Clavicle fixation

Surgeon-side topic for clavicle fixation. Backed by 373 articles from the corpus, retrieved via combined MeSH + title-text matching.

Overview

Rigid clavicular fixation serves as a safe and effective option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in adolescents [1], while plate fixation of nonunions remains successful regardless of plate or graft type [3]. For displaced midshaft fractures, a multicentre randomised controlled trial is designed to compare consolidation and functional outcomes between non-operative treatment and plate fixation [4]. Although the majority of adolescent clavicular fractures are treated nonoperatively [8], selected cases benefit from operative management with plate and screw application, which yields consistently good outcomes and low complication rates [8]. Patients with medial clavicle fractures who survive the initial trauma can expect good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [13].

Operative strategies for specific fracture patterns include augmented distal clavicle osteosynthesis using a Fibertape coracoclavicular cerclage, which produces good clinical outcomes with minimal complications [2], and arthroscopic fixation of unstable distal fractures, which achieves union rates comparable to traditional open techniques [98]. Limited incision plating of acute midshaft fractures achieves good functional and radiographic outcomes with a low complication rate comparable to standard incision techniques [26]. There may be circumstances beyond absolute indications that warrant open reduction and internal fixation for displaced midshaft clavicle fractures in adolescents [40]. While operative management of delayed union and non-union is cost-effective, functional deficits persist at long-term follow-up compared to patients who unite with non-operative management [5]. Furthermore, dual plating for displaced midshaft fractures is cost-effective compared to single plating when indicated [41, 95].

Anatomy & Pathophysiology

Osseous Morphology and Ossification

The clavicle is the only long bone to ossify via intramembranous ossification, beginning from two primary centers by 5 to 6 weeks of gestation and assuming its overall "S" contour by 7 to 8 weeks [11][49]. It is one of the first bones to ossify but also one of the last to complete ossification, with the medial epiphysis being the final site in the body to fuse between 23 and 25 years of age [49][11]. The bone forms a unique S-shaped curve on axial view, resembling an italic S with a greater anteriorly convex medial radius and a smaller posteriorly convex lateral radius [11][53]. In the AP plane, the distal clavicle is flat, while the medial end features a 30% incidence of a rhomboid fossa for costoclavicular ligament insertion and a 2.5% incidence of an actual articular surface facing the first rib [11][53]. The middle portion contains the subclavian groove for subclavius insertion, and the lateral portion features the coracoclavicular process [53]. Muscles inserting on the clavicle include the trapezius on the posterosuperior distal end and the subclavius on the inferior middle third, while muscles originating from it include the deltoid, pectoralis major, sternocleidomastoid, and sternohyoid [53]. The clavicle acts primarily as a point of muscle attachment and a strut between the axial and appendicular skeletons [53][54].

Ligamentous and Joint Complexes

The clavicle serves as the primary stabilizer between the axial skeleton via the sternoclavicular (SC) joint and the appendicular skeleton via the acromioclavicular (AC) joint [11]. The Superior Shoulder Suspensory Complex (SSSC) is a bone–soft-tissue ring composed of the distal clavicle, acromion, coracoid process, and glenoid neck, along with the AC and coracoclavicular (CC) ligamentous complexes [11]. The CC ligaments consist of the conoid ligament (medial) and trapezoid ligament (lateral), which are the primary stabilizers to superior translation of the distal clavicle [11]. The conoid ligament attaches to the conoid tubercle at the lateral end, while the trapezoid ligament attaches to the trapezoid line just lateral to it; the distance from the lateral edge to the conoid tubercle is approximately 45 mm, and to the trapezoid center is approximately 25 mm [53]. The medial end of the clavicle has a 30% incidence of a rhomboid fossa where costoclavicular ligaments insert [53]. The glenoid fossa is pear-shaped and deepened by the labrum by up to 50%, with the scapula serving as the origin or insertion for 18 muscles [48]. The acromion possesses three ossification centers: meta-acromion, mesoacromion, and preacromion [48].

Vascular and Neural Relationships

The primary blood supply to the clavicle is periosteal, with no nutrient blood supply [11]. Important posterior relationships include the subclavian vein and artery and the brachial plexus [53]. The medial anterior curve of the clavicle accommodates these structures, and the curve serves as a landmark for finding the subclavian vein [53]. In trauma, clavicular injury usually does not affect these structures despite their close proximity [53]. However, when neurovascular trauma occurs, it typically involves injury to the carotid artery from a displaced medial clavicle or compression of structures over the first rib [53].

Fracture Epidemiology and Mechanisms

Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [11]. Approximately 80% occur in the middle third, 15% in the distal third, and 5% in the medial third [11]. Most fractures result from a lateral blow to the shoulder from a fall or a direct blow to the clavicle [11]. A direct blow on the point of the shoulder is the commonest mechanism for midshaft fractures, which occur where the bone is narrowest and soft tissue coverage is scarce [54]. Simple falls from standing height are unlikely to cause displaced fractures in healthy young persons but can injure elderly, osteoporotic individuals, typically resulting in distal third fractures [54]. Mechanisms include motor vehicle accidents, bicycling, skiing, sports collisions, and falls [54]. Medialization of a fracture greater than 20 mm is associated with a measurable decrease in functional outcome [11]. Most cases of neurovascular trauma involve injury to the carotid artery or compression over the first rib [53].

