कुंडली फ्रैक्चर

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• If patients with medial clavicle fractures survive the initial trauma, good clinical and functional outcomes are expected regardless of whether surgical or nonsurgical management is chosen [1].
• Close follow-up is warranted for nonoperatively treated clavicle fractures [2].
• Specific treatment of clavicle fractures should be individualized based on fracture characteristics and patient expectations rather than broadly applied [9].
• The most common complications following clavicle fractures, whether treated operatively or non-operatively, are non-unions and malunions [10].
• Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications [17].
• The Sleutel-TRIAL provides level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures [19].
• Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment [25].
• Most mid-shaft clavicle fractures can be treated effectively by non-operative means [36].
• A select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications benefit from surgical fixation which has been shown to result in improved outcomes compared with non-operative measures [36].
• Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively [43].
• Operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected cases of adolescent clavicular fractures [43].
• There may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation for displaced midshaft clavicle fractures in the adolescent population [44].
• There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents due to concerns about symptomatic malunion and poor functional outcomes with nonsurgical management [102].
• Definitive indications for fixation of markedly displaced midshaft clavicle fractures in adolescents remain unclear [102].
• Patient selection for surgery may influence functional outcome after midshaft clavicle fracture [107].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The clavicle is the only long bone to ossify by intramembranous ossification [12].
• The clavicle begins ossification from two primary centers (medial and lateral) by 5 to 6 weeks of gestation [48].
• By 7 to 8 weeks of gestation, the clavicle has assumed its overall contour and “S” shape [48].
• Approximately 80% of clavicle growth occurs from the medial physis [48].
• The lateral epiphysis of the clavicle fuses at approximately 18 to 19 years of age [48].
• The medial epiphysis is the last in the body to ossify, occurring at 18 to 20 years of age [48].
• The medial epiphysis completes ossification at 23 to 25 years of age [48].
• In the transverse plane, the clavicle resembles an italic S [52].
• The greater radius of curvature occurs at the medial curve, which is anteriorly convex [52].
• The smaller lateral curve of the clavicle is posteriorly convex [52].
• The clavicle is somewhat rounded in its midsection and medially, and relatively flat laterally [52].
• The distal clavicle is flat in the AP plane [12].
• The medial end of the clavicle has a 30% incidence of a rhomboid fossa on its inferior surface where the costoclavicular ligaments insert [52].
• The medial end of the clavicle has a 2.5% incidence of an actual articular surface facing inferiorly toward the first rib [52].
• The middle portion of the clavicle contains the subclavian groove where the subclavius muscle has a fleshy insertion [52].
• The lateral portion of the clavicle has a coracoclavicular process when present [52].
• The conoid ligament attaches to the clavicle at the conoid tubercle [52].
• The trapezoid ligament attaches to the clavicle at the trapezoid line [52].
• The distance from the lateral edge of the clavicle to the medial edge of the conoid tubercle is approximately 45 mm in male and female specimens [52].
• The distance from the lateral edge of the clavicle to the center of the trapezoid tuberosity is approximately 25 mm in male and female specimens [52].
• The primary blood supply to the clavicle is periosteal [12].
• There is no nutrient blood supply to the clavicle [12].
• The clavicle is subcutaneous [12].
• The muscular envelope of the clavicle includes the platysma, pectoralis major, deltoid, and some of the strap muscles of the neck [12].

Ligaments and Soft Tissue Attachments¶

• The coracoclavicular (CC) ligaments consist of the conoid (medial) and trapezoid (lateral) components [12].
• The CC ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [12].
• The trapezius muscle inserts on the posterosuperior surface of the distal end of the clavicle [52].
• The subclavius muscle has a fleshy insertion on the inferior surface of the middle third of the clavicle [52].
• The deltoid originates on the anterior portion of the inner surface of the lateral curve of the clavicle [52].
• The pectoralis major originates from the anterior portion of the medial two-thirds of the clavicle [52].
• The sternocleidomastoid largely originates on the posterior portion of the middle third of the clavicle [52].
• The sternohyoid originates on the clavicle just medial to the origin of the sternocleidomastoid [52].
• The subclavian vein, subclavian artery, and brachial plexus are located posterior to the clavicle [52].
• The medial anterior curve of the clavicle is described as an accommodation for the subclavian vein and artery and brachial plexus [52].
• The mean distance of the neurovascular bundle from the posterior border of the clavicle is 9.2 mm [123].

Biomechanics and Functional Role¶

• The clavicle serves as the primary stabilizer between the axial skeleton (via the sternoclavicular joint) and the appendicular skeleton (via the acromioclavicular joint) [12].
• The clavicle acts as the main strut maintaining position of the shoulder girdle when subjected to compression force directed from laterally [54].
• The clavicle is the only bony articulation between the axial skeleton and the upper limb [54].
• Functionally, the clavicle mainly acts as a point of muscle attachment [52].
• Some literature suggests that with good repair of the muscle, the only functional consequences of surgical removal of the clavicle are limitations in heavy overhead activity [52].
• Others have found that sudden loss of the clavicle in adulthood has a devastating effect on shoulder function [52].
• The superior shoulder suspensory complex (SSSC) is a bone–soft-tissue ring that provides a stable connection of the glenoid and scapula to the clavicle [12].
• The SSSC is composed of four bony landmarks: distal clavicle, acromion, coracoid process, and glenoid neck [12].
• The SSSC includes the supporting ligamentous complexes of the AC joint and the CC ligaments [12].

