Objective <p>To systematically compare the efficacy of titanium elastic nailing (TEN) versus conservative treatment for displaced mid-shaft clavicle fractures in adolescent athletes, with emphasis on return-to-sport time, season loss, and functional recovery, and to evaluate the value of a sport-type stratification model based on clavicle biomechanical demands in therapeutic decision-making.</p> Methods <p>A multicenter retrospective cohort study was conducted, enrolling 96 adolescent athletes with acute, unilateral mid-shaft clavicle fractures and displacement ≥ 2&#xa0;cm. Patients were divided into surgical (<i>n</i> = 54) and conservative treatment (<i>n</i> = 42) groups. Athletes were stratified into four subgroups based on clavicle functional demand in their sports: structure-dependent, kinetic-dependent, coordination-dependent, and function-independent. Within the surgical group, 13 athletes were in structure‑dependent sports, 10 in kinetic‑dependent sports, 21 in coordination‑dependent sports, and 10 in function‑independent sports; within the conservative group, 15 were in structure‑dependent sports, 6 in kinetic‑dependent sports, 14 in coordination‑dependent sports, and 7 in function‑independent sports. Primary endpoints included time to return to training, time to return to competition, and days of season loss. Secondary endpoints included Numeric Pain Rating Scale (NPRS), Constant-Murley shoulder score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and Tampa Scale for Kinesiophobia (TSK).</p> Results <p>The median time to return to competition was 38 days in the surgical group, significantly shorter than in the conservative group (<i>P</i> &lt; 0.05), with an average reduction in season loss of 7–10 days. Subgroup analysis revealed that surgical treatment significantly shortened return-to-sport times in structure- and kinetic-dependent sports, whereas no significant differences were observed in coordination- or function-independent sports. Early postoperative scores (2–4 weeks) for NPRS, Constant-Murley, DASH, and TSK were superior in the surgical group (<i>P</i> &lt; 0.05); however, all functional and psychological scores converged at 1-year follow-up, with no statistically significant differences. Complication rates were low, with only one case of minor wound reaction in the surgical group.</p> Conclusion <p>For adolescent athletes engaged in structure- or kinetic-dependent sports with high clavicle functional demand, TEN fixation significantly accelerates return to sport, reduces season loss, and enhances early functional and psychological recovery, while achieving long-term functional outcomes equivalent to conservative treatment. The proposed decision model integrating “season time window” and “sport-type stratification” overcomes the limitations of traditional displacement-based criteria and provides evidence-based support for individualized management of clavicle fractures in adolescent athletes.</p>