Golf enthusiasts endlessly debate club design and selection when approaching standard situations on the course. For example, for a shot to a large green from 100 yards, one golfer might choose a pitching wedge, while another would opt for a sand wedge or even a chocked-down nine iron. There are no style points in golf for this shot—what matters is getting the ball close to the pin.
There is a strong similarity between this club-selection dilemma and fixation of midshaft clavicle fractures. Two well-done Level I randomized controlled trials in the April 15, 2015 edition of The Journal (van der Meijden et al. and Andrade-Silva et al.) support the notion that, when a patient’s fracture displacement and clinical characteristics warrant fixation, it does not matter whether the surgeon chooses an intramedullary pin or a plate. This decision must be made based on the surgeon’s experience, skill, prior outcomes, and a candid discussion of the options with the patient.
One area of particular concern is the highly comminuted midshaft fracture that is not length-stable. The Andrade-Silva et al. trial showed that, in this setting, the reconstruction plate may well result in clavicular shortening that is statistically greater than shortening with the intramedullary device, but was not found to be clinically important. Still, in those cases a more rigid plate construct may be preferable.
Otherwise, pin or plate achieves equivalent clinical outcomes, just as the sand wedge and pitching wedge can both get the ball close to the pin. It is the experience and skill of the person with the club in hand that matters.
Click here for a commentary by Gordon Groh, MD on the Andrade-Silva et al. article.
Marc Swiontkowski, MD