Mechanism of Injury and Deformity¶

• A direct blow to the point of the shoulder is the commonest reported mechanism of injury that produces a midshaft fracture of the clavicle [54].
• The most common mechanism of injury in clavicle fractures is a direct blow to the shoulder, whether following a fall or because of direct trauma [40].
• A fall on an outstretched hand can result in a clavicle fracture [40].
• A fall on the shoulder or the outstretched hand may fracture the clavicle [4].
• When the shoulder girdle is subjected to compression force directed from laterally, failure can occur in the acromioclavicular articulation, the clavicle, or the sternoclavicular joint [54].
• Most (85%) clavicle fractures occur in the midshaft of the bone where the bone is narrowest and enveloping soft tissue structures are most scarce [54].
• The direction of the initial deforming force, and both gravitational and muscular forces on the clavicle result in the typical deformity seen after fracture [54].
• In a displaced midshaft fracture, the distal fragment is translated inferiorly, anteriorly, and medially (shortened), and rotated anteriorly [54].
• The lateral fragment of a fractured clavicle is pulled down by the weight of the arm [4].
• The medial fragment of a fractured clavicle is held up by the sternomastoid muscle [4].
• The typical deformity of middle-third fractures is caused by a medial fragment pulled superiorly by the sternocleidomastoid muscle, with the weight of gravity pulling downward on the lateral fragment [12].
• The distal fragment being translated inferiorly, anteriorly, and medially results in the scapula being protracted [54].
• It is typical to see a large abrasion or contusion on the posterior aspect of the shoulder in patients with displaced midshaft clavicular fractures [54].
• Simple falls from a standing height are unlikely to produce a displaced fracture in a healthy young person but can result in injury in elderly, osteoporotic individuals [54].
• Fractures resulting from trivial mechanisms in elderly patients are typically seen in the distal third of the clavicle [54].
• Clavicle fractures are rarely open, despite being caused by high-energy trauma [40].
• Vascular and neurological complications are rare [4].
• Damage to the lung or vessels beneath the clavicle is very rare despite deformity [4].

Classification¶

Epidemiology and Mechanism¶

• Clavicle fractures are the most commonly occurring fracture, with the middle third being the most frequent site [6].
• A fall on an outstretched hand can result in a clavicle fracture, a mechanism initially thought to be the most common cause [40].
• The incidence of clavicle fractures was 1.23% [82].

Allman Classification¶

• Clavicle fractures were initially classified in 1967 based on their anatomic location and in descending order of incidence [40].
• In the Allman classification, Type I fractures involve the middle third of the clavicle [40].
• In the Allman classification, Type II fractures involve the lateral third of the clavicle [40].
• In the Allman classification, Type III fractures involve the medial third of the clavicle [40].
• The Allman classification divides the clavicle into thirds [111].

Neer Classification (Distal/Lateral)¶

• In 1968, the Neer classification subclassified Type II (lateral third) clavicle fractures into three types depending on the integrity of the CC ligaments and the relationship of the fracture line with the CC ligaments and AC joint [40].
• Neer Type I lateral third fractures occur lateral to the CC ligaments and are usually stable [40].
• Neer Type II lateral third fractures are medial to the CC ligaments, are usually unstable, and require surgical management [40].
• Neer Type IIA lateral third fractures occur medial to the intact conoid and trapezoid ligaments [40].
• Neer Type IIB lateral third fractures occur lateral to the torn conoid ligament but medial to the intact trapezoid ligament [40].
• Neer Type III lateral third fractures are intra-articular fractures through the AC joint with intact CC ligaments [40].
• Neer Type III lateral third fractures are usually stable but can result in the development of AC joint arthritis [40].
• Neer Type IV lateral third fractures involve disruption of the clavicular periosteal sleeve in pediatric patients, with displacement occurring at the junction of the metaphysis and physis [40].
• Neer Type V lateral third fractures involve a small, inferior cortical bone fragment remaining attached to the CC ligaments, with the proximal and distal fragments not connected to the coracoid process [40].
• Neer Type V lateral third fractures are rare and generally require surgical intervention for reduction and stabilization [40].
• The modified Neer classification remains the predominantly cited classification system for distal clavicle fractures [55].
• The intra- and interobserver reliability of the modified Neer classification has been demonstrated to be inconsistent, which can lead to incorrect treatment choices and misclassifications in research [55].
• The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair [71].
• Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice [71].
• Nondisplaced distal clavicle fractures can be treated with nonoperative management, specifically Neer types I, III, and IV [95].
• According to the classifications of Neer and Jäger/Breitner, a clear therapeutic strategy for lateral clavicular fractures can be defined [85].