Deformity and Classification

The typical deformity of middle-third fractures involves the medial fragment being pulled superiorly by the sternocleidomastoid muscle and the lateral fragment being pulled downward by gravity [11]. The distal fragment is translated inferiorly, anteriorly, and medially (shortened) and rotated anteriorly, resulting in scapular protraction [54]. The pectoralis major, pectoralis minor, and latissimus dorsi draw the distal segment downward and medially, causing overriding [71]. The trapezius and sternocleidomastoid muscles act to draw the clavicular segment superiorly and posteriorly [71].

Lateral Third Fracture Classifications (Neer): * Type I: Fracture lateral to the CC ligaments, usually stable [67]. * Type II: Fracture medial to the CC ligaments, usually unstable, requiring surgical management [67]. * Type IIA: Fracture medial to intact conoid and trapezoid ligaments [67]. * Type IIB: Fracture lateral to the torn conoid ligament but medial to the intact trapezoid ligament [67]. * Type III: Intra-articular fracture through the AC joint with intact CC ligaments [67]. * Type IV: Pediatric periosteal sleeve disruption with displacement at the metaphysis-physis junction [67]. * Type V: Comminuted fracture with a small inferior cortical fragment attached to CC ligaments, while proximal and distal fragments are not connected to the coracoid [67].

Distal Clavicle Fracture Classifications (Robinson): * Type I: Coracoclavicular ligaments remain intact [71]. * Type II: Coracoclavicular ligaments detached from the medial segment [71]. * Type IIA: Both conoid and trapezoid ligaments on the distal segment [71]. * Type IIB: Conoid ligament ruptured, trapezoid attached to distal segment [71]. * Type III: Articular surface of the AC joint alone without ligamentous injury [71]. * Type IV: Pediatric displacement due to muscle forces with CC ligaments attached to bone or periosteum [71]. * Type V: Comminuted with ligaments attached neither proximally nor distally but to an inferior fragment [71].

AC Joint and Scapular Pathology

AC Joint Injuries (Rockwood): * Type I: AC ligament sprain without CC injury or joint widening [52]. * Type II: Complete AC rupture, CC sprain, AC widening, and <25% increase in CC distance [52]. * Type III: Disruption of AC and CC ligaments, AC widening, and 25% to 100% increase in CC distance [52]. * Type IV: Posterior displacement of the distal clavicle into the trapezius muscle [52]. * Type V: Disruption of deltotrapezial fascia with >100% increase in CC distance [52]. * Type VI: Inferior displacement of the clavicle into the subcoracoid space [52].

SC injuries are rare, typically associated with posteriorly directed blows against the medial clavicle or distal shoulder girdle [54]. Posterior SC dislocations result from blows against the medial clavicle, while anterior dislocations result from blows to the distal shoulder girdle [54]. Scapular fractures account for 3% to 5% of shoulder girdle injuries and less than 1% of all fractures [48]. They typically result from high-energy events like motor vehicle accidents (90%) and are associated with hemothorax or pneumothorax (80%), ipsilateral extremity injury (50%), head injury (15%), cervical injury (15%), and neurovascular injury (10%) [48]. Scapulothoracic dissociation involves lateral scapular displacement with severe soft-tissue, brachial, and vascular injury [48].

Outcomes and Nonunion

Most clavicular fractures heal uneventfully without serious consequences with nonoperative treatment [21]. Historically, bony prominences were preferred over unsightly scars from open reduction and internal fixation [21]. Neer and Rowe's series showed nonunion rates of less than 1% in conservatively managed fractures compared with nearly 4% in operatively treated fractures [21]. However, a prospective observational study of 868 patients found a nonunion rate of 6.2% with nonoperative treatment [21]. Risk factors for nonunion in this cohort included advanced age, female sex, 100% displacement, and comminution [21]. A meta-analysis of 2144 fractures showed a 15% nonunion rate for displaced fractures treated nonoperatively versus a 2% rate for operative fixation (ORIF) [21]. Fuglesang et al. reported a 15% nonunion rate with worsening outcomes in patients with displacement greater than 100% [21]. The Canadian Orthopaedic Trauma Society (COTS) concluded that operative treatment resulted in improved functional outcomes and lower rates of malunion and nonunion [21]. In the COTS study, complications occurred in 37% of operative patients versus 63% of nonoperative patients [21]. Smoking, comminution, and fracture displacement were the strongest predictors of nonunion [21].

Classification

New Simple Classification: A recently proposed simple classification system for lateral clavicle fractures demonstrates substantial inter- and intraobserver reliability [57].

Other Considerations: Operative fixation of displaced medial clavicle fractures achieves anatomic reconstruction and excellent functional outcomes, remaining effective even in the setting of symptomatic nonunion [22]. Surgical treatment of clavicular nonunions and malunions yields a 100% union rate and very good clinical results [39]. Plate fixation for delayed and non-union is a successful treatment method regardless of plate or graft type [3] and represents a cost-effective intervention [5]; however, outcomes in delayed and non-union cases remain worse compared to patients who unite with non-operative management [5]. Effective management of lateral clavicular fractures remains an ongoing challenge [19]. Rigid clavicular fixation is a safe and effective option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in adolescents [1]. A modified method of augmented distal clavicle fracture osteosynthesis using Fibertape coracoclavicular cerclage produces good clinical outcomes and minimal complications [2]. The overall incidence of clavicular hardware removal following operative treatment of middle- and distal-third clavicular fractures is 12.6% [25]. Once clavicle fractures are healed, further radiographic imaging provides no notable information [16].

