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Clavicle Fracture

Clavicle fractures — when conservative management is fine and when fixation is indicated.

126 citationsUpdated Sep 2026

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Overview

Clavicle fractures are predominantly managed nonoperatively, with most patients achieving excellent outcomes through conservative care [10, 72]. This approach is particularly effective in adolescents, where nonoperative treatment yields lower complication rates and similar functional satisfaction compared to operative intervention [14, 38]. Even in cases of complete displacement, teenage patients can expect excellent radiographic and clinical results five years post-injury [4]. While initial nonsurgical management is reasonable given similar functional outcomes despite delayed surgery [3], close follow-up is warranted due to a higher-than-expected risk of persistent symptoms [2, 5]. For medial clavicle fractures, good clinical and functional outcomes are expected regardless of the treatment modality chosen, provided the patient survives the initial trauma [1].

Surgical fixation is reserved for a select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications, where it has been shown to improve outcomes compared to non-operative measures [72]. In adolescents, although definitive indications for fixing markedly displaced midshaft fractures remain unclear [161], there is an increasing trend toward stabilization due to concerns about symptomatic malunion [161]. Operative treatment with plate and screw application offers consistently good outcomes with a low complication rate in selected adolescent cases [38], and clavicle fixation is considered safe and effective in the pediatric population with a lack of serious complications [30]. The Sleutel-TRIAL provides level-1 evidence comparing consolidation and functional outcomes between standardized treatment options for dislocated midshaft fractures [33].

Complication rates following surgical clavicle fracture care average 8.1% [18], with non-unions and malunions being the most common complications regardless of treatment method [20]. Posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes, and findings do not support routine operative reduction and fixation based solely on functional outcome arguments [56]. Consequently, displaced midshaft clavicular fractures intended to achieve a 'good' outcome must be managed non-operatively [66]. Specific treatment should be individualized based on fracture characteristics and patient expectations rather than broadly applied [19]. For distal clavicle fractures, both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation are viable options, offering minimal risk of complications and similar high union rates [170], though no clearly favoured method of internal fixation exists in the reporting unit [85].

Anatomy & Pathophysiology

Bony Anatomy and Development

The clavicle is the first bone in the body to ossify, beginning from two primary ossification centers (medial and lateral) by 5 to 6 weeks of gestation [97]. It is the only long bone to ossify by intramembranous ossification [26]. By 7 to 8 weeks of gestation, the clavicle has already assumed its overall contour and “S” shape [97]. Most growth (80%) of the clavicle occurs from the medial physis [97]. The lateral epiphysis forms and fuses at around 18 to 19 years of age [97]. The medial epiphysis is the last in the body to ossify, at the age of 18 to 20 years, and completes ossification at the age of 23 to 25 years [97].

The clavicle is a relatively straight bone when anteriorly viewed, whereas in the transverse plane, it resembles an italic S [99]. The greater radius of curvature occurs at the medial curve of the clavicle, which is anteriorly convex [99]. The smaller lateral curve of the clavicle is posteriorly convex [99]. The bone is somewhat rounded in its midsection and medially and relatively flat laterally [99]. The distal clavicle is flat in the AP plane [26]. The clavicle forms a unique S-shaped curve on the axial view [26].

Specific anatomical landmarks include a 30% incidence of a rhomboid fossa on the inferior surface of the medial end where the costoclavicular ligaments insert, and a 2.5% incidence of an actual articular surface facing inferiorly toward the first rib [99]. The middle portion contains the subclavian groove where the subclavius muscle has a fleshy insertion [99]. The lateral portion has the coracoclavicular process when present [99]. The conoid ligament attaches to the clavicle at the conoid tubercle [99]. The trapezoid ligament attaches to the clavicle at the trapezoid line, which lies in an anteroposterior direction just lateral to the conoid tubercle [99]. 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 [99]. 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 [99].

The primary blood supply to the clavicle is periosteal; there is no nutrient blood supply [26]. The clavicle is subcutaneous, and its muscular envelope includes the platysma, pectoralis major, deltoid, and some of the strap muscles of the neck [26].