Craig Classification¶

• In 1990, Craig introduced a classification of clavicle fractures based on variable fracture patterns seen within the three broad groups of Allman’s classification [41].
• Craig Group I fractures are fractures of the middle third and account for 80% of clavicle fractures [41].
• Craig Group II fractures are fractures of the distal third and account for 12% to 15% of all clavicle fractures [41].
• Craig Group III fractures are fractures of the proximal third [41].
• Craig Type I distal fractures are interligamentous, occurring between the conoid and trapezoid or between the coracoclavicular and acromioclavicular ligaments, with minimal displacement [41].
• Craig Type I distal fractures are the most common by a ratio of 4:1 [41].
• Craig Type II distal fractures are displaced secondary to a fracture medial to the coracoclavicular ligaments [41].
• Craig Type IIA distal fractures have both conoid and trapezoid ligaments attached to the distal segment [41].
• Craig Type IIB distal fractures have the conoid ligament torn while the trapezoid ligament remains attached to the distal segment [41].
• There is no functional difference between Craig Type IIA and Type IIB distal fractures [41].
• Craig Type III distal fractures involve the articular surface of the acromioclavicular joint alone [41].
• Craig Type IV distal fractures occur in children with ligaments intact to the periosteum and displacement of the proximal fragment [41].
• Craig Type V distal fractures are comminuted, with ligaments attached neither proximally nor distally, but to an inferior, comminuted fragment [41].
• The Craig classification best predicted nonunion or delayed union of lateral third clavicle fractures [40].

Robinson/Edinburgh Classification¶

• The Edinburgh classification was proposed in 1998, dividing clavicular fractures by anatomic location into type I (medial third), type II (middle third), and type III (lateral third) [40].
• In the Robinson classification, a medial clavicle fracture is defined as a fracture in the medial fifth of the clavicle [113].
• In the Robinson classification, a lateral clavicle fracture is defined as a fracture in the lateral fifth of the clavicle [113].
• In the Robinson classification, a clavicle shaft fracture is defined as a fracture in the intermediate three-fifth of the clavicle [113].
• The Edinburgh classification subgroup A indicates displacement less than 100% and subgroup B indicates displacement more than 100% [40].
• The Edinburgh classification subgroup 1 indicates no articular involvement and subgroup 2 indicates intra-articular extension of the fracture [40].
• The Edinburgh classification Type II subgroup 1 indicates simple or wedge-type fractures and subgroup 2 indicates comminuted or segmented fractures [40].
• The Robinson classification had the best prognostic potential for middle third clavicle fractures [40].
• The Edinburgh classification has shown a relationship with clinical outcome for shaft fractures [113].
• Neer Type IIB fractures are also known as Robinson type 3B [93].

AO/OTA Classification¶

• The AO/OTA classification assigns the number 15 to the clavicle [113].
• In the AO/OTA classification, the clavicle is divided into a medial (1), shaft (2), and lateral (3) part [113].
• The AO/OTA classification uses the A, B, and C system for simple, wedge, and comminuted fractures with additional numbers representing different fracture patterns [113].

Pediatric Classification¶

• In children, displacement of the lateral clavicle occurs through the periosteal sleeve rather than through the coracoclavicular ligaments [116].
• Most injuries to the lateral end of the clavicle in the immature skeleton are fractures involving the metaphyseal or physeal regions (Salter-Harris type I or II fractures) [116].
• The lateral epiphysis of the clavicle does not ossify until the age of 18 or 19 years [116].
• Pediatric lateral clavicle injuries are classified into six types based on the Dameron and Rockwood classification [116].
• Pediatric Type I injuries are caused by low-energy trauma with mild strain of the acromioclavicular ligaments and no disruption of the periosteal tube [116].
• Pediatric Type II injuries involve complete disruption of the acromioclavicular ligaments with partial damage to the superolateral aspect of the periosteal sleeve [116].
• Pediatric Type III injuries involve complete disruption of the acromioclavicular ligaments and greater disruption of the periosteal sleeve, resulting in gross instability [116].
• In Pediatric Type III injuries, the coracoid–clavicle interval is increased by 25% to 100% compared to the uninjured contralateral side [116].
• Pediatric Type IV injuries involve posterior displacement of the lateral clavicle, which can pierce the trapezius muscle and/or fascia [116].
• Pediatric Type V injuries involve complete disruption of the superior aspect of the periosteal sleeve, resulting in displacement of the distal clavicle through the trapezial fascia into the subcutaneous tissues [116].
• In Pediatric Type V injuries, the coracoid-clavicle interval is increased by 100% or more compared to that of the contralateral side [116].
• Pediatric Type VI injuries involve inferior displacement of the distal clavicle, with the distal end displaced inferior to the coracoid process [116].

Reliability and Assessment Tools¶

• The Utrecht Score for clavicle fractures is a compact tool developed to assess functional outcome specifically in patients with a clavicle fracture, consisting of patient-reported and objective measures [32].
• The Constant score was found to be reliable for assessing patients with clavicle fractures, especially at the group level [94].
• A new simple classification system for lateral clavicle fractures showed substantial inter- and intraobserver reliability [51].
• A new classification system for distal clavicle fractures demonstrated moderate interobserver and substantial intraobserver reliability [58].

Clinical Presentation¶

Epidemiology and Mechanism¶

• Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [12].
• Approximately 80% of clavicular fractures are middle third, 15% are distal third, and 5% are medial third [12].
• Most clavicular fractures are related to a lateral blow to the shoulder from a fall or a direct blow to the clavicle [12].
• Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side [72].

