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Clavicle fixation

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

133 citationsUpdated Sep 2026

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Overview

Clavicle fracture management is individualized based on fracture characteristics and patient expectations rather than broadly applied protocols [30]. While most patients achieve excellent outcomes with conservative management [8], surgical intervention is indicated for specific presentations. In adult patients with displaced mid-third clavicle fractures, surgical treatment leads to a greater likelihood of union at one year of follow-up [33]. For adolescents, the majority of clavicular fractures can and should be treated nonoperatively, though operative treatment with plate and screw application yields consistently good outcomes with a low complication rate in selected cases [14]. Distal clavicle fractures managed nonoperatively exhibit higher nonunion rates, yet shoulder function remains excellent with a low risk of complications and delayed surgery [19]. Medial clavicle fractures, if the patient survives the initial trauma, are expected to yield good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [23].

Surgical fixation is associated with reliable bony union and improved shoulder function when thoughtful planning, appropriate implant choice, and meticulous technique are applied to clavicle nonunion and malunion [2]. Open reduction and internal fixation with bone grafting provides good long-term functional and radiological results, allowing most patients to return to a functional level close to the general population [4]. Plate fixation remains a successful method for treating clavicle nonunions [7], and surgical treatment of these conditions is associated with very good clinical results and a 100% union rate [15]. Operative fixation of displaced medial clavicle fractures results in anatomic reconstruction and excellent functional outcomes, even when performed for symptomatic nonunion [16]. For distal clavicle fractures, both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation present similar, high union rates with minimal risk of complications [22]. Arthroscopic fixation yields good functional outcomes with union rates comparable to traditional open techniques [71], while augmented fixation of the distal clavicle is effective with minimal complications [1]. A new technique for internal fixation of distal clavicle fractures is promising as an alternative, although observations are short term [13].

Long-term follow-up of acute midshaft clavicle fracture fixation demonstrates excellent functional outcomes, with no difference in reoperation rates between plate types or locations [10]. A limited incision approach for plating acute midshaft clavicle fractures achieves good functional and radiographic outcomes with a low complication rate comparable to standard incision techniques [55]. When indicated, operative management of displaced midshaft clavicle fractures with dual-plating is cost-effective compared to single-plating [83, 85]. Clavicle fixation for delayed and non-union is a cost-effective intervention, though outcomes are worse compared to patients that unite with non-operative management [6]. Rigid clavicular fixation is a safe and effective treatment option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in an adolescent [3]. Hardware removal is more common in women, who are four times more likely than men to undergo the procedure, and patients undergoing clavicle hardware removal report worse long-term outcomes than those with hardware retained [11].

Anatomy & Pathophysiology

Bony Anatomy

The clavicle is the only long bone to ossify by intramembranous ossification [34]. Ossification begins from two primary centers, medial and lateral, by 5 to 6 weeks of gestation [103]. By 7 to 8 weeks of gestation, the bone assumes its overall contour and "S" shape [103]. Approximately 80% of clavicle growth occurs from the medial physis [103]. The lateral epiphysis fuses at approximately 18 to 19 years of age [103]. The medial epiphysis is the last in the body to ossify, occurring at 18 to 20 years of age, and completes ossification at 23 to 25 years [103]. The medial clavicular epiphysis may persist in patients until 25 to 30 years of age [77].

In the transverse plane, the clavicle resembles an italic S, with the greater radius of curvature at the medial curve (anteriorly convex) and the smaller lateral curve being posteriorly convex [105]. The bone is somewhat rounded in its midsection and medially, and relatively flat laterally [105]. The distal clavicle is flat in the AP plane [34]. The medial end features a rhomboid fossa on its inferior surface in 30% of cases, where the costoclavicular ligaments insert, and an actual articular surface facing inferiorly toward the first rib in 2.5% of cases [105]. The middle portion contains the subclavian groove where the subclavius muscle has a fleshy insertion [105]. The lateral portion has a coracoclavicular process when present [105].

The primary blood supply to the clavicle is periosteal, with no nutrient blood supply [34]. The clavicle is subcutaneous, with a muscular envelope including the platysma, pectoralis major, deltoid, and some strap muscles of the neck [34].

Ligaments and Soft Tissue

The coracoclavicular (CC) ligaments consist of the conoid (medial) and trapezoid (lateral) ligaments [34]. These ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [34]. The conoid ligament attaches to the clavicle at the conoid tubercle, while the trapezoid ligament attaches at the trapezoid line, which lies in an anteroposterior direction just lateral to the conoid tubercle [105]. 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 [105]. 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 [105].

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 [34]. The SSSC is composed of four bony landmarks: distal clavicle, acromion, coracoid process, and glenoid neck [34]. It includes the supporting ligamentous complexes of the AC joint and the CC ligaments [34].

Muscular attachments define the soft tissue envelope. The pectoralis major originates from the anterior portion of the medial two-thirds of the clavicle [105], merging with the origin of the anterior deltoid laterally [108]. The sternocleidomastoid largely originates on the posterior portion of the middle third of the clavicle [105], with the sternohyoid originating just medial to this origin [105]. The deltoid originates on the anterior portion of the inner surface of the lateral curve of the clavicle [105]. The trapezius inserts on the posterosuperior surface of the distal end of the clavicle [105], blending superiorly with the deltoid origin at the lateral margin [108]. The subclavius muscle inserts on the undersurface of the clavicle and serves as a soft tissue buffer in the subclavicular space superior to the brachial plexus and subclavian vessels [108]. The platysma usually envelopes the anterior and superior aspects of the clavicle [108].

Neurovascular Anatomy

The supraclavicular nerves originate from cervical roots C3 and C4 and exit from a common trunk behind the posterior border of the sternocleidomastoid muscle [112]. There are typically three major branches (anterior, middle, and posterior) that cross the clavicle superficially from medial to lateral [112].