Muscular and Ligamentous Anatomy

The clavicle serves as the primary stabilizer between the axial skeleton (via the sternoclavicular joint) and the appendicular skeleton (via the acromioclavicular joint) [26]. The coracoclavicular ligaments consist of the conoid (medial) and trapezoid (lateral) components [26]. These ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [26]. The superior shoulder suspensory complex is a bone–soft-tissue ring that provides a stable connection of the glenoid and scapula to the clavicle [26]. It is composed of four bony landmarks—distal clavicle, acromion, coracoid process, and glenoid neck—and the supporting ligamentous complexes of the AC joint and the CC ligaments [26].

Medially, the pectoralis major muscle originates from the clavicular shaft anteroinferiorly [103]. The sternocleidomastoid originates superiorly on the clavicle [103]. The pectoralis origin merges with the origin of the anterior deltoid laterally [103]. The trapezius insertion blends superiorly with the deltoid origin at the lateral margin of the clavicle [103]. The undersurface of the clavicle is the insertion site of the subclavius muscle [103]. The platysma usually envelopes the anterior and superior aspects of the clavicle and runs in the subcutaneous tissues, extending superiorly to the mandible and the deeper facial muscles [103].

The trapezius inserts on the posterosuperior surface of the distal end of the clavicle [99]. The subclavius muscle has a fleshy insertion on the inferior surface of the middle third of the clavicle [99]. The deltoid originates on the anterior portion of the inner surface of the lateral curve of the clavicle [99]. The pectoralis major originates from the anterior portion of the medial two-thirds of the clavicle [99]. The sternocleidomastoid largely originates on the posterior portion of the middle third of the clavicle [99]. The sternohyoid originates on the clavicle just medial to the origin of the sternocleidomastoid [99].

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 [111]. There are typically three major branches of the supraclavicular nerves (anterior, middle, and posterior) that cross the clavicle superficially from medial to lateral [111]. The subclavian vein runs directly below the subclavius muscle and above the first rib [111]. The subclavian artery and the brachial plexus lie more posteriorly than the subclavian vein, separated from the vein and clavicle by the additional layer of the scalenus anterior muscle medially [111]. The brachial plexus is closest to the clavicle in its midportion [111].

In the middle third of the clavicle, the subclavian artery is a mean of 17 mm from the clavicle [111]. In the middle third of the clavicle, the subclavian vein is a mean of 13 mm from the clavicle [111]. In the middle third of the clavicle, the subclavian vessels are located at an approximate angle of 60 degrees to the horizontal, posterior-inferior to the clavicle [111]. Laterally, the subclavian artery is a mean of 63 mm from the clavicle [111]. Laterally, the subclavian vein is a mean of 76 mm from the clavicle [111]. 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 [111]. The mean distance of the neurovascular bundle from the posterior border of the clavicle is 9.2 mm [186].

Mechanism of Injury and Deformity

A direct blow on the point of the shoulder is the commonest reported mechanism of injury that produces a midshaft fracture of the clavicle [101]. Most (85%) clavicle fractures occur in the midshaft of the bone where the bone is narrowest and enveloping soft tissue structures are most scarce [101]. The direction of the initial deforming force, and both gravitational and muscular forces on the clavicle result in the typical deformity seen after fracture [101]. In a displaced midshaft clavicle fracture, the distal fragment is translated inferiorly, anteriorly, and medially (shortened), and rotated anteriorly [101]. The medial clavicular fragment is elevated by the unopposed pull of the sternocleidomastoid muscle [103]. The distal clavicular fragment is held inferiorly by the deltoid and medially by the pectoralis major [103].

A fall on the shoulder or the outstretched hand may fracture the clavicle; the lateral fragment is pulled down by the weight of the arm, while the medial fragment is held up by the sternomastoid muscle [13]. 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 [26]. Most fractures result from a fall onto the shoulder or a direct blow, with the majority occurring in males and associated with vehicular trauma, falls, or sporting injuries [8]. The most common mechanism of injury in clavicle fractures is a direct blow to the shoulder, whether following a fall or because of direct trauma [62]. A fall on an outstretched hand can result in a clavicle fracture; this mechanism was initially thought to be the most common cause of these fractures [62]. These injuries are rarely open, despite being caused by high-energy trauma [62]. 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 [101]. Fractures resulting from trivial mechanisms in elderly patients are typically seen in the distal third of the clavicle [101].