Physical Examination¶

• The lateral fragment is pulled down by the weight of the arm, while the medial fragment is held up by the sternomastoid muscle [4].
• The fracture is often displaced, producing a lump along the ‘collar-bone’ [4].
• Fractures of the outer third are easily mistaken for acromioclavicular injuries [4].
• A distal neurovascular examination is important because of the proximity of the brachial plexus and the subclavian vessels to the zone of injury [12].
• Tenting of the skin should be evaluated carefully because it can be a sign of impending open fracture [12].
• Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms [28].

Imaging¶

• Upright and supine radiographs, including an AP view of the clavicle and a 15° cephalad tilt view, should be obtained to define displacement when the patient is upright [12].
• A bilateral panoramic view of both shoulders should be obtained to measure clavicular shortening [12].
• CT is the most accurate modality for determining fracture shortening and morphology but not typically obtained [12].
• X-rays show that the fracture is usually in the middle third of the bone and the lateral fragment lies below the medial [4].
• Outer-third injuries need special views to define any fracture [4].
• Lateral clavicle fractures can be well visualized with AP radiographs using a Zanca view, which helps delineate the fracture by removing the overlap of the thoracic cage [99].
• Fractures of the medial clavicle, especially those involving the SC joint, are notoriously difficult to accurately assess with plain radiographs [105].
• CT scanning is the radiographic procedure of choice when the anatomy of a medial clavicle fracture is unclear [105].
• CT scanning can help distinguish between a medial epiphyseal fracture and true SC dislocations [105].
• Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [5].

Prognosis and Outcomes¶

• If patients with medial clavicle fractures can survive the initial trauma, there is every reason to expect good clinical and functional outcomes, regardless of whether surgical or nonsurgical management is chosen [1].
• Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury [18].
• Most patients with clavicle fractures have an excellent outcome using conservative management [7].
• Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively [34].
• Clavicle malunion is a distinct clinical entity that can be treated successfully [14].
• Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial pain syndrome, although the diagnosis was given 1-2 years earlier for people with a previous fracture [8].
• Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [12].

Investigations¶

Clinical Examination¶

Radiography¶

• Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture [79].
• The diagnosis may also be made from a single AP chest radiograph, which may be the only available film in an urgent trauma setting [79].
• The chest radiograph can be used to evaluate the deformity of the involved clavicle relative to the normal side and to look for associated skeletal injuries such as rib, glenoid, and scapular fractures [79].
• A measurement of length can be made on the chest radiograph comparing the injured to the uninjured side [79].
• Shortening of 2 cm or more represents a relative indication for primary fixation [79].
• A radiograph should be taken in the upright position to demonstrate maximal deformity when determining whether operative intervention is warranted [79].
• Ideally, the radiographic beam for the AP radiograph of the clavicle should be angled 20 degrees superiorly to eliminate the overlap of the thoracic cage and show the clavicle in profile [79].
• If the torso is internally rotated a similar 20 degrees, the scapula and shoulder girdle are placed parallel to the cassette for a true AP film [79].
• An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management [131].
• Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons [135].
• When clavicle shortening is considered in the decision to pursue operative management, the use of plain radiograph-based measurements is not recommended [132].

Computed Tomography¶

• CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting [79].
• CT imaging can demonstrate the complex three-dimensional deformity that affects the shoulder girdle with these injuries, including significant scapular angulation and protraction [79].
• CT is useful for evaluating fractures of the medial third of the clavicle and the remainder of the shoulder girdle, such as the glenoid neck in cases of a “floating shoulder” [79].

Follow-up Assessment¶

• Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management [46].
• Close follow-up of nonoperatively treated clavicle fractures is warranted [2].

Treatment¶

General Principles and Epidemiology¶

• Historically, most clavicle fractures have been managed nonoperatively [23].
• In a study year, 8.6% of clavicle fractures were managed by primary surgery [23].
• The highest prevalence of primary surgery was in OTA type B diaphyseal fractures, where 10.4% were managed surgically [23].
• 7.2% of OTA type C lateral fractures were treated with primary surgery [23].
• There were no OTA type A medial fractures in the study year [23].
• Fractures of the clavicle constitute 2% to 5% of all fractures in adults [24].
• Fractures of the clavicle constitute 35% to 44% of all fractures in the shoulder [24].
• The incidence of clavicle fractures is 50 to 64 per 100,000 persons annually [24].
• The risk for clavicle fracture is increased in men aged 30 years or younger and all patients older than 70 years [24].
• Middle third fractures comprise approximately 69% to 81% of all clavicle fractures [24].
• Lateral third fractures account for approximately 17% to 28% of all clavicle fractures [24].
• Medial third fractures constitute the remaining 2% to 3% of all clavicle fractures [24].
• Treatment of clavicle fractures should be tailored to each patient and the type of fracture, amount of displacement and comminution, age and level of activity of the patient, and to some extent, the aesthetic appearance of the shoulder [24].
• Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations [9].
• A targeted approach to the management of mid-shaft clavicle fractures is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union [76].