The subclavian vein runs directly below the subclavius muscle and above the first rib [112]. The subclavian artery and brachial plexus lie more posteriorly than the subclavian vein, separated from the vein and clavicle by the scalenus anterior muscle medially [112]. The brachial plexus is closest to the clavicle in its midportion [112]. In the middle third of the clavicle, the subclavian artery is a mean of 17 mm from the clavicle, and the subclavian vein is a mean of 13 mm from the clavicle [112]. In this region, the subclavian vessels are located at an approximate angle of 60 degrees to the horizontal, posterior-inferior to the clavicle [112]. Laterally, the subclavian artery is a mean of 63 mm from the clavicle, and the subclavian vein is a mean of 76 mm from the clavicle [112]. The subclavian vessels are closest to the clavicle at the medial end, with the vein directly apposed to the posterior cortex of the medial clavicle in some cases [112].

Mechanism of Injury and Deformity

Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [34]. Approximately 80% are middle third, 15% are distal third, and 5% are medial third [34]. A direct blow on the point of the shoulder is the commonest reported mechanism of injury that produces a midshaft fracture [106]. Most (85%) clavicle fractures occur in the midshaft of the bone where the bone is narrowest and enveloping soft tissue structures are most scarce [106]. A fall on the shoulder or the outstretched hand may fracture the clavicle, with the lateral fragment pulled down by the weight of the arm and the medial fragment held up by the sternomastoid muscle [29]. 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, typically seen in the distal third of the clavicle [106].

The direction of the initial deforming force, and both gravitational and muscular forces on the clavicle result in the distal fragment being translated inferiorly, anteriorly, and medially (shortened), and rotated anteriorly [106]. The medial clavicular fragment is elevated by the unopposed pull of the sternocleidomastoid muscle [108]. The distal clavicular fragment is held inferiorly by the deltoid and medially by the pectoralis major [108]. 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 [34]. Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [34].

A large abrasion or contusion on the posterior aspect of the shoulder is typical in patients with displaced midshaft clavicular fractures [106]. Tenting of the skin can be a sign of impending open fracture [34]. Fractures of the outer third are easily mistaken for acromioclavicular injuries [29]. Vascular and neurological complications of clavicle fractures are rare [29].

Pathophysiology of Displacement and Instability

The clavicle serves as the primary stabilizer between the axial skeleton (via the sternoclavicular joint) and the appendicular skeleton (via the acromioclavicular joint) [34]. In Group II (distal third) clavicle fractures, the coracoclavicular ligaments are detached from the medial segment in Type II fractures [138]. In Type IIA distal clavicle fractures, both the conoid and trapezoid ligaments are on the distal fragment [138]. In Type IIB distal clavicle fractures, the conoid ligament is ruptured while the trapezoid ligament remains attached to the distal segment [138]. The high rate of nonunion in Type II distal clavicle fractures may be secondary to excessive motion at the fracture site [138].

In Type II distal clavicle fractures, the outer fragment is pulled downward and forward by the weight of the arm [138]. The pectoralis major, pectoralis minor, and latissimus dorsi draw the distal segment downward and medially, causing overriding [138]. The scapula may rotate the distal segment as the arm is moved [138]. The trapezius muscle draws the clavicular segment superiorly and posteriorly, often into the substance of the trapezius muscle [138]. The proximal fragment is retracted upward and backward within the substance of the trapezius muscle [145]. The distal fragment drops downward and forward and is rotated by any movements of the scapula [145]. Fractures of the distal third of the clavicle can become unacceptably displaced if the continuity of the coracoclavicular ligament between the coracoid process and the proximal clavicular segment is disrupted [147]. The same situation of unacceptable displacement can occur with type I distal clavicle fractures if the coracoid process is fractured [147].

Type III distal clavicle fractures involve the articular surface of the acromioclavicular joint alone [138]. These fractures may be manifested as late degenerative joint arthrosis of the acromioclavicular joint [138]. Weightlifter’s clavicle, or resorption of the distal end of the clavicle, might occur from increased vascularity secondary to microtrauma or microfractures [138].

In children, displacement of the lateral clavicle occurs through the periosteal sleeve rather than through the coracoclavicular ligaments [109]. 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) [109]. The lateral epiphysis of the clavicle does not ossify until the age of 18 or 19 years, allowing these metaphyses to manifest radiographically as an acromioclavicular dislocation (pseudodislocation) [109].

AC joint injuries are classified by ligamentous disruption and displacement. In Type II AC joint injuries, the AC ligament is completely ruptured, the CC ligament is sprained, and the CC distance is increased by less than 25% compared with the contralateral shoulder [57]. In Type III AC joint injuries, the AC and CC ligaments are disrupted, and the CC distance is increased 25% to 100% compared with the contralateral shoulder [57]. In Type IV AC joint separation, the distal clavicle is displaced posteriorly into the trapezius muscle [57]. In Type V AC joint injury, the CC distance is increased by more than 100% compared with the contralateral shoulder because of disruption of the deltotrapezial fascia [57]. In Type VI AC joint injury, the clavicle is displaced inferiorly into the subcoracoid space [57].

A floating shoulder represents a double disruption of the SSSC, typically involving a glenoid neck fracture and a midshaft clavicle fracture [115]. In a floating shoulder, each disruption has the potential to make the other unstable [115]. Clavicle fixation alone does not result in a statistically significant immediate improvement in radiographic parameters of scapular alignment, including glenopolar angle, medialization, sagittal angulation, and sagittal displacement [95]. Restoration of clavicular length alone is insufficient to counteract gravitational forces and muscular vectors acting on the coracoid-based distal fragment in double disruptions of the SSSC [95]. Angular rotations and positions of the clavicle and scapula change significantly with position due to the effect of gravity [179].

Classification

Robinson: This classification defines the lateral one-fifth of the clavicle as Type 3 [193].

Neer: Type IIB fractures involve a torn conoid ligament with the trapezoid ligament presumed to remain attached to the distal fragment [42]. Type IV fractures involve disruption of the periosteal sleeve in the pediatric population and are injuries to the growth plate [42]. Type V fractures were subsequently added to the classification [42]. A modified Neer classification has been proposed to be updated to include the extra-lateral distal clavicle fracture pattern as a type IIC fracture [44].

Edinburgh: This system has the highest correlation with prognosis for middle-third fractures of the clavicle [26]. Middle-third clavicle fractures are defined as greater than one-third distance from the medial edge of the clavicle [26]. The cutoff for lateral to middle third clavicle fractures is defined as the medial edge of the conoid ligament, described as 31% of the length of the clavicle from the lateral border [26].

