Anterior-Inferior versus Superior Plating for Displaced Midshaft Clavicle Fractures: A Systematic Review and Meta-Analysis

Author(s): Yousef El-Tawil, Umair Baig, Praveen Rajan, Saif Shehadeh, Vishnuga Uthayamohan, Bhargava Krishna Balineni, Malaika Menon, Meenakshi Bheemavarapu

Introduction: Displaced midshaft clavicle fractures are commonly treated with plate fixation, yet the optimal plate position-superior versus anteroinferior-remains debated. Superior plating provides strong biomechanical stability but is often associated with hardware prominence, whereas anteroinferior plating may reduce implant-related irritation without compromising fixation integrity.

Methods: We conducted a systematic review and meta-analysis of randomised controlled trials comparing superior and anteroinferior plating for displaced midshaft clavicle fractures. Primary outcomes included hardware removal and functional recovery; secondary outcomes were nonunion and complications. Effect sizes were pooled using random-effects models, heterogeneity was assessed with I², and publication bias was explored using contour-enhanced funnel plots.

Results: Three trials (n = 95) met inclusion criteria. Hardware removal showed no significant difference between techniques (log RR = -0.79; 95% CI: -3.94 to 1.74; I² = 0%). Functional outcomes favoured anteroinferior plating (SMD = -0.51; 95% CI: -1.27 to 0.25), though this difference was not statistically significant, and heterogeneity was substantial (I² = 92.7%), reflecting variability in outcome measures and follow-up intervals. Nonunion rates were comparable (log RR = 0.39; 95% CI: -2.55 to 3.13; I² = 0%), with both techniques achieving union rates exceeding 95% and low complication frequencies. Superior plating remained consistently associated with greater implant prominence and irritation.

Conclusions: Both plating orientations provide reliable fracture healing and excellent long-term function. Anteroinferior plating may offer a modest advantage in reducing hardware-related morbidity and improving early functional outcomes, but evidence is limited by small sample sizes and high heterogeneity. Larger, standardised multicentre trials are needed to confirm these findings.