Non-Operative Management¶

• Nonsurgical management has been the preferred initial mode of treatment for most clavicle fractures [24].
• Nonoperative care is the treatment of choice for most fractures of the clavicle shaft, especially those that are minimally displaced or undisplaced or those that occur in elderly, ill, noncompliant, or sedentary individuals in whom the risk of surgical intervention is too high or the potential benefit is too low [69].
• Nondisplaced clavicle fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment [80].
• Accurate closed reduction is neither possible nor essential for undisplaced middle-third fractures [4].
• For undisplaced middle-third fractures, all that is needed is to support the arm in a sling until the pain subsides, usually 1–3 weeks [4].
• Thereafter, active shoulder exercises should be encouraged, particularly in older patients [4].
• Most surgeons use a sling when treating clavicle fractures nonoperatively [23].
• The sling is usually maintained for 2 weeks and then physical therapy is started [23].
• Comparative studies have shown no advantage of the figure-of-eight bandage over a simple sling [23].
• The figure-of-eight bandage was associated with a higher pain score and no difference in the amount of clavicular shortening compared to a sling [23].
• The sling caused less discomfort and fewer complications than the figure-of-eight bandage [23].
• Patients preferred the sling over the figure-of-eight bandage [69].
• There is little or no convincing evidence that any significant improvement can be made to the original position of the fracture in most cases [69].
• One must typically accept the displacement seen on injury films [69].
• Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up [15].
• Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment [61].
• Proportional shortening of 8% is not associated with impaired function or patient dissatisfaction [23].
• Proportional shortening of 8% did not significantly correlate with the DASH score, Constant score, or SF-12 score at any time during follow-up [23].
• There was no correlation between proportional shortening of 8% and patient satisfaction [23].
• Radiographic malunion was universal in the non-operative group for completely displaced middle third fractures [33].
• The non-union rate was 14% in the non-operative group for completely displaced middle third fractures [33].
• Complications, including non-union and symptomatic malunion, were more frequent in the non-operative group for completely displaced middle third fractures [33].
• There was a direct relationship in the non-operative group between increased displacement and worse DASH score [33].
• Nonsurgical and surgical management provide similar results for distal clavicle fractures [68].
• Fracture displacement and the development of nonunion may not, in isolation, affect outcome especially in the elderly for distal and medial clavicle fractures [70].

Operative Management: Indications¶

• A select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications benefit from surgical fixation [36].
• For healthy, active adults, midshaft clavicular fractures should undergo consideration for surgical stabilization if significantly displaced (2 cm of shortening, 100% displacement or significant comminution) [70].
• Indications for operative treatment of midshaft clavicle fractures include displacement >2 cm [39].
• Indications for operative treatment of midshaft clavicle fractures include shortening >2 cm [39].
• Indications for operative treatment of midshaft clavicle fractures include increasing comminution (>3 fragments) [39].
• Indications for operative treatment of midshaft clavicle fractures include segmental fractures [39].
• Indications for operative treatment of midshaft clavicle fractures include open fractures [39].
• Indications for operative treatment of midshaft clavicle fractures include impending open fractures with soft tissue compromise [39].
• Indications for operative treatment of midshaft clavicle fractures include obvious clinical deformity [39].
• Indications for operative treatment of midshaft clavicle fractures include scapular malposition and winging on initial examination [39].
• Associated injuries that are indications for operative treatment include vascular injury requiring repair [39].
• Associated injuries that are indications for operative treatment include progressive neurologic deficit [39].
• Associated injuries that are indications for operative treatment include ipsilateral upper extremity injuries/fractures [39].
• Associated injuries that are indications for operative treatment include multiple ipsilateral upper rib fractures [39].
• Associated injuries that are indications for operative treatment include “floating shoulder” [39].
• Associated injuries that are indications for operative treatment include bilateral clavicle fractures [39].
• Patient factors that are indications for operative treatment include polytrauma with requirement for early upper extremity weight-bearing/arm use [39].
• Patient factors that are indications for operative treatment include patient motivation for rapid return of function (e.g., elite sports or the self-employed professional) [39].
• Treating displaced middle-third fractures with shortening of more than 2 cm by simple splintage incurs a risk of symptomatic malunion and an increased incidence of non-union [4].
• There is a growing trend towards internal fixation of acute clavicular fractures associated with severe displacement, fragmentation or shortening [4].
• Outer-third fractures are quite troublesome and may need open reduction and internal fixation [4].
• Fractures of the outer (lateral) third with elevation of the clavicular shaft due to rupture of the coracoclavicular ligament may also require internal fixation [4].
• Operative repair should be reserved for medically well, physically active patients who stand to benefit the most from a rapid restoration of normal anatomy and stable fixation [39].
• The consensus is that operative intervention should be reserved for older, larger adolescents with severely displaced fractures [39].
• There may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation in the adolescent population [44].