CCI: The various subtypes of this classification belong to a common group of one entity [79].

Other Considerations: A proposed classification system for monopolar and bipolar combination injuries of the clavicle includes higher-grade, complete, and unstable joint dislocations of the SCJD type Allman III and ACJD at least from type Rockwood III(b) [79]. A new simple classification system for lateral clavicle fractures showed substantial inter- and intraobserver reliability [111].

Clinical Presentation

History and Mechanism

Most clavicular fractures result from a lateral blow to the shoulder during a fall or a direct blow to the clavicle [34]. A fall on the shoulder or an outstretched hand may also fracture the bone [29]. The lateral fragment is pulled down by the weight of the arm, while the medial fragment is held up by the sternomastoid muscle [29]. This mechanism often produces displacement, creating a palpable lump along the ‘collar-bone’ [29]. While vascular and neurological complications are rare [29], a small percentage of clavicular fractures are associated with more severe injuries, including scapulothoracic dissociation, scapular fractures, rib fractures, pneumothorax, and neurovascular compromise [34].

Physical Examination

A distal neurovascular examination is essential due to the proximity of the brachial plexus and subclavian vessels to the zone of injury [34]. Skin tenting must be evaluated carefully, as it can indicate an impending open fracture [34].

Imaging

Standard X-rays typically show the fracture in the middle third of the bone, with the lateral fragment lying below the medial fragment [29]. Outer-third injuries require special views to define any fracture [29]. To define displacement when the patient is upright, obtain upright and supine radiographs, including an AP view of the clavicle and a 15° cephalad tilt view [34]. A bilateral panoramic view of both shoulders should be obtained to measure clavicular shortening [34]. CT is the most accurate modality for determining fracture shortening and morphology but is not typically obtained [34].

Lateral Clavicle Fractures: Lateral clavicle fractures are well visualized with AP radiographs using the Zanca view, which delineates the fracture by removing thoracic cage overlap [150]. CT scanning is rarely required clinically but can be useful in selected cases to determine intra-articular extension or displacement [151].

Medial Clavicle Fractures: Fractures of the medial clavicle, especially those involving the SC joint, are notoriously difficult to accurately assess with plain radiographs [151]. CT scanning is the radiographic procedure of choice when the anatomy of a medial clavicle fracture is unclear [151]. CT can help distinguish between a medial epiphyseal fracture and true SC dislocations [151].

Epidemiology and Classification

Allman Classification: Defines fractures of the proximal (medial), middle (midshaft), and distal (lateral) thirds of the clavicle [34].

Neer Classification: Classifies lateral-third fractures based on the integrity of the CC ligament complex and the involvement of the AC joint [34].

Medial Third Fractures: Classified according to the displacement and involvement of the SC joint [34].

Robinson Classification: Describes medial fractures as Type I, middle third fractures as Type II, and distal third fractures as Type III [151].

AO/OTA Classification: Designates the clavicle as segment 15 and divides it into medial metaphyseal, diaphyseal, and lateral metaphyseal fractures [151].

Prognostic Indicators

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 [21].

Investigations

Imaging

Plain radiography: Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture [61]. To best delineate the fracture, radiographs should be taken in the upright position to demonstrate maximal deformity due to gravity [61]. The radiographic beam for the AP radiograph should be angled 20 degrees superiorly to eliminate overlap of the thoracic cage and show the clavicle in profile [61]. Internal rotation of the torso by 20 degrees places the scapula and shoulder girdle parallel to the cassette for a true AP film [61]. A single AP chest radiograph can be used to evaluate clavicular deformity relative to the normal side and to identify associated skeletal injuries such as rib, glenoid, and scapular fractures [61]. Shortening of 2 cm or more on chest radiograph represents a relative indication for primary fixation [61]. Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared to non-weighted views [220]. For patients undergoing ORIF of isolated clavicular fractures, obtaining a postoperative chest radiograph may be an unnecessary practice given its low sensitivity [100]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [39].

CT: CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting but can demonstrate complex three-dimensional deformity affecting the shoulder girdle, including significant scapular angulation and protraction [61]. 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” [61]. CT is the most accurate modality for determining fracture shortening and morphology but is not typically obtained [34].

Classification and Assessment

Neer classified lateral-third fractures based on the integrity of the coracoclavicular ligament complex and the involvement of the acromioclavicular joint [34]. Medial third fractures are classified according to the displacement and involvement of the sternoclavicular joint [34]. The use of 3D imaging, modeling, and printing with open-source software allows for reproducible results in correcting complex clavicle malunions [224].

Associated Injuries and Complications

Clavicle fixation alone does not result in a statistically significant immediate improvement in radiographic parameters of scapular alignment, including the glenopolar angle, medialization, sagittal angulation, and sagittal displacement [95]. Restoration of clavicular length alone is insufficient to counteract gravitational forces and muscular vectors acting on the coracoid-based distal fragment in double disruptions of the superior shoulder suspensory complex [95].

Treatment

Non-Operative

Conservative treatment of clavicle fractures yields significantly good clinical and radiological outcomes [24]. In adolescents, nonoperative management of mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up [25], and comparably excellent outcomes for severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment [140]. Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively [14].

Operative

Indications: Specific treatment of clavicle fractures should be individualized based on fracture characteristics and patient expectations rather than broadly applied [30]. 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) [50]. A targeted approach is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union [128]. 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 [32]. In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment [64]. 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 [54]. Stabilisation of the clavicle gives better functional scores compared to conservative treatment in the short term for patients with a 'floating shoulder' [28]. 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 [205].