Clinical Presentation

Clavicular fractures represent 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [11]. Approximately 80% occur in the middle third, 15% in the distal third, and 5% in the medial third [11]. Most result from a lateral blow to the shoulder during a fall or a direct blow to the clavicle [11]. A small percentage are associated with severe injuries including scapulothoracic dissociation, scapular fractures, rib fractures, pneumothorax, and neurovascular compromise [11]. The clavicle is subcutaneous with a muscular envelope including the platysma, pectoralis major, deltoid, and neck strap muscles [11].

The typical deformity of middle-third fractures involves a medial fragment pulled superiorly by the sternocleidomastoid muscle and a lateral fragment pulled downward by gravity [11]. This displacement often produces a palpable lump along the 'collar-bone' [10]. Fractures of the outer third are easily mistaken for acromioclavicular injuries [10]. Vascular and neurological complications are rare, and damage to the lung or vessels beneath the clavicle is very rare despite deformity [10]. Tenting of the skin should be evaluated carefully as it can be a sign of impending open fracture [11]. A distal neurovascular examination is important due to the proximity of the brachial plexus and subclavian vessels to the zone of injury [11].

Radiographic Evaluation: X-rays typically show the fracture in the middle third with the lateral fragment lying below the medial [10]. 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 [11]. A bilateral panoramic view of both shoulders should be obtained to measure clavicular shortening [11]. CT is the most accurate modality for determining fracture shortening and morphology but is not typically obtained [11]. For medial clavicle fractures, CT scanning is the procedure of choice, though serendipity and Hobbs views can be performed as initial investigations [79]. Medial clavicle fractures involving the SC joint are notoriously difficult to assess with plain radiographs due to overlap of bony axial structures and the spinal column [80]. CT scans can distinguish between a medial epiphyseal fracture (common in individuals up to 25 years of age) and true SC dislocations [80]. Outer-third injuries require special views to define any fracture [10]. Lateral clavicle fractures can be well visualized with AP radiographs using the Zanca view (a 10- to 15-degree cephalic tilt) to remove overlap of the thoracic cage [79]. To accurately delineate the degree of fracture displacement, lateral clavicle radiographs should be taken with the patient standing and the arm unsupported [80]. A stress view with a 2.26- to 4.53-kg (5- to 10-lb) weight suspended from the wrist may be useful to determine coracoclavicular ligament integrity [80]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [16].

Classification and Deformity: The Allman classification defines fractures of the proximal (medial), middle (midshaft), and distal (lateral) thirds of the clavicle [11]. Neer classified lateral-third fractures based on the integrity of the CC ligament complex and involvement of the AC joint [11]. Medial third fractures are classified according to displacement and involvement of the SC joint [11]. Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [11]. Malunion is inevitable in displaced fractures, though in children the bone is soon remodelled while in adults the slight deformity must be accepted unless there is a very unsightly bump with skin irritation [10].

Anatomical Context: The clavicle is the only long bone to ossify by intramembranous ossification [11]. It serves as the primary stabilizer between the axial skeleton (via the sternoclavicular joint) and the appendicular skeleton (via the acromioclavicular joint) [11]. The conoid ligament is medial and the trapezoid ligament is lateral [11]. The coracoclavicular ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [11]. The superior shoulder suspensory complex (SSSC) is a bone–soft-tissue ring providing a stable connection of the glenoid and scapula to the clavicle [11]. The SSSC is composed of four bony landmarks: distal clavicle, acromion, coracoid process, and glenoid neck, along with the supporting ligamentous complexes of the AC joint and CC ligaments [11]. The primary blood supply to the clavicle is periosteal; there is no nutrient blood supply [11]. The clavicle forms a unique S-shaped curve on the axial view [11]. The distal clavicle is flat in the AP plane [11].

Investigations

Plain radiography: Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries, with approximately 15% occurring in the distal third, 80% in the middle third, and 5% in the medial third [11]. Most result from a lateral blow to the shoulder or a direct blow to the clavicle [11]. The typical deformity of middle-third fractures involves a medial fragment pulled superiorly by the sternocleidomastoid muscle and a lateral fragment pulled downward by gravity [11]. Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis, which may also be made from a single AP chest radiograph in urgent trauma settings [60]. A chest radiograph can evaluate deformity relative to the normal side and identify associated skeletal injuries such as rib, glenoid, and scapular fractures [60]. To best delineate a fracture, a radiograph should be taken in the upright position where gravity demonstrates maximal deformity [60]. 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 [11]. Ideally, the radiographic beam for the AP radiograph of the clavicle should be angled 20 degrees superiorly to eliminate thoracic cage overlap and show the clavicle in profile [60]. 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 [60]. A bilateral panoramic view of both shoulders should be obtained to measure clavicular shortening [11]. A measurement of length can be made on the chest radiograph comparing the injured to the uninjured side [60]. Shortening of 2 cm or more represents a relative indication for primary fixation [60]. X-rays show that the fracture is usually in the middle third of the bone and the lateral fragment lies below the medial [10]. Outer-third injuries need special views to define any fracture [10]. Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [11]. Tenting of the skin should be evaluated carefully as it can be a sign of impending open fracture [11]. A small percentage of clavicular fractures are associated with severe injuries including scapulothoracic dissociation, scapular fractures, rib fractures, pneumothorax, and neurovascular compromise [11].

CT: CT is the most accurate modality for determining fracture shortening and morphology but is not typically obtained [11]. CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting but can demonstrate complex three-dimensional deformity affecting the shoulder girdle [60]. 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" [60]. 3D CT has been shown to be the most sensitive and specific for detection of scapular fractures and has the highest interobserver and intraobserver reliability for measurement of glenopolar angle and angulation [61]. 3D CT with subtraction of the thoracic cage, clavicle, and humerus should be performed when available and may be used in place of radiographs [61]. CT scans can help further examine the fracture pattern and the involvement of the glenoid in pediatric scapula fractures [64].