Operative Management: Techniques and Outcomes¶

• Specific contoured locking plates are available for clavicle fracture fixation [4].
• An advantage of internal fixation is that the patient can mobilize the arm and return to work and independence more quickly [4].
• The use of a pre-contoured plate facilitates surgical care of clavicular fractures, reducing hardware prominence and secondary surgical procedures [70].
• Dual plating may be used as an adjuvant in highly comminuted cases [70].
• Dual plating with 2.4- or 2.7-mm plates may additionally have a benefit of decreased hardware prominence [70].
• High-quality evidence shows that surgical treatment of displaced clavicle fractures in adults results in higher union rates and better early patient-reported outcomes compared with nonsurgical treatment [63].
• Long-term outcomes are similar between surgical and nonsurgical treatment for displaced clavicle fractures in adults [63].
• Plate fixation significantly reduced nonunion, although not having a significant effect on final functional outcomes [16].
• Secondary surgical procedures were performed less often in the surgically treated group when excluding planned hardware removals [16].
• When plate removal was included, revision surgeries were not different between surgical and nonoperative groups [16].
• Surgical management outperformed nonsurgical management in both Disabilities of the Arm, Shoulder and Hand and Constant scores, although averages do not reach minimally clinically important difference at a minimum of 1-year posttreatment follow-up [16].
• The number needed to treat for decreased nonunion in surgically treated patients is 10 [16].
• Risk of revision surgery across all treatment arms when including plate removal was the same [16].
• The operative group had significantly better Constant and DASH scores at all time points compared to the non-operative group for completely displaced middle third fractures [33].
• The operative group was significantly more likely to be satisfied with their shoulder compared to the non-operative group [33].
• There was no significant difference between groups for range of motion for completely displaced middle third fractures [33].
• There is consistent evidence that the rates of malunion and nonunion are less with primary surgery [23].
• There is essentially no evidence that primary surgical treatment improves final patient function [23].
• Tamaoki et al. reported no difference in the DASH scores at 6 weeks, 6 months, and 1 year between operative and nonoperative groups [23].
• Tamaoki et al. reported no difference in pain levels, time to return to previous activities, and dissatisfaction with the cosmetic result between operative and nonoperative groups [23].
• Analysis of the DASH score favored operative management in a review of published evidence [23].
• Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment [27].
• Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome [13].
• In a randomized study, the percentage of patients reporting implant irritation was no different between plate (70%) and intramedullary nail (66%) fixation [16].
• Intramedullary fixation was associated with a higher likelihood of implant removal (82%) compared to plate fixation (50%) [16].
• Superiorly applied plate fixation is an effective treatment for clavicular nonunion [64].
• Treatment of middle-third clavicle non-union after initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited and effective treatment [75].
• Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management [60].
• Bone marrow injection for the treatment of clavicle nonunion is promising, with low morbidity and preliminary success justifying further trials [59].
• Nonunion of the clavicle is treated by bone graft and plating [4].
• In a unit, there is no clearly favoured method of internal fixation of lateral clavicle fractures [100].
• Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [103].

Complications and Cosmetic Outcomes¶

• Damage to the lung or vessels beneath the clavicle is very rare [4].
• Malunion is inevitable in displaced fractures [4].
• In children, the bone is soon remodelled after malunion [4].
• In adults, the slight deformity has to be accepted unless there is a very unsightly bump with skin irritation [4].
• Non-union sometimes occurs in middle-third fractures [4].
• The "Droopy" shoulder complaint was reported by 0 patients in the operative group and 10 patients in the nonoperative group (p=0.001) [37].
• The "Bump/asymmetry" complaint was reported by 0 patients in the operative group and 22 patients in the nonoperative group (p=0.001) [37].
• The "Scar" complaint was reported by 3 patients in the operative group and 0 patients in the nonoperative group (p=0.253) [37].
• The "Sensitive/painful fracture site" complaint was reported by 9 patients in the operative group and 10 patients in the nonoperative group (p=0.891) [37].
• The "Hardware irritation/prominence" complaint was reported by 11 patients in the operative group and 0 patients in the nonoperative group (p=0.001) [37].
• The "Incisional numbness" complaint was reported by 18 patients in the operative group and 0 patients in the nonoperative group (p=0.001) [37].
• 52 patients in the operative group and 26 patients in the nonoperative group were satisfied with the appearance of the shoulder (p=0.001) [37].
• The incidence of clavicle fracture repair increased by 705% from 2001 to 2012 in Sweden [37].
• The overall incidence of clavicle fractures increased from 36 per 100,000 person-years in 2001 to 59 per 100,000 person-years in 2012 [37].
• The authors recommend a more prolonged surveillance period in children with recurrent fractures of the clavicle [21].

Complications¶

General and Non-Operative¶

• Vascular and neurological complications following clavicle fractures are rare [4].
• In children, malunion is soon remodelled, but in adults the slight deformity has to be accepted unless there is a very unsightly bump with skin irritation [4].
• Non-union sometimes occurs in middle-third fractures and is treated by bone graft and plating [4].
• Treating displaced middle-third clavicle fractures with shortening of more than 2 cm by simple splintage incurs a risk of symptomatic malunion, mainly pain and lack of power during shoulder movements [4].
• Treating displaced middle-third clavicle fractures with shortening of more than 2 cm by simple splintage incurs an increased incidence of non-union [4].
• There is a direct relationship in the non-operative group between increased displacement and worse DASH score [33].
• The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively [110].
• Ipsilateral clavicle fracture and acromioclavicular joint injury has an incidence of 6.8% overall [115].