Surgical Approach / Technique: The patient is positioned in the beach-chair semi-sitting position on a regular operating room table with an attached foot piece to support the legs for clavicle plate fixation [160]. It is helpful to place a small pad behind the involved shoulder to elevate it and ensure that the anticipated superior drill trajectory is free from obstruction during clavicle plating [160]. Radiographs of the injured clavicle are usually sufficient for preoperative planning, allowing the surgeon to observe displacement severity, fragment number, and main fracture line location [160]. The difficulty of reduction and fixation for midshaft clavicle fractures does not increase until approximately 2 weeks following injury, so it may be prudent to delay operative intervention until soft tissue is more robust [160]. An infraclavicular approach aims to preserve soft tissue attachments and allow for the wound to not be in contact with the plate, whilst maintaining good surgical access and providing a more cosmetically acceptable scar [96]. Oblique and transverse incisions have equivalent effects on recovery of shoulder joint function for fractures of the middle and outer third of the clavicle [45]. A superior approach and plating is a preferred technique for open reduction and fixation of clavicle fractures, using a precontoured 3.5-mm clavicular DCP [153]. There is often a vertically oriented anterosuperior fragment in midshaft clavicle fractures which may benefit from lag screw fixation, and mini-fragment screws should be available as this fragment may be quite narrow [160]. The number of screws that potentially can be placed into the distal fragment can be determined preoperatively so that the appropriate size of plate can be available [160]. If a lag screw is placed during clavicle plating, it is sufficient to insert three bicortical screws (six cortices) proximally and three distally; if a lag screw is not possible, four screws should be placed proximally and four distally [153]. For medial clavicle fractures, following identification, debridement, and reduction, the fracture can be temporarily held reduced with K-wires before definitive plate fixation [77]. 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 [77]. There is a significant expansion of the medial clavicle which allows for placement of longer (22 to 24 mm) cancellous screws [77]. If there is insufficient purchase in the medial fragment, the plate can be extended across the joint onto the sternum, a construct that will eventually loosen due to motion at the SC joint but typically stabilizes the fracture long enough (3 months) for union to occur, at which point the plate should be removed [77]. Rarely, fixation with a hook plate intrasternally or retrosternally may be required for medial clavicle fractures, a highly specialized technique where cardiovascular support should be available in the event of inadvertent injury to the vascular structures found retrosternally [77]. Fixation of the medial clavicle fracture using smooth wires or pins alone is contraindicated, due to the potential for migration and visceral injury [77]. The Triple Endobutton technique for the treatment of Neer type II lateral clavicle fractures involves an arc incision beginning at the acromial angle, curved inwards toward the distal clavicle, and extended inferiorly toward the top of the coracoid [178]. In the Triple Endobutton technique, a 2.0-mm guide pin is drilled into the top of the clavicle midway between the anterior and posterior border and directly in line with the base of the coracoid [178]. In the superior locking plate with braided PDS technique, a high tensile suture is passed as a shuttling suture before fracture reduction and exchanged after plate fixation [218].

Implant Selection: A fixation set that includes plates which are precontoured, or "anatomic," to fit the S shape of the clavicle is ideal for midshaft fracture fixation [160]. Precontoured plates typically save significant time associated with extensive contouring required to make a straight plate fit the bone and reduce the subsequent requirement for hardware removal [160]. Precontoured plates help to decrease the soft tissue irritation that occurs when the end of a straight plate protrudes past the end of the bone as the clavicle curves away [160]. The use of a pre-contoured plate facilitates surgical care of clavicular fractures, reducing hardware prominence and secondary surgical procedures, whereas dual plating may be used as an adjuvant in highly comminuted cases [50]. Dual plating with 2.4- or 2.7-mm plates may additionally have a benefit of decreased hardware prominence [50]. When indicated, operative management of displaced midshaft clavicle fractures using dual plating was found to be cost-effective compared with single plating [85]. A hybrid uni-cortical approach to clavicle plate fixation demonstrates comparable bending strength to current bi-cortical approaches while potentially reducing the risk of intra-operative vascular damage [130]. The plate fixation significantly stabilizes the fracture gap, reduces the implant stress, and serves as the recommended fixation for the mid-shaft clavicle fracture based on finite element analysis [158]. The study supports the need for further development of clavicle fixation devices, specifically variable-shape and gender-specific designs, and suggests that varying plate width and multi-plane pre-contouring would improve anatomic fit [155]. Fixation of uncomplicated midshaft clavicle fractures with titanium elastic nails (TENs) provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates [69]. The technique of intramedullary screw fixation is a safe, simple, and reliable method for fixation of displaced mid-shaft clavicle fractures with minimal complications and excellent functional outcomes [122]. In a systematic review of four trials with a high risk of bias, there was low-quality evidence of a lack of a clinically important difference in function between intramedullary fixation and plate fixation [153]. Three randomized controlled trials comparing plate fixation versus intramedullary nailing for displaced midshaft clavicle fractures found no statistical differences between the two methods regarding functional endpoints and incidence of nonunion at 1-year follow-up [153]. The results of intramedullary fixation appear to be more unpredictable than the results of plate fixation, with anatomy and biomechanical aspects of fixation appearing inferior in resisting displacement compared with plate fixation [153]. Cerclage wiring in isolation is inadequate to control the deforming forces at the site of a displaced clavicle fracture and is to be avoided [160]. Older series describing fixation of clavicle fractures have described poor results when inadequate fixation such as cerclage wires alone or plates of inadequate size or length are used [160]. For distal clavicle fractures, the described technique of augmented fixation with a Fibertape coracoclavicular cerclage is effective, produces good clinical outcomes, and has minimal complications [1]. Although observations are short term, the technique of internal fixation for unstable distal clavicle fractures is promising as an alternative [13]. Excellent clinical and radiological outcomes can be achieved with a minimally invasive all-suture fixation technique for displaced distal clavicle fractures, which allows for an anatomic reduction and stable fixation [66]. The results demonstrate that arthroscopic stabilization using Tightrope 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 [120]. This combined surgical strategy of locking plate with titanium cable can be considered an effective method for treating unstable distal clavicle fractures [127]. CC fixation adds stability to type IIB distal clavicle fractures fixed with plate and screws when loaded to failure [81]. This technique of superior locking plate with braided PDS coracoclavicular fixation is used for unstable fractures of the distal clavicle, typically involving fractures within 3 cm of the CC ligaments or those involving the CC ligaments [218]. For medial clavicle fractures, surgical treatment using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results [129].