MRI: Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to distal clavicle fractures should be recommended [103].

Other Considerations: A glenopolar angle (GPA) of 20° or lower has been correlated with poor functional outcomes and has been suggested as an indication for surgical intervention [61]. Normal values of the GPA have been defined between 30° and 46° [61]. The GPA has been shown to be most accurately measured on a 3D CT, whereas measurements made on a chest or shoulder radiograph consistently yielded 5° to 6° lower values [61]. A step-off of approximately 4 to 5 mm or affecting ≥20% of the glenoid has been suggested as an indication for surgical intervention [61]. Any intra-articular glenoid fracture with residual glenohumeral subluxation or instability following a closed reduction should undergo surgical fixation [61]. A lateral border offset of greater than or equal to 20 mm has been proposed as an indication for surgical intervention in extra-articular scapular fractures [61]. Dedicated scapula radiographs including an AP, scapular Y, and axillary lateral should be performed [64]. Radiographs may show lateral displacement of the scapula relative to the spinous processes compared with the contralateral side (increased scapular index) in scapulothoracic dissociation [64]. Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared to non-weighted views [110]. 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 [42]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [16].

Treatment

Non-Operative

The majority of clavicular fractures, including most in adolescents, heal uneventfully with conservative management, yielding excellent functional and radiological outcomes [8, 9, 14, 17, 21]. Historically, nonunion rates were reported as less than 1% in conservatively managed fractures compared with nearly 4% in operatively treated fractures [21]. However, recent evidence indicates that displaced fractures treated nonoperatively carry a higher risk of nonunion, with a meta-analysis reporting a 15% nonunion rate for displaced fractures versus 2% for ORIF [21]. Risk factors for nonunion in nonoperative treatment include advanced age, female sex, 100% displacement, comminution, and smoking [21]. While displacement greater than 100% is associated with higher nonunion rates, some studies show no difference in long-term outcome measures between treatment types [21]. Initial nonsurgical management is reasonable as patients often achieve similar functional outcomes even with delayed surgery [18]. A pain score exhibiting no or minimal change from 2 to 4 weeks after nonoperative treatment of a displaced midshaft fracture is associated with a high risk of symptomatic nonunion [108].

Operative

Indications: Operative treatment is indicated for midshaft fractures with displacement greater than 2 cm, shortening greater than 2 cm, increasing comminution (greater than 3 fragments), segmental fractures, open fractures, impending open fractures with soft tissue compromise, and obvious clinical deformity [24]. Surgery is also indicated for associated injuries including vascular injury requiring repair, progressive neurologic deficit, ipsilateral upper extremity injuries/fractures, multiple ipsilateral upper rib fractures, "floating shoulder," and bilateral clavicle fractures [24]. Patient factors indicating operative treatment include polytrauma requiring early upper extremity weight-bearing/arm use and patient motivation for rapid return of function [24]. For healthy, active adults, surgical stabilization should be considered if significantly displaced (2 cm of shortening, 100% displacement, or significant comminution) [73]. Operative intervention for adolescents should be reserved for older, larger adolescents with severely displaced fractures, though symptomatic malunion can occur in nonoperatively treated displaced midshaft fractures [24]. Clavicular combination injuries are more common than previously believed and should be considered an indication for surgery [82].

Surgical Approach / Technique: The author's preferred technique is open reduction and fixation with precontoured 3.5-mm clavicular DCP using a superior approach [84]. The patient is positioned in the beach-chair semi-sitting position on a regular operating room table with an attached foot piece, with a small pad behind the involved shoulder to elevate it and ensure the anticipated superior drill trajectory is free from obstruction [89]. Fluoroscopy is not mandatory and is used at the discretion of the surgeon if a difficult reduction is anticipated; if used, the C-arm is placed ipsilaterally and enters from the side [89]. The difficulty of reduction and fixation does not increase until approximately 2 weeks following injury, so it may be prudent to delay operative intervention until soft tissue is more robust [89]. Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function [74]. For medial clavicle fractures, if the medial fragment is large enough, standard plate and screw fixation can be performed; a plate with an expanded end section may augment multiple screw purchase [78]. If there is insufficient purchase in medial fragment fixation, the plate can be extended across the joint onto the sternum [78]. Fixation of the fracture using smooth wires or pins alone is contraindicated due to the potential for migration and visceral injury [78].

Implant Selection: Pre-contoured titanium anterior plating of midshaft clavicle fractures results in a 7.7% hardware removal rate for symptomatic hardware, compared to an estimated 20%-60% rate for symptomatic superior clavicle plates [7]. The use of a pre-contoured plate facilitates surgical care, reducing hardware prominence and secondary surgical procedures [73]. Precontoured or "anatomic" plates are ideal as they save time associated with contouring and reduce the requirement for hardware removal [89]. Precontoured plates help to decrease soft tissue irritation that occurs when the end of a straight plate protrudes past the end of the bone [89]. Dual plating with 2.4- or 2.7-mm plates may have a benefit of decreased hardware prominence [73]. A 3.5-mm pelvic reconstruction plate may have a higher failure rate when used in larger, more physically active patients compared to stronger, precontoured plates [89]. Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union [23]. Augmented distal clavicle fracture osteosynthesis using a Fibertape coracoclavicular cerclage produces good clinical outcomes with minimal complications [2]. Both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation can be used to treat distal clavicle fractures, presenting similar, high union rates with minimal risk of complications [29]. Arthroscopic stabilization of acute distal clavicle fractures and dislocations using Tightrope is a safe, simple, cosmetically acceptable, and reproducible method [59]. A new technique for internal fixation of unstable distal clavicle fractures is promising as an alternative, though observations are short-term [62].

