Both the ESIN group and the plate group produced satisfactory clinical outcomes for displaced midshaft clavicle fractures in adolescents. The ESIN is superior to the plate, given that it permits a shorter operative time, a shorter hospital stay, less esthetic concern, and easier implant removal.

Operative management is gaining popularity for clavicle fractures in adults because of better clinical outcomes [5]. In children, nonoperative management usually results in good functional outcomes [18, 19]. However, surgical treatment for teenagers seems to have been popular over the past 10 years [20]. Especially for adolescents that demand early functional recovery and have a high activity level, surgery is an alternative choice [7, 9, 10, 21]. However, nonoperative management should remain the gold standard when treating pediatric and adolescent clavicle fractures [22, 23]. Therefore, operative management should be carried out discretely. Besides, the pros and cons must be explained thoroughly to the parents and the patients before undertaking the surgery. Evidently, the ESIN demonstrated the advantages of a minimally invasive approach as it allowed a smaller incision, faster surgery, and a shorter hospital stay than the plate. Besides, the removal of the ESIN was easier than the removal of the plate. In contrast, the ESIN has a high risk of implant prominence, and patients are immobilized in an arm sling for 1–2 weeks after the operation to ensure recovery and stability. Besides, plating leads to better anatomical reduction and stronger fixation.

In our study, the clinical outcomes in both groups were satisfactory, consistent with previous reports [24,25,26,27,28]. There were no statistically significant differences in terms of shoulder function and serious complications between the two groups. Also, there was no case of nonunion or malunion in both groups.

Previous studies reported early complications such as nail breakage, bending, threatened skin perforation, and clavicle shortening in the ESIN group [24, 27, 29]. However, these complications were not significant in our study, possibly because of the routine immobilization in an arm sling for 1 to 2 weeks, good patient compliance, and the exclusion of multi-fragmentary fractures from our study. Besides, the refracture rates of both groups were low, consistent with previous reports, and two patients suffered from a refracture resulting from an accidental fall after plate removal [11, 19, 28, 29].

As shown in “Results” section, the SCAR scale was much higher in the plate group than in the ESIN group at different time points. Besides, the percentage of the patients who sought cosmetic counsel due to esthetic concerns was higher in the plate group (71.4%) than in the ESIN group (22.2%).

We undertook a retrospective investigation, so our findings should be interpreted with caution. Firstly, the process of allocating patients to either the ESIN group or the plate group depended partly on the preference of the surgeon in charge, and this strategy may have caused allocation bias. Besides, preoperative radiographic parameters, including displacement and angulation, were not recorded and analyzed. In the follow-up visits, certain morphological abnormalities of the clavicle were noticed in the radiograph but not recorded and analyzed, because the gross appearance seemed normal. Moreover, patients treated with nonoperative methods were not included because the purpose of this study was to discuss the pros and cons of operative choices. Furthermore, there was an insignificant difference in complications between the two groups due to the small number of included patients.

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