Other Considerations: 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 [20]. Superiorly applied plate fixation is an effective treatment for clavicular nonunion [70]. Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union [49]. Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function [143]. Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment [37]. Fractures that are significantly displaced may warrant operative repair, especially if there is posterior displacement of the shaft fragment for medial clavicle fractures [77]. The primary technical difficulty with medial clavicle fractures is the fixation in the medial fragment [77]. It is important to remember that the subclavian vessels are in close proximity to the bone medially during medial clavicle fracture fixation [77]. The medial clavicular epiphysis is the last long bone epiphysis to fuse in the body, and may persist in patients until 25 to 30 years of age, meaning medial clavicular fractures are often epiphyseal fracture–subluxations or fracture–dislocations [77]. This case adds to the limited literature and supports the role of rigid clavicular fixation as a safe and effective treatment option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in an adolescent [3]. 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 [91]. Retaining the clavicular hook-plate indefinitely carries a potential risk of developing osteolysis and fracture around the implant [78]. Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [156]. Only 7.7% of patients required hardware removal for symptomatic hardware following pre-contoured titanium anterior plating of midshaft clavicle fractures, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates [12]. The overall incidence of clavicular hardware removal was 12.6% following operative treatment of middle- and distal-third clavicular fractures [27].

Complications and Risks: Complication rates following surgical clavicle fracture care averaged 8.1% [97]. Minor morbidity includes incisional and proximal chest wall numbness which have been reported to occur in 12% to 29% of clavicle fractures after surgical management, suggesting injury to the supraclavicular nerve branches [209]. Wang et al. reported 83% of sensory disorders after plate fixation in clavicle fractures and recommended using the vertical incision [200]. Leroux et al. reported only five neurologic complications and five vascular complications out of 1,350 clavicle fractures treated with plate fixation [200]. Surgeons should be wary of supraclavicular nerve branches during surgical exposure and consider neuropathy in patients with persistent pain after clavicle fracture [222]. The three terminal branches of the superficial supraclavicular sensory nerves, which originate from the C3 and C4 nerve roots, traverse the clavicle in an unpredictable pattern on the superior surface [209]. 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 [9]. The subclavian artery and vein, along with the brachial plexus, pass from a posterosuperior to a posteroinferior direction, crossing under the clavicle near Kilka's point, the junction of the middle and medial thirds [209]. The subclavius muscle lies under the clavicle providing only a thin layer of separation from the critical structures in this region [209]. One patient detailed an intraoperative death from an iatrogenic air embolus from a subclavian vein tear while being operated in the beach chair position [209]. In a cadaveric study by Galley et al., the vascular risk was high in the most medial quarter of the clavicle [200]. On the posterior side of the most medial quarter of the clavicle, the common carotid artery and in particular the internal jugular vein axis is at risk when drilling anterior to posterior [200]. An image study performed by Sinha et al. showed that drilling should be directed superiorly in the most medial quarter and posteriorly [200]. The site of osteotomy for assessing subclavian vein injury during internal fixation of midshaft clavicle fractures should be 2cm lateral to the sternoclavicular joint, as this is comfortably medial to the most medial drilling trajectory and allows enough bone for fixation [198]. More medial osteotomy positions may put the subclavian vein further at risk, as it has been documented to be closest to the clavicle one-centimetre lateral to the sternoclavicular joint, and possibly tethered to the periosteum at this point [198]. Two blunt levering retractors are placed on the superior and inferior aspect of the medial clavicle to prevent further damage to the subclavian vein during osteotomy [198]. Retractors and bone levers must not be inserted blindly as this may further damage. This suggests the etiology of midshaft clavicle nonunions may result from a combination of suboptimal mechanical fixation and latent infection, with a high incidence of Propionibacterium acnes [51].

Complications

General Complication Rates: The overall complication rate following surgical clavicle fracture care averages 8.1% [97], rising to 14.5% in multi-trauma settings [237]. Construct failure after open reduction and plate fixation of displaced midshaft fractures occurs in 6.9% of cases [86]. In a large cohort of 1,350 patients with at least two years of follow-up, the overall revision surgery rate was 24.6% [176]. The overall incidence of hardware removal is 12.6% [27], though clavicular fixation using locking or hook plates is considered safe with a very low reoperation rate for hardware removal or revision [234].

Infection: Infection rates following surgical treatment range from 0% to 18% [159], with a mean rate of 5% after fixation of displaced midshaft fractures [214]. In the 1,350-patient ORIF cohort, the infection rate was 2.6% [176]. Nonunion after clavicle osteosynthesis is associated with a high incidence of Propionibacterium acnes [51]. The etiology of midshaft clavicle nonunions may result from a combination of suboptimal mechanical fixation and latent infection [51].

Hardware-Related Complications: Hardware irritation requiring removal ranges from 50% to 100% [159], while implant irritation from any form of surgical fixation ranges from 3.7% to 40% [176]. The lowest rates of implant irritation and removal are reported with dual plating techniques [176]. Women are four times more likely than men to have hardware removed [11], with female patients at the highest risk for secondary surgery due to implant irritation at an average of 12 months post-index surgery [176]. Patients undergoing hardware removal report worse long-term outcomes than those with retained hardware [11]. Only 7.7% of patients required removal for symptomatic hardware when treated with pre-contoured titanium anterior plating [12]. Clavicular hook plates are associated with rotator cuff injury, shoulder stiffness, and acromioclavicular joint osteoarthritis, which occurred in 21% of patients in one series [191]. These plates cause discomfort with shoulder elevation and are routinely removed; removal earlier than 6 months can lead to nonunion or refracture [191]. Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft fractures [236]. In displaced medial end clavicle fractures, plate prominence or irritation was reported in 30% of operative patients, with 27% requiring additional surgery for implant removal [212]. Rates of plate removal in individual studies of these fractures ranged from 0% to 80% [212]. Implant or fixation failure occurred in 3 patients (3%) in a systematic review of displaced medial end clavicle fractures [212]. Distal clavicular locking plates fail when the extra-lateral fragment is too small to enable screw purchase and stability [44].