Epidemiology and Classification

Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [26]. Approximately 15% of clavicular fractures are distal third, 80% are middle third, and 5% are medial third [26]. Fractures of the clavicle constitute 2% to 5% of all fractures in adults and 35% to 44% of all fractures in the shoulder [47]. The incidence of clavicle fractures is 50 to 64 per 100,000 persons annually [47]. The risk for clavicle fracture is increased in men aged 30 years or younger and all patients older than 70 years [47]. Middle third fractures comprise approximately 69% to 81% of all clavicle fractures [47]. Lateral third fractures account for approximately 17% to 28% of all clavicle fractures [47]. Medial third fractures constitute the remaining 2% to 3% of all clavicle fractures [47]. Clavicle fractures have an incidence of 30 per 100,000 and represent 2.6%-4% of all fractures [90]. Fractures of the clavicle shaft account for 69% of all clavicle fractures [90]. Lateral clavicle fractures account for 28% of all clavicle fractures [90]. Medial clavicle fractures account for 3% of all clavicle fractures [90]. The classical injury mechanisms are a simple fall on the shoulder (31%), followed by road traffic accidents (27%) and then sports (23%) [90]. Medial clavicle fractures occur more often as part of a high-energy trauma or trauma with multiple injuries [90].

Classification Systems: Allman: Defines fractures of the proximal (medial), middle (midshaft), and distal (lateral) thirds of the clavicle [26]. Neer: Classified lateral-third fractures based on the integrity of the CC ligament complex and the involvement of the AC joint [26]. Medial Third: Classified according to the displacement and involvement of the SC joint [26]. Craig: Group I fractures involve the middle third and occur at the point at which the clavicle changes to a flattened cross section from a prismatic cross section [81]. Group I fractures account for 80% of clavicle fractures [81]. Group II fractures account for 12% to 15% of all clavicle fractures and are subclassified according to the location of the coracoclavicular ligaments relative to the fracture fragments [81]. Distal Clavicle Types: Type I distal clavicle fractures are interligamentous fractures that occur between the conoid and the trapezoid or between the coracoclavicular and acromioclavicular ligaments [81]. Type II distal clavicle fractures involve the coracoclavicular ligaments being detached from the medial segment [81]. Type III distal clavicle fractures involve the articular surface of the acromioclavicular joint alone [81]. Type IV distal clavicle fractures occur in children and may be confused with complete acromioclavicular dislocations [81]. Edinburgh: Divides clavicular fractures by anatomic location into type I (medial third), type II (middle third), and type III (lateral third) [62]. In the Edinburgh classification, subgroup A indicates displacement less than 100% and subgroup B indicates displacement more than 100% [62]. In the Edinburgh classification, subgroup 1 indicates no articular involvement and subgroup 2 indicates intra-articular extension of the fracture [62]. Type II fractures in the Edinburgh classification are subdivided into subgroup 1 (simple or wedge-type fractures) and subgroup 2 (comminuted or segmented fractures) [62].

A 2011 study reported that the Craig classification best predicted nonunion or delayed union of lateral third clavicle fractures [62]. A 2011 study reported that the Robinson classification had the best prognostic potential for middle third clavicle fractures [62].

Pathophysiology and Associated Injuries

The shoulder is a closed chain mechanism and constitutes the combined function of 4 joints: the sternoclavicular, the acromioclavicular, the scapulothoracic, and the glenohumeral joint [16]. Two of the four shoulder joints are articulations of the clavicle; therefore, clavicle malunion affects the whole shoulder girdle [16]. Symptomatic malunion after midshaft clavicular fractures has been recognized in the last 15 years to be a cause of shoulder dysfunction [16]. Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [26].