Alignment / Balancing Strategy: Where plate fixation is considered appropriate, the use of a reconstruction plate fixed superiorly on the main distal fragment and anteriorly on the main proximal fragments may be more effective than fixation with an S-shaped plate fixed on the superior surface [84]. Randomized controlled trials found no statistical differences between superior plating and anteroinferior plating regarding the incidence of nonunion and Constant and UCLA scores [84]. Randomized controlled trials found no statistical differences between plate fixation and IM nailing regarding functional endpoints and incidence of nonunion at 1-year follow-up [84]. The results of IM fixation appear more unpredictable than the results of plate fixation [84]. There is low-quality evidence of a lack of a clinically important difference in function between intramedullary (IM) fixation and plate fixation [84]. There is uncertainty regarding the reliability of findings that overall adverse events may be less frequent after IM fixation compared to plate fixation [84].

Pain Management: Patients with displaced clavicle fractures benefit clinically and financially from stabilization, experiencing less chronic pain, deformity, and weakness with better range of motion and earlier return to work [37]. Operative management of displaced midshaft clavicle fractures with dual-plating is cost-effective compared to single-plating when indicated [41].

Adjuncts: The risk of iatropathic brachial plexus injury can be reduced by thorough release of tissues from the inferior surface of the clavicle and ensuring no shortening occurs during fixation [6]. Cerclage wiring in isolation is inadequate to control deforming forces at the site of a displaced clavicle fracture and is to be avoided [89].

Setting of Care: Most fractures are amenable to plate fixation and this procedure is within the skill set of most orthopedic surgeons [89].

Revision: Total claviculectomy may be a useful salvage procedure when restoration of normal clavicular osseous anatomy is impossible [15]. Corrective osteotomy can be performed after malunion of midshaft fractures of the clavicle, and extension osteotomy can be performed in malunited clavicular fractures [32]. Thoracic outlet syndrome can be treated by double osteotomy of a clavicular malunion [32].

Other Considerations: Malunion of the clavicle causes significant glenoid malposition and can lead to delayed brachial plexus neurapraxia, impingement syndrome, and late thoracic outlet syndrome [32]. Shortening of the clavicle after fracture has an incidence and clinical significance [32]. Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [86]. Only sutures plus buttons reconstruction restored all stability measures (anterior, posterior, superior, inferior) to native values in AC joint reconstruction implants, while tape implants anteriorized the clavicle [81]. Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among survivors, but a high proportion will die within 3 years of the injury [45]. Low et al. reported successful treatment of five cases of completely displaced medial clavicle fractures using internal fixation (plates and/or screws) [78]. The largest series of displaced medial clavicle fractures (24 patients) showed all healed uneventfully with only three returning for hardware removal after plate fixation [78]. Medial clavicular fractures are often epiphyseal fracture–subluxations or fracture–dislocations, as the medial clavicular epiphysis may persist until 25 to 30 years of age [78]. Fractures that are significantly displaced may warrant operative repair, especially if there is posterior displacement of the shaft fragment [78]. Rigid clavicular fixation is a safe and effective treatment option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in adolescents [1]. Plate fixation of clavicle nonunions remains a successful method of treatment regardless of plate or graft type [3]. Plate fixation for delayed and non-union clavicle fractures is a cost-effective intervention, though functional deficits persist at long-term follow-up compared to patients who unite with non-operative management [5]. The overall incidence of clavicular hardware removal following operative treatment of middle- and distal-third clavicular fractures is 12.6% [25]. 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 [40]. Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations [34]. Treatment recommendations for medial clavicle fractures, lateral clavicle fractures, and scapular fractures are based on lower level research and expert opinion compared to midshaft fractures [73]. The management of scapular fractures continues to evolve with current evidence-based parameters including a GPA of ≤20° or intra-articular step-off of ≥4 to 5 mm [73]. The decision to perform surgery on a displaced scapular fracture based on other criteria should be made on a case-by-case basis [73]. Parameters for the management of distal and medial clavicle fractures remain unclear and should be assessed on a case-by-case basis [73]. Floating shoulder injuries should be carefully assessed on the basis of component injuries individually because surgical management has not been shown to result in improved clinical outcomes [73]. Excellent clinical and radiological outcomes can be achieved with a minimally invasive all-suture fixation technique for displaced distal clavicle fractures, allowing for anatomic reduction and stable fixation [31]. Operative treatment of displaced midshaft clavicle fractures in adults is associated with higher union rates and better early patient-reported outcomes than non-operative treatment, though long-term outcomes are similar [72]. The procedure using lateral clavicle autograft for osteochondritis dissecans of the medial elbow trochlea significantly improved patient pain and mobility without affecting the donor clavicle site at the acromioclavicular joint [106].

Complications

Infection (PJI): Rates of infection following surgical clavicle fracture care range from 0% to 18% [88]. In the specific context of surgery for midshaft clavicle fracture nonunion, wound infection is the most common complication [83]. Complications of surgical treatment include wound infection or dehiscence, deep infection, and problems with the hardware used for fixation [88].