Neurological Complications: Vascular and neurological complications are rare in clavicle fractures [29]. Iatropathic brachial plexus injury risk is reduced by thorough release of tissues from the inferior surface of the clavicle and ensuring no shortening occurs during fixation [9]. Supraclavicular numbness from iatrogenic injury to branches of the supraclavicular nerve is a common complication [176]. Transient brachial plexus symptoms are an adverse event associated with surgical interventions [159]. Temporary brachial plexus palsy is a reported shortcoming of intramedullary fixation [182]. In the 1,350-patient ORIF cohort, the rate of neurovascular injury was 0.003% [176]. Incisional numbness was reported in 18 of 62 patients (29%) in the operative group compared to 0 of 49 patients (0%) in the nonoperative group [53].

Vascular and Thoracic Complications: Damage to the lung or vessels beneath the clavicle is very rare despite deformity [29]. In the 1,350-patient ORIF cohort, the rate of pneumothorax was 0.01% [176]. Rare intraoperative vascular injury is a complication related to plate fixation [182]. Reports of vascular injuries associated with clavicle fixation are summarized in literature reviews [40]. One patient had an intraoperative vascular complication with no long-term adverse outcome in a systematic review of displaced medial end clavicle fractures [212].

Bony Healing Complications: Symptomatic nonunion occurs in 14% to 24% of patients treated nonoperatively for clavicle fractures [176]. In the 1,350-patient ORIF cohort, the rate of nonunion was 2.6% and malunion was 1.1% [176]. Nonunion is a complication associated with surgical interventions [159]. Non-union was recorded in four patients in a study comparing ESIN and plate fixation for clavicular mid-shaft fractures [118]. In a study of 36 patients treated by ESIN, the majority of surgical complications were caused by medial nail protrusion, followed by non-union in 3 cases [118]. No cases of surgically managed infection or implant failure were noted in that ESIN study [118]. All fractures healed within an average of 15.6 weeks (range, 11-18 weeks) in a study of percutaneous plating for comminuted midshaft fractures, with no patients developing nonunion or delayed union [46]. Although solid union after realignment of symptomatic nonunion or malunion is predictable, patients can remain functionally impaired [87]. Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates [19]. In a systematic review of displaced medial end clavicle fractures, all operatively treated fractures united successfully with no reported nonunions [212]. Conversely, 5 (13%) symptomatic nonunions and 2 (5%) malunions were reported after nonoperative treatment [212]. Two (5%) painful atrophic delayed unions proceeded to plate fixation and iliac crest bone graft after an average of 4 months post-injury [212].

Wound and Soft Tissue Complications: Wound infection, dehiscence, and deep infection are complications of surgical treatment [159]. Hypertrophic and noncosmetic scars, as well as complex regional syndrome, are adverse events with surgical interventions [159]. Skin breakdown over entry portals is a reported shortcoming of intramedullary fixation [182]. Hypertrophic or dysesthetic scars, implant loosening, and refracture after plate removal are complications related to plate fixation [182]. In a study of 5 patients with Hook plate fixation for displaced medial end clavicle fractures, one patient developed a wound hematoma 3 days postoperatively which healed after debridement [212].

Specific Technique Complications: In a study of 19 patients with lateral clavicle fractures, 6 nonunions (5 symptomatic) and 5 infections (3 deep) occurred in the Kirschner wire group [191]. Eight of the poor results in that study were in patients treated with Kirschner wire fixation [191]. Fixation of uncomplicated midshaft clavicle fractures with titanium elastic nails provides faster relief of pain and return to normal function than fixation with 3.5-mm reconstruction plates [69]. A limited incision approach for plating of acute midshaft clavicle fractures achieved a low complication rate comparable to standard incision techniques [55]. Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal [90]. ORTSD fixation for isolated displaced lateral-end clavicular fractures in medically fit patients is associated with a low rate of complications in the medium term [92]. Both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation for unstable distal clavicular fractures have a minimal risk of complications [22]. The described technique of augmented fixation of the distal clavicle has minimal complications [1]. Operative treatment with plate and screw application for clavicular fractures in adolescents has a low complication rate [14]. In a retrospective study on 43 adolescent patients with displaced midshaft clavicle fractures, complications in the plate group were minor [31]. A systematic review showed similar major complication rates among techniques for Neer type IIB (IIC) distal clavicle fractures, but the hook plate technique demonstrated inferior clinical results [240]. Superior and anteroinferior plating of midshaft clavicle fractures provide comparable complication rates [241].

Recovery

Light activity (weeks): High-quality evidence indicates that surgical treatment of displaced clavicle fractures in adults yields higher union rates and better early patient-reported outcomes compared with nonsurgical treatment [89]. Specifically, plate fixation of midshaft clavicular fractures provides an early functional gain at six weeks compared with nonoperative treatment [99]. Fixation with a pre-contoured plate and locking screws results in faster functional recovery than nonoperative treatment [228].

Full activity (months): There is no difference in function between surgical and nonoperative groups after six months and one year [228]. 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 [194]. Adolescent patients undergoing anatomic ORIF of midshaft clavicle fractures may return to play more quickly than previously thought [221]. Accelerated return to play after ORIF of adolescent clavicle fractures was not associated with a significantly increased risk of refracture, nonunion, or other complications compared with a more traditional timeline [227].

Complete recovery / outcome plateau (months): Long-term outcomes are similar between surgical and nonsurgical treatments [89]. TEN fixation achieves long-term functional outcomes equivalent to conservative treatment [194]. Late reconstruction of nonunion and malunion after displaced midshaft fractures is a reliable procedure that restores objective muscle strength similar to immediate fixation; however, subtle decreases in endurance strength and outcome are observed compared with acute fracture repair [223].

Rehabilitation protocol: Internal plating for bipolar clavicle injury allows early mobilization and results in good joint function [169]. A limited incision approach for plating of acute midshaft clavicle fractures achieves good functional and radiographic outcomes with a low complication rate comparable to standard incision techniques [55]. 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 [92]. Satisfactory recovery of radiographic and functional outcomes is obtained after wide excision with allograft reconstruction for large parosteal osteoma of the clavicle [233]. 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 [98].

Functional milestones: Patients report a good quality of life and functional outcome after plating for midshaft clavicular fractures [196]. Surgical treatment with ORIF of displaced middle-third clavicular fractures results 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 [165]. TEN fixation of displaced midshaft clavicular fractures allows for faster functional recovery, higher patient satisfaction, and a more cosmetically satisfactory appearance than plate fixation [189].

