman CT, Eismann EA, Matey DA. Pediatric refracture rates after angulated and completely
displaced clavicle shaft fractures. J Orthop Trauma 2014;28(11):648-52. https://doi.org/10.1097/BOT.0000000000000135
16. Mehlman CT, Yihua G, Bochang C, Zhigang W. Operative treatment of completely displaced clavicle shaft fractures in children. J Pediatr Orthop 2009;29(8):851-5. https://doi.org/10.1097/BPO.0b013e3181c29c9c
17. Namdari S, Ganley TJ, Baldwin K, Rendon Sampson N, Hosalkar H, Nikci V, et al. Fixation of displaced midshaft
clavicle fractures in skeletally immature patients. J Pediatr Orthop 2011;31:507-11. https://doi.org/10.1097/BPO.0b013e318220ba48
18. Robinson C. Fractures of the clavicle in the adult. J Bone Joint Surg Br 1998;80(3):476-84. https://doi.org/10.1302/0301-620x.80b3.0800476
19. Wylie JD, Beckmann JT, Granger E, Tashjian RZ. Functional outcomes assessment in shoulder surgery. World J
Orthop 2014;5:623-33. https://doi.org/10.5312/wjo.v5.i5.623
20. 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. https://doi.org/10.1177/0363546508328103
21. Frye BM, Rye S, McDonough EB, Bal GJ. Operative treatment of adolescent clavicle fractures with an intramedullary clavicle pin. J Pediatr Orthop 2012;32(4):334-9. https://doi.org/10.1097/BPO.0b013e31825611da
22. La Salvia JC, Reis de Moraes P, Ammar TY, Schwartsmann CR. Fluoroscopy duration in orthopedic surgery. Rev
Bras Ortop 2011;46(2):136-8. https://doi.org/10.1016/S2255-4971(15)30228-7
23. Barry T. Radiation exposure to an orthopaedic surgeon. Clin Orthop Relat Res 1984;(182):160-4. PMID: 6692610
24. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond) 2005;55(6):498-500. https://doi.org/10.1093/occmed/kqi048
25. Hoogervorst P, van Dam T, Verdonschot N, Hannink G. Functional outcomes and complications of intramedullary fixation devices for midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskelet Disord 2020;21(1):395. https://doi.org/10.1186/s12891-020-03256-8
26. Jubel A, Andermahr J, Faymonville C, Binnebösel M, Prokop A, Rehm KE. [Reconstruction of shoulder-girdle
symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage]. Chirurg
2002;73(10):978-81. [En alemán] https://doi.org/10.1007/s00104-002-0544-z
27. 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;78:424-9.
https://doi.org/10.1080/17453670710014022
28. Lu CC, Liu PC, Huang SH, Hsieh CH, Tien YC, Chien SH. Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures. Orthopedics 2014;37:e377-83. https://doi.org/10.3928/01477447-20140401-60
29. Hulsmans MHJ, van Heijl M, Frima H, van der Meijden OAJ, van den Berg HR, van der Veen AH, et al. Predicting
suitability of intramedullary fixation for displaced midshaft clavicle fractures. Eur J Trauma Emerg Surg 2018;44(4):581-7. https://doi.org/10.1007/s00068-017-0848-9
30. van der Meijden OA, Houwert RM, Hulsmans M, Wijdicks F-JG, Dijkgraaf MGW, Meylaerts SAG, et al. Operative
treatment of dislocated midshaft clavicular fractures: Plate or intramedullary nail fixation? A randomized controlled trial. J Bone Joint Surg Am 2015;97:613-9. https://doi.org/10.2106/JBJS.N.00449