Wound complications: Most complications and the need for secondary procedures in patients undergoing open reduction and plate fixation are related to hardware irritation and/or prominence of the plate [63]. In one surgeon's practice, more than 50% of patients needed plate removal [63]. Anteroinferior plating is associated with fewer symptoms of hardware irritation compared to superior plating [63]. Other adverse events with surgical interventions include hypertrophic and noncosmetic scars [88].

Hardware failure / Irritation: Rates of hardware irritation requiring removal of material range from 50% to 100% [88]. The overall incidence of clavicular hardware removal was 12.6% [25]. Only 7.7% of patients required hardware removal for symptomatic hardware following pre-contoured titanium anterior plating of midshaft clavicle fractures, compared to an estimated 20%-60% reported in literature for symptomatic superior clavicle plates [7]. A retrospective cohort study involving 81 patients reported a low rate of implant removal for soft-tissue irritation (3.7%) using dual mini-fragment plating [83]. Other adverse events with surgical interventions include hardware migration [88].

Neurovascular injury: Vascular and neurological complications are rare in clavicular fractures [10]. Despite deformity, damage to the lung or vessels beneath the clavicle is very rare [10]. No iatrogenic pneumothoraces occurred after plate fixation in a series of 89 patients with isolated clavicular fractures without preoperative pneumothorax [119]. Iatrogenic brachial plexus injury risk can be reduced by thorough release of tissues from the inferior surface of the clavicle and ensuring no shortening occurs during fixation [6]. Transient brachial plexus symptoms are listed among other adverse events with surgical interventions [88].

Nonunion / Malunion: The most common adverse events following conservative treatment are nonunion and malunion [63]. Studies of nondisplaced fractures have reported low rates of nonunion around 0.03% [63], whereas studies of displaced fractures have reported high rates of nonunion up to 15% [63]. Nonunion is the most important predictor of a detrimental or negative functional outcome [63]. Risk factors for nonunion identified in nonoperative treatment include advanced age, female sex, 100% displacement (lack of cortical contact), and presence of comminution [21]. A meta-analysis including 2144 fractures showed a nonunion rate of 15% for displaced clavicular fractures treated nonoperatively, whereas the nonunion rate for ORIF was only 2% [21]. In a prospective randomized trial of 160 patients, the rate of nonunion was significantly greater in the nonsurgical group (23% vs 2.4%) [83]. In a trial of 117 patients, the rate of nonunion was 15% with nonsurgical treatment compared with no nonunions with surgical treatment [83]. In a multicenter trial of 301 patients, there were fewer nonunions in the surgical group (0.8%) than the nonsurgical group (11%) at nine months [83]. Malunion is inevitable in displaced fractures, though in children the bone is soon remodelled while in adults the slight deformity must be accepted unless there is a very unsightly bump with skin irritation [10]. Nonunion sometimes occurs in middle-third fractures and is treated by bone graft and plating [10].

Instability: Anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture is a presentation where rigid clavicular fixation is supported as a safe and effective treatment option [1]. Operative management of an extra-lateral distal clavicle fracture pattern resulted in very good clinical outcomes [33]. Open reduction and tunneled suspensory device fixation for isolated displaced lateral-end clavicular fractures is associated with good functional outcomes and a low rate of complications in the medium term [118].

Other Considerations: Plate fixation for delayed and non-union of midshaft clavicle fractures is a cost-effective intervention, though functional deficits persist at long-term follow-up compared to patients who unite with non-operative management [5]. Operative treatment with plate and screw application in adolescents has consistently good outcomes with a low complication rate in selected cases [8]. A modified method of augmented distal clavicle fracture osteosynthesis with a Fibertape coracoclavicular cerclage produces good clinical outcomes and has minimal complications [2]. Arthroscopically assisted coracoclavicular stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal [44]. Both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation for unstable distal clavicular fractures have a minimal risk of complications and present similar, high union rates [29]. Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate [39]. Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union [23]. 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 [43]. In a Canadian Orthopaedic Trauma Society (COTS) study, complications occurred in 37% of patients treated operatively compared with 63% of patients treated nonoperatively [21]. A prospective observational study of 868 patients treated nonoperatively found a nonunion rate of 6.2% [21]. Fuglesang et al. reported a 15% nonunion rate with worsening outcome scores in patients with displacement greater than 100% [21]. Historically, bony prominences from nonoperative treatment were believed preferable to unsightly scars from open reduction and internal fixation (ORIF) [21]. Nonunion rates in conservatively managed fractures were historically reported as less than 1% compared with nearly 4% in operatively treated fractures [21]. A retrospective cohort study of 1,215 patients found a higher rate of total complications in patients who had surgery for midshaft clavicle fracture nonunion compared with surgical fixation of acute midshaft clavicle fracture [83]. Concomitant chest wall injury did not affect surgery-related complications after clavicle fracture repair [120]. Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision [121]. The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation [122]. Complication rates following surgical clavicle fracture care averaged 8.1% in England [117]. Total claviculectomy may be a useful salvage procedure for clinical situations in which the restoration of normal clavicular osseous anatomy is impossible [15]. Satisfactory clinical and functional results can be achieved following partial or total claviculectomy without reconstruction, with a low complication rate and acceptable mid- to long-term function [46]. A limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to standard incision techniques [26].

Recovery

Light activity (weeks): Patients undergoing rigid fixation for anterior sternoclavicular joint disruption or plate fixation for nonunions can typically resume light activities once union is predictable, though specific week ranges for desk work or driving are not explicitly quantified in the provided evidence [1, 3, 23]. For displaced midshaft fractures managed nonoperatively, delayed assessment at 6 weeks enables accurate prediction of union potential, suggesting a timeline for activity progression based on radiographic healing [42].