Other Considerations: Workers' compensation patients return to work at roughly the same time whether treated surgically or nonoperatively, with surgery being roughly 3 times more expensive [134]. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature for patients with symptomatic superior clavicle plates [12]. Dual plating of acute displaced midshaft clavicle fractures may lead to lower rates of reoperation for symptomatic hardware removal without compromising fracture healing [206]. Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively [48]. Adolescent athletes managed following best practice guidelines provide predictable return to athletics including collision sports [231]. This case supports the role of rigid clavicular fixation as a safe and effective treatment option in similar presentations [3]. Effective management of lateral clavicular fractures remains an ongoing challenge [18].

Key Evidence

• [L4] The described technique of augmented fixation of the distal clavicle is effective, produces good clinical outcomes, and has minimal complications. [1] (10.5397/cise.2022.00913)
• [L5] Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique. [2] (10.1016/j.jse.2013.01.022)
• [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. [3] (10.1016/j.xrrt.2026.100697)
• [L4] We conclude that open reduction and internal fixation with bone grafting gives good long-term functional and radiological results in clavicular non-union with most patients returning to a functional level close to the general population. [4] (10.1016/s0020-1383(03)00239-0)
• [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. [6] (10.1177/1758573221990367)
• [L4] Plate fixation of clavicle nonunions remains a successful method of treatment. [7] (10.1016/j.jse.2020.06.035)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. [8] (10.1016/j.jse.2019.06.022)
• [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. [9] (10.1302/0301-620x.95b1.29625)
• [L4] No difference in reoperation rates between plate types or location could be detected, and excellent functional outcomes continue to be observed several years after clavicle fracture fixation. [10] (10.1016/j.injury.2014.04.032)
• [L3] Women are 4 times more likely than men to have hardware removed, and patients undergoing clavicle hardware removal report worse long-term outcomes than patients with hardware retained. [11] (10.1016/j.jse.2015.09.029)
• [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. [12] (10.1016/j.jse.2021.05.021)
• [L4] Although observations are short term, the technique is promising as an alternative for internal fixation of distal clavicle fractures. [13] (10.1016/j.jse.2007.04.012)
• [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. [14] (10.2106/jbjs.22.01036)
• [L3] Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate. [15] (10.1016/j.jseint.2023.07.005)
• [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. [16] (10.1016/j.jse.2015.04.011)
• [L2] Effective management of lateral clavicular fractures remains an ongoing challenge. [18] (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. [19] (10.1016/j.jse.2023.12.006)
• [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. [20] (10.1016/j.otsr.2013.09.011)
• [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. [21] (10.2106/jbjs.19.00955)
• [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. [22] (10.1016/j.jseint.2021.05.007)
• [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. [23] (10.1097/corr.0000000000001916)
• [L4] Conservative treatment of clavicle fractures yields significantly good clinical and radiological outcomes. [24] (10.1016/j.xrrt.2026.100679)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. [25] (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L3] [26] (10.1016/j.jse.2014.09.037)
• [L4] The overall incidence of clavicular hardware removal was 12.6%. [27] (10.1016/j.jse.2020.06.034)
• [L2] Stabilisation of the clavicle gives better functional scores compared to conservative treatment in the short term. [28] (10.1302/0301-620x.95b6.31060)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. [30] (10.1016/j.jse.2011.08.053)
• [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. [33] (10.1097/corr.0000000000000986)
• [L3] Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. [37] (10.1016/j.otsr.2017.03.021)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. [39] (10.5435/jaaos-d-17-00598)
• [L4] [40] (10.1177/1758573214546058)
• [L4] [42] (10.5435/00124635-201107000-00002)
• [L4] [44] (10.1016/j.jse.2020.10.006)
• [L2] These 2 approaches have equivalent effects on recovery of shoulder joint function. [45] (10.1016/j.jse.2019.03.021)
• [L4] [46] (10.1016/j.injury.2012.09.030)
• [L2] Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. [48] (10.1177/2325967123s00041)
• [L4] Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union. [49] (10.1016/j.jseint.2020.04.002)
• [L4] This suggests the etiology of midshaft clavicle nonunions may result from a combination of suboptimal mechanical fixation and latent infection. [51] (10.1097/bot.0000000000000770)
• [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. [54] (10.1016/j.jse.2012.06.006)
• [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. [55] (10.1016/j.jse.2025.06.002)
• [L2] In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. [64] (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. [66] (10.1016/j.xrrt.2022.01.005)
• [L3] Fixation of uncomplicated midshaft clavicle fractures with TENs provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates. [69] (10.1016/j.jse.2011.08.065)
• [L4] Superiorly applied plate fixation is an effective treatment for clavicular nonunion. [70] (10.1016/j.jse.2008.05.046)
• [L4] Arthroscopic fixation of distal clavicle fractures resulted in good functional outcomes with union rates comparable to traditional open techniques. [71] (10.1177/23259671211001773)
• [L5] Retaining the clavicular hook-plate indefinitely carries a potential risk of developing osteolysis and fracture around the implant. [78] (10.1016/j.injury.2004.08.010)
• [L4] [79] (10.3390/jcm10245764)
• [L5] CC fixation adds stability to type IIB distal clavicle fractures fixed with plate and screws when loaded to failure. [81] (10.1016/j.arthro.2013.02.024)
• [L5] When indicated, operative management of displaced midshaft clavicle fractures with dual-plating is cost-effective compared to single-plating. [83] (10.1177/2325967123s00167)
• [L2] When indicated, operative management of displaced midshaft clavicle fractures using dual plating was found to be cost-effective compared with single plating. [85] (10.2106/jbjs.23.00338)
• [L3] Overall construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures occurred in 6.9 percent. [86] (10.1016/j.injury.2017.01.040)
• [L4] Although solid union after realignment of symptomatic nonunion or malunion of midshaft clavicle fractures is predictable, the patients can remain functionally impaired. [87] (10.1016/j.jse.2006.12.002)