Operative¶

• Complication rates following surgical clavicle fracture care averaged 8.1% [57].
• Hardware irritation or prominence was reported by 11 of 62 patients in the operative group compared to 0 of 49 in the non-operative group [37].
• Incisional numbness was reported by 18 of 62 patients in the operative group compared to 0 of 49 in the non-operative group [37].
• A limited incision approach for plating of acute midshaft clavicle fractures achieved a low complication rate comparable to the reported rate for standard incision techniques [31].
• Operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected adolescent cases [43].
• The technique of clavicle pinning resulted in minimal complications [74].
• Complications in the plate group for adolescent displaced midshaft clavicle fractures were minor [39].
• Five patients in the nonoperative group of an adolescent study with a mean of 26 mm of shortening developed a symptomatic malunion, with four patients choosing corrective osteotomy [39].

Recovery¶

General Outcomes and Prognosis¶

• Patients with medial clavicle fractures who survive the initial trauma are expected to have good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [1].
• Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among patients who survive the trauma [18].
• A high proportion of patients with medial clavicle fractures will die within 3 years of the injury [18].
• Adolescent mid-shaft clavicular fracture displacement does not predict nonunion or inferior functional outcome at long-term follow-up [15].
• Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures [27].
• Recovery occurs earlier following acute treatment compared to non-united clavicle fractures [27].
• Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures [83].
• In a large cohort with long-term follow-up, a limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes [31].
• The complication rate for limited incision plating of acute midshaft clavicle fractures is comparable to the reported rate for standard incision techniques [31].
• Patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern [29].
• Sixty-eight patients with medial clavicle fractures identified over a 5-year period showed excellent functional results following conservative management [22].

Nonoperative Management and Follow-up¶

• Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates [42].
• Shoulder function remains excellent following nonoperative management of displaced distal clavicle fractures [42].
• The risk of complications and delayed surgery is low following nonoperative management of displaced distal clavicle fractures [42].
• Proportional shortening of 8% in nonoperatively treated clavicle fractures is not associated with impaired function or patient dissatisfaction [23].
• Proportional shortening of 8% did not correlate with patient satisfaction in nonoperatively treated clavicle fractures [23].
• A sling is usually maintained for 2 weeks when treating clavicle fractures nonoperatively, after which physical therapy is started [23].
• Comparative studies have shown no advantage of the figure-of-eight bandage over a simple sling for nonoperative management of clavicle fractures [23].
• The figure-of-eight bandage is associated with higher pain scores compared to a simple sling [23].
• There is no difference in the amount of clavicular shortening between the use of a figure-of-eight bandage and a simple sling [23].

Complications and Risk Factors¶

• The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union [126].
• Risk factors for nonunions in lateral clavicle fractures include early mechanical stress, a lateral clavicular fragment larger than 3 cm, and time delay to surgery [136].
• A fracture involving the upper one-third of the ribs significantly increases the rate of the clavicle fracture being > 100% displaced on early follow-up [129].
• Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial pain syndrome (SAPS) [8].
• The diagnosis of subacromial pain syndrome was given 1-2 years earlier for people with a previous clavicle fracture [8].