Full activity (months): Surgical stabilization of displaced clavicle fractures in adults and adolescents facilitates earlier return to work and sport compared to nonoperative management, with titanium elastic nail (TEN) fixation significantly accelerating return to sport for adolescent athletes [104, 105]. While workers' compensation patients return to work at roughly the same time regardless of surgical or nonoperative treatment, surgery is associated with a shorter time to complete return to work in working populations [69, 94]. Adolescent patients undergoing anatomic open reduction internal fixation (ORIF) may return to play more quickly than previously thought [111].

Complete recovery / outcome plateau (months): Although solid union after realignment of symptomatic nonunion or malunion is predictable, patients may remain functionally impaired, and late reconstruction results in subtle decreases in endurance strength and outcome compared with acute repair [96, 113]. High-quality evidence indicates that while surgical treatment yields better early patient-reported outcomes and higher union rates at 1 year, long-term functional outcomes between surgical and nonoperative groups are similar [43]. Medial clavicle fractures demonstrate favorable functional outcomes and pain relief at minimum 1-year follow-up, though a high proportion of patients may die within 3 years of the injury [45].

Rehabilitation protocol: The provided evidence does not specify detailed rehabilitation protocols, including PT phasing, immobilisation duration, or sling removal timing. However, surgical management with ORIF of displaced middle-third fractures results in earlier bone healing, which may influence the timeline for weight-bearing and range of motion progression [94].

Functional milestones: Surgical treatment leads to less chronic pain, deformity, and weakness with better range of motion and earlier return to work compared to nonoperative management [37]. Nonoperative management of adolescent mid-shaft fractures results in excellent functional outcomes at long-term follow-up, while displaced distal fractures managed nonoperatively result in higher nonunion rates but maintain excellent shoulder function [17, 20]. Patients with medial clavicle fractures who survive the initial trauma can expect good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [13].

Other Considerations: Rigid clavicular fixation is a safe and effective treatment option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in adolescents [1]. Plate fixation of clavicle nonunions remains successful regardless of plate or graft type, with cortical bone grafting associated with restoration of clavicular length and high union rates [3, 23]. Satisfactory results can be achieved following partial or total claviculectomy without reconstruction for oncologic causes, with low complication rates and acceptable mid- to long-term function [46]. The risk of iatropathic brachial plexus injury can be reduced by thorough release of tissues from the inferior surface of the clavicle and ensuring no shortening occurs during fixation [6]. Symptomatic hardware removal is required in only 7.7% of patients with pre-contoured titanium anterior plating, compared to an estimated 20%-60% for superior clavicle plates [7]. A limited incision approach achieves outcomes comparable to standard techniques with a low complication rate [26]. Arthroscopically assisted coracoclavicular ligament stabilization demonstrates high union rates while limiting complications or the need for secondary hardware removal [44]. Effective management of lateral clavicular fractures remains an ongoing challenge [19]. Conservative management is supported for uncomplicated displaced fractures, but a lower threshold for early surgery should be considered where optimal shoulder function is required [93]. Initial nonsurgical management may be reasonable as patients had similar functional outcomes even when surgery was delayed [18].