• [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. [89] (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. [90] (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. [91] (10.1097/corr.0000000000001839)
• [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. [92] (10.2106/jbjs.18.00569)
• [L4] [95] (10.5435/jaaosglobal-d-26-00048)
• [L4] [96] (10.1016/j.injury.2005.03.007)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. [97] (10.1186/s12891-022-05075-5)
• [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. [98] (10.1016/j.jse.2023.03.010)
• [L1] This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. [99] (10.1016/j.jseint.2023.12.011)
• [L4] Therefore, for patients undergoing ORIF of isolated clavicular fractures obtaining a postoperative chest radiograph may be an unnecessary practice, especially given their low sensitivity. [100] (10.1016/j.jse.2018.09.016)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. [111] (10.1016/j.jse.2025.04.021)
• [L3] [118] (10.1016/j.injury.2015.11.025)
• [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. [120] (10.1016/j.arthro.2009.04.017)
• [L4] The technique is a safe, simple, and reliable method for fixation of displaced mid-shaft clavicle fractures with minimal complications and excellent functional outcomes. [122] (10.1007/s00402-013-1809-3)
• [L4] This combined surgical strategy can be considered an effective method for treating unstable distal clavicle fractures. [127] (10.1186/s12891-021-04137-4)
• [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. [128] (10.1016/j.injury.2020.11.066)
• [L4] Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results. [129] (10.1186/s12891-021-04775-8)
• [L5] A hybrid uni-cortical approach to clavicle plate fixation demonstrates comparable bending strength to current bi-cortical approaches while potentially reducing the risk of intra-operative vascular damage. [130] (10.1016/j.injury.2016.01.042)
• [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. [134] (10.1016/j.jse.2016.02.004)
• [L2] Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment. [140] (10.1177/2325967121s00214)
• [L4] Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function. [143] (10.1016/j.jse.2015.11.036)
• [L5] The study supports the need for further development of clavicle fixation devices, specifically variable-shape and gender-specific designs, and suggests that varying plate width and multi-plane pre-contouring would improve anatomic fit. [155] (10.1186/1749-799x-5-21)
• [L4] Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. [156] (10.1186/s12891-021-04841-1)
• [L5] The plate fixation significantly stabilizes the fracture gap, reduces the implant stress, and serves as the recommended fixation for the mid-shaft clavicle fracture. [158] (10.1016/j.injury.2016.06.004)
• [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. [165] (10.1016/j.jse.2014.11.041)
• [L4] Internal plating for bipolar clavicle injury allowed early mobilization and resulted in good joint function. [169] (10.1186/s12891-023-06126-1)
• [L4] [176] (10.5435/jaaos-d-17-00442)
• [L4] [178] (10.1016/j.jse.2022.10.024)
• [L4] The present study showed that angular rotations and positions of the clavicle and scapula change significantly with position due to the effect of gravity. [179] (10.1186/s13018-020-01934-w)
• [L2] [182] (10.1016/j.jhsa.2009.10.012)
• [L3] TEN fixation of displaced midshaft clavicular fractures allows for a faster functional recovery, higher patient satisfaction, and a more cosmetically satisfactory appearance than plate fixation. [189] (10.1016/j.jse.2011.03.007)
• [L4] [191] (10.1016/j.jhsa.2011.02.012)
• [L4] [193] (10.1177/1758573214536535)
• [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. [194] (10.1186/s13018-026-06708-4)
• [L3] Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures. [196] (10.1016/j.injury.2017.10.032)
• [L5] [198] (10.1177/17585732211047206)
• [L5] [200] (10.5397/cise.2021.00388)
• [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. [205] (10.1097/corr.0000000000001411)
• [L2] Dual plating of acute displaced midshaft clavicle fractures may lead to lower rates of reoperation for symptomatic hardware removal without compromising fracture healing. [206] (10.1177/17585732211002495)
• [L5] [209] (10.5435/jaaos-d-20-00799)
• [L4] [212] (10.1016/j.jseint.2022.09.010)
• [L5] [214] (10.2106/jbjs.21.00292)
• [L4] [218] (10.1016/j.xrrt.2024.07.001)
• [L4] Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared to non-weighted views. [220] (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. [221] (10.1177/2325967125s00119)
• [L4] Surgeons should be wary of supraclavicular nerve branches during surgical exposure and consider neuropathy in patients with persistent pain after clavicle fracture. [222] (10.1016/j.jse.2006.09.015)
• [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. [223] (10.1016/j.jse.2007.01.001)
• [L4] The use of 3D imaging, modeling, and printing with open-source software allows for reproducible results in correcting complex clavicle malunions through an easier and faster method. [224] (10.1016/j.jseint.2021.04.008)
• [L3] Accelerated return to play after ORIF of adolescent clavicle fractures was not associated with a significantly increased risk of refracture/nonunion or other complications compared with a more traditional RTP timeline. [227] (10.1177/23259671251374299)
• [L1] Fixation of a displaced midshaft clavicular fracture with a pre-contoured plate and locking screws results in a higher rate of union and faster functional recovery compared with nonoperative treatment, but there is no difference in function after six months and one year. [228] (10.1302/0301-620x.100b10.bjj-2017-1137.r3)
• [L4] Adolescent athletes managed following best practice guidelines for clavicular fractures provide predictable return to athletics including collision sports. [231] (10.1016/j.jse.2021.04.006)
• [Case_report] Satisfactory recovery of radiographic and functional outcomes was obtained after wide excision with allograft reconstruction for large parosteal osteoma of the clavicle. [233] (10.5397/cise.2021.00465)
• [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. [234] (10.1016/j.jseint.2021.11.001)
• [L1] Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures. [236] (10.1016/j.jse.2016.01.018)
• [L4] Surgical fixation of midshaft clavicle fractures in a multi-trauma setting shows a 14.5% overall complication rate. [237] (10.1016/j.injury.2016.02.005)
• [L1] The systematic review showed similar major complication rates among techniques, but the hook plate technique demonstrated inferior clinical results. [240] (10.1186/s13018-022-03108-2)
• [L1] Superior and anteroinferior plating of midshaft clavicle fractures provide comparable union rates, functional outcomes, and complication rates. [241] (10.5397/cise.2025.01179)

See Also

• Clavicle Fracture
• Fractures
• Internal Fixation
• Soft Tissue Structures
• Os Acromiale
• Brachial Plexus Injury
• Rotator Cuff

References

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