Key Evidence¶

• [L5] If patients with medial clavicle fractures can survive the initial trauma, there is every reason to expect good clinical and functional outcomes, regardless of whether surgical or nonsurgical management is chosen. [1] (10.1097/corr.0000000000001916)
• [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. [2] (10.1016/j.jse.2018.01.004)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. [5] (10.5435/jaaos-d-17-00598)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. [7] (10.1016/j.jse.2019.06.022)
• [L4] Clavicle fractures were not correlated to an increased occurrence of later diagnosis of SAPS, although the diagnosis was given 1-2 years earlier for people with a previous fracture. [8] (10.1016/j.xrrt.2024.01.008)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. [9] (10.1016/j.jse.2011.08.053)
• [L4] Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome. [13] (10.1007/s00068-018-1024-6)
• [L4] Clavicle malunion is a distinct clinical entity that can be treated successfully. [14] (10.3109/17453674.2010.480939)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. [15] (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L4] Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications. [17] (10.1177/2325967119s00056)
• [L4] Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. [18] (10.1097/corr.0000000000001839)
• [L1] This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. [19] (10.1186/1471-2474-12-196)
• [L5] The authors recommend a more prolonged surveillance period in children with recurrent fractures of the clavicle. [21] (10.1097/bpb.0000000000000231)
• [Paper] Sixty eight patients with medial clavicle fractures were identified over a 5 year period, with excellent functional results seen following conservative management. [22] (10.1016/j.injury.2016.06.011)
• [L2] Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment. [25] (10.1177/2325967119s00428)
• [L3] Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. [27] (10.1016/j.otsr.2017.03.021)
• [L4] Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms. [28] (10.1177/03635465000280062301)
• [L4] The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. [29] (10.1016/j.jse.2020.10.006)
• [L5] In this large cohort with long-term follow-up, a limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to the reported rate for standard incision techniques. [31] (10.1016/j.jse.2025.06.002)
• [L4] The Utrecht Score for clavicle fractures is a compact yet complete tool that was developed to assess functional outcome specifically in patients with a clavicle fracture, consisting of patient-reported and objective measures. [32] (10.1007/s00068-018-0979-7)
• [L2] Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. [34] (10.1177/2325967123s00041)
• [L4] Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. [42] (10.1016/j.jse.2023.12.006)
• [L4] Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively, although operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected cases. [43] (10.2106/jbjs.22.01036)
• [Case_report] Although ORIF of displaced midshaft clavicle fractures remains controversial in the adolescent population, there may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation. [44] (10.1016/j.xrrt.2023.03.004)
• [L1] Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. [46] (10.2106/jbjs.19.00955)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. [51] (10.1016/j.jse.2025.04.021)
• [L5] The modified Neer classification remains the predominantly cited classification system for distal clavicle fractures, yet its intra- and interobserver reliability has been demonstrated to be inconsistent, which can lead to incorrect treatment choices and misclassifications in research. [55] (10.1097/corr.0000000000001456)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. [57] (10.1186/s12891-022-05075-5)
• [L3] The study demonstrated moderate interobserver and substantial intraobserver reliability of the new classification system and the associated treatment choice for distal clavicle fractures. [58] (10.1016/j.otsr.2018.05.015)
• [L4] Bone marrow injection for the treatment of clavicle nonunion is promising, with low morbidity and preliminary success justifying further trials. [59] (10.1016/j.jse.2006.05.001)
• [L3] Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management. [60] (10.1177/1758573221990367)
• [L2] Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment. [61] (10.1177/2325967121s00214)
• [L1] High-quality evidence shows that surgical treatment of displaced clavicle fractures in adults results in higher union rates and better early patient-reported outcomes compared with nonsurgical treatment, though long-term outcomes are similar. [63] (10.5435/jaaos-d-23-00472)
• [L4] Superiorly applied plate fixation is an effective treatment for clavicular nonunion. [64] (10.1016/j.jse.2008.05.046)
• [L4] Nonsurgical and surgical management provide similar results for distal clavicle fractures. [68] (10.5435/00124635-201107000-00002)
• [L4] [69] (10.1016/j.ocl.2009.12.005)
• [L3] The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair, and additional 3D CT did not improve the overall level of interrater or intrarater agreement of the classification system or associated treatment choice. [71] (10.1177/0363546515593949)
• [L4] Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. [72] (10.1177/2325967120921344)
• [L4] The technique of clavicle pinning resulted in minimal complications, short hospital stay and excellent functional outcomes. [74] (10.4103/0973-6042.57895)
• [L4] Treatment of middle-third clavicle non-union after initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited and effective treatment. [75] (10.1016/j.otsr.2013.09.011)
• [L5] A targeted approach to the management of mid-shaft clavicle fractures is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union. [76] (10.1016/j.injury.2020.11.066)
• [L4] Nondisplaced clavicle fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment. [80] (10.3810/psm.2011.09.1930)
• [L4] The incidence of clavicle fractures was 1.23%. [82] (10.1016/j.injury.2011.04.008)
• [L3] Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures. [83] (10.1016/j.injury.2017.10.032)
• [L4] According to the classifications of Neer and Jäger/Breitner, a clear therapeutic strategy for lateral clavicular fractures can be defined. [85] (10.1016/0020-1383(95)00156-5)
• [L4] [93] (10.1302/0301-620x.95b7.31316)
• [L4] The Constant score was found to be reliable for assessing patients with clavicle fractures, especially at the group level. [94] (10.1016/j.jse.2016.02.022)
• [Paper] Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). [95] (10.2106/jbjs.rvw.25.00260)
• [L4] In our unit there is no clearly favoured method of internal fixation of lateral clavicle fractures. [100] (10.1007/s00590-021-03173-z)
• [L5] There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents due to concerns about symptomatic malunion and poor functional outcomes with nonsurgical management, though definitive indications for fixation in this population remain unclear. [102] (10.5435/00124635-201301000-00002)
• [L4] Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. [103] (10.1186/s12891-021-04841-1)
• [L1] This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. [107] (10.1177/1758573218777996)
• [L4] The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. [110] (10.1186/s13018-023-04450-9)
• [L5] [111] (10.1007/s10140-018-1586-y)
• [L4] [113] (10.1007/s00068-019-01122-4)
• [L3] Ipsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall. [115] (10.1016/j.injury.2016.12.021)
• [L5] [123] (10.1016/s0020-1383(15)30035-8)
• [L4] The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union. [126] (10.1097/01.blo.0000183088.60639.05)
• [L2] In addition, a fracture involving the upper one-third of the ribs significantly increases the rate of the clavicle fracture being > 100% displaced on early follow-up. [129] (10.1097/bot.0000000000000758)
• [L4] An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management. [131] (10.1097/bot.0000000000000727)
• [L4] When clavicle shortening is considered in the decision to pursue operative management, the use of plain radiograph-based measurements is not recommended. [132] (10.4055/cios.2016.8.4.367)
• [L3] Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons. [135] (10.1177/0363546514523926)
• [L4] Risk factors for nonunions include early mechanical stress, a lateral clavicular fragment larger than 3 cm, and time delay to surgery. [136] (10.1007/s00402-018-3075-x)

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