Key Evidence

• [Case_report] This case adds to the limited literature and supports the role of rigid clavicular fixation as a safe and effective treatment option in similar presentations. (10.1016/j.xrrt.2026.100697)
• [L4] The described technique of augmented fixation of the distal clavicle is effective, produces good clinical outcomes, and has minimal complications. (10.5397/cise.2022.00913)
• [L4] Plate fixation of clavicle nonunions remains a successful method of treatment. (10.1016/j.jse.2020.06.035)
• [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. (10.1186/1471-2474-12-196)
• [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. (10.1177/1758573221990367)
• [L4] The risk can be reduced by thorough release of tissues from the inferior surface of the clavicle and ensuring no shortening occurs during fixation. (10.1302/0301-620x.95b1.29625)
• [L4] Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates. (10.1016/j.jse.2021.05.021)
• [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. (10.2106/jbjs.22.01036)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. (10.1016/j.jse.2019.06.022)
• [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. (10.1097/corr.0000000000001916)
• [L4] Conservative treatment of clavicle fractures yields significantly good clinical and radiological outcomes. (10.1016/j.xrrt.2026.100679)
• [L4] Total claviculectomy may be a useful salvage procedure for clinical situations in which the restoration of normal clavicular osseous anatomy is impossible. (10.2106/jbjs.e.01436)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. (10.5435/jaaos-d-17-00598)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L3] Initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. (10.5435/jaaos-d-16-00130)
• [L2] Effective management of lateral clavicular fractures remains an ongoing challenge. (10.1016/j.xrrt.2024.11.002)
• [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. (10.1016/j.jse.2023.12.006)
• [L4] Operative fixation of displaced medial clavicle fractures results in anatomic reconstruction and excellent functional outcomes, even in the setting of fixation performed for symptomatic nonunion. (10.1016/j.jse.2015.04.011)
• [L4] Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union. (10.1016/j.jseint.2020.04.002)
• [L4] The overall incidence of clavicular hardware removal was 12.6%. (10.1016/j.jse.2020.06.034)
• [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. (10.1016/j.jse.2025.06.002)
• [L3] Both procedures can be used to treat distal clavicle fractures because they have a minimal risk of complications and present similar, high union rates. (10.1016/j.jseint.2021.05.007)
• [L2] In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. (10.1016/j.jse.2013.06.025)
• [L4] Excellent clinical and radiological outcomes can be achieved with this minimally invasive all-suture fixation technique for displaced distal clavicle fractures, which allows for an anatomic reduction and stable fixation. (10.1016/j.xrrt.2022.01.005)
• [L4] The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. (10.1016/j.jse.2020.10.006)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. (10.1016/j.jse.2011.08.053)
• [L4] Nonsurgical management of adolescent diaphyseal clavicle fractures yields equivalent functional outcomes to surgical management but with nearly four times fewer complications, supported by the clavicle's robust remodeling potential in this population. (10.5435/jaaos-d-23-00116)
• [L3] Patients with displaced clavicle fractures benefit clinically and financially from stabilization, experiencing less chronic pain, deformity, and weakness with better range of motion and earlier return to work. (10.1016/j.jse.2012.06.006)
• [L3] Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate. (10.1016/j.jseint.2023.07.005)
• [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. (10.1016/j.xrrt.2023.03.004)
• [L5] When indicated, operative management of displaced midshaft clavicle fractures with dual-plating is cost-effective compared to single-plating. (10.1177/2325967123s00167)
• [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. (10.2106/jbjs.19.00955)
• [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. (10.5435/jaaos-d-23-00472)
• [L4] Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal. (10.1016/j.xrrt.2024.02.003)
• [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. (10.1097/corr.0000000000001839)
• [L4] Satisfactory clinical and functional results can be achieved following partial or total claviculectomy without reconstruction, with a low complication rate and acceptable mid- to long-term function. (10.1016/j.jse.2023.03.010)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. (10.1016/j.jse.2025.04.021)
• [L4] The results demonstrate that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coracoclavicular ligaments or the distal clavicle. (10.1016/j.arthro.2009.04.017)
• [L4] Although observations are short term, the technique is promising as an alternative for internal fixation of distal clavicle fractures. (10.1016/j.jse.2007.04.012)
• [L2] Workers' compensation patients treated for clavicle fractures return to work at roughly the same time whether they are treated surgically or nonoperatively, with surgery being roughly 3 times more expensive. (10.1016/j.jse.2016.02.004)
• [L4] Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function. (10.1016/j.jse.2015.11.036)
• [L5] Only the sutures + buttons reconstruction restored all stability measures (anterior, posterior, superior, inferior) to native values, while tape implants wrapped around the bones anteriorised the clavicle. (10.1007/s00167-021-06700-x)
• [L4] Clavicular combination injuries (CCI) are more common than previously believed and should be considered an indication for surgery. (10.3390/jcm10245764)
• [L4] Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. (10.1186/s12891-021-04841-1)
• [L3] We support the conservative management of uncomplicated displaced clavicle fractures but recognize that a lower threshold for early surgery should be considered where optimal shoulder function is required. (10.1016/j.jse.2014.09.037)
• [L1] Surgical treatment with ORIF of displaced middle-third clavicular fractures resulted in good and excellent functional results, shorter time to complete return to work, earlier bone healing, and fewer cases of nonunions in a working population under injury compensation. (10.1016/j.jse.2014.11.041)
• [L2] When indicated, operative management of displaced midshaft clavicle fractures using dual plating was found to be cost-effective compared with single plating. (10.2106/jbjs.23.00338)
• [L4] Although solid union after realignment of symptomatic nonunion or malunion of midshaft clavicle fractures is predictable, the patients can remain functionally impaired. (10.1016/j.jse.2006.12.002)
• [L4] Arthroscopic fixation of distal clavicle fractures resulted in good functional outcomes with union rates comparable to traditional open techniques. (10.1177/23259671211001773)
• [L1] Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to distal clavicle fractures should be recommended. (10.1186/s13018-022-02919-7)
• [L3] 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. (10.1186/s13018-026-06708-4)
• [L1] Surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. (10.1097/corr.0000000000000986)
• [Case_report] The procedure significantly improved patient pain and mobility and did not affect the donor clavicle site at the acromioclavicular joint. (10.1016/j.xrrt.2024.09.001)
• [L3] A pain score that exhibits no or minimal change from 2 to 4 weeks after nonoperative treatment of a displaced midshaft fracture of the clavicle is associated with a high risk that symptomatic nonunion will develop. (10.1097/corr.0000000000001411)
• [L4] Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared to non-weighted views. (10.1016/j.jseint.2023.06.011)
• [L3] These data suggest that adolescent patients undergoing anatomic ORIF of midshaft clavicle fractures may be able to return to play more quickly than previously thought. (10.1177/2325967125s00119)
• [L3] Late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle is a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair. (10.1016/j.jse.2007.01.001)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. (10.1186/s12891-022-05075-5)
• [L4] ORTSD fixation for isolated displaced lateral-end clavicular fractures in medically fit patients is associated with good functional outcomes and a low rate of complications in the medium term. (10.2106/jbjs.18.00569)
• [L4] Within this series of 89 patients with isolated clavicular fractures without preoperative pneumothorax, no iatrogenic pneumothoraces occurred after plate fixation. (10.1016/j.jse.2018.09.016)
• [L3] CWI did not affect surgery-related complications after clavicle fracture repair. (10.1186/s12891-021-04148-1)
• [L3] Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision. (10.1016/j.jseint.2021.11.001)
• [L2] The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. (10.1016/j.jse.2022.03.016)

See Also

• Clavicle Fracture
• Fractures
• Internal Fixation
• Os Acromiale
• Fracture Fixation

References

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