Associated injuries are increasingly common in patients with fractures of the clavicle compared to the incidence reported in older traditional studies [48]. Patients who have sustained high-energy vehicular trauma are more likely to have associated injuries to the thoracic cage, including ipsilateral rib fractures, scapular and/or glenoid fractures, proximal humeral fractures, and hemo/pneumothoraces [48]. Multiple ipsilateral rib fractures may be associated with higher rates of poor outcome in the associated clavicle fracture [48]. A “floating shoulder” injury involves a displaced, shortened clavicle fracture and a comminuted glenoid neck fracture [48]. Symmetry of the shoulder can be restored by clavicle fixation alone in some floating shoulder injuries, making it unnecessary to repair the glenoid fracture [48]. A floating shoulder represents one of many possible double disruptions of the superior shoulder suspensory complex [116]. In a floating shoulder, each disruption (glenoid neck fracture and midshaft clavicle fracture) has the potential to make the other unstable [116]. The situation is rendered even more unstable if an additional disruption of the clavicular-acromioclavicular joint-acromial strut is present or if the C-4 linkage is violated [116]. Surgical reduction and stabilization of the clavicular fracture site is advisable to avoid non-union, alleviate tensile forces on the brachial plexus, restore normal anatomic relationships, and ensure restoration of normal shoulder function [116]. The glenoid neck fracture may reduce satisfactorily with stabilization of the clavicle [116].

Clavicle fractures do not increase the occurrence of later subacromial pain syndrome [11]. The results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome [11]. Glenohumeral internal rotation deficit after operative treatment of mid-shaft clavicle fractures is a subclinical, scapula-related phenomenon [12]. The observed association with a tendency toward scapular protraction may provide insight into the phenomenon of glenohumeral internal rotation deficit [12]. Vascular and neurological complications are rare in clavicle fractures [13]. Damage to the lung or vessels beneath the clavicle is very rare despite deformity [13]. Malunion is inevitable in displaced fractures; in children, the bone is soon remodelled, but in adults the slight deformity has to be accepted unless there is a very unsightly bump with skin irritation [13]. Non-union sometimes occurs in middle-third fractures and is treated by bone graft and plating [13]. Fractures of the outer third are easily mistaken for acromioclavicular injuries [13]. Outer-third fractures are quite troublesome and may need open reduction and internal fixation [13]. The question of stability in complex scapula and ipsilateral clavicle fractures is preoperatively less relevant than the question of whether the dislocated fragments lead to compromised shoulder function [79]. Approximately two-thirds of displaced midshaft clavicle fractures are secondary to a high-energy mechanism, of which 85.4% were caused by a motor vehicle injury [164].

Classification

General and Anatomic Classifications

Allman: Introduced in 1967, this system classifies clavicle fractures by anatomic location in descending order of incidence [62]. Type I involves the middle third, Type II the lateral third, and Type III the medial third [62]. Lateral third fractures include those extending from medial to the coracoclavicular ligaments to the acromioclavicular joint itself [167].

Edinburgh: This classification subdivides Type II fractures into subgroup 1 for simple or wedge-type fractures and subgroup 2 for comminuted or segmented fractures [62].

Robinson: The Robinson classification offers the best prognostic potential for middle-third clavicle fractures [62]. Midshaft clavicular fractures should be classified according to this system on two-plane radiography to optimize treatment decisions [146].

Craig: Introduced in 1990, the Craig classification is based on variable fracture patterns within the three broad groups of Allman’s classification [81]. It best predicted nonunion or delayed union of lateral third clavicle fractures [62]. Group I fractures involve the middle third and account for 80% of clavicle fractures [81]. Group II fractures involve the distal third and account for 12% to 15% of all clavicle fractures [81]. Group III fractures involve the proximal third [81].

Distal (Lateral) Clavicle Fractures

Neer: The Neer classification separates distal third clavicle fractures into five main types [167]. Type I fractures are distal to the coracoclavicular ligaments, within 2 cm of the acromioclavicular joint without intra-articular extension, and are minimally displaced [167]. Type II fractures are medial to the coracoclavicular ligaments and result in displacement of the medial fragment [148]. These represent displaced fractures of one-fifth of the bone, occurring lateral to a vertical line drawn from the centre of the base of the coracoid process [148]. Type II is also known as Robinson type 3B [148]. Type IIA fractures are medial to the conoid ligament, with the proximal fragment displaced [167]. Type IIB fractures occur between the conoid and trapezoid ligaments, with the conoid ligament ruptured and the trapezoid ligament remaining attached to the distal segment [167]. Type III fractures involve the articular surface of the acromioclavicular joint alone [81]. Type IV fractures occur in children and involve disruption of the periosteal sleeve [81]. Type V fractures are comminuted, with ligaments attached neither proximally nor distally, but to an inferior, comminuted fragment [81].

Robinson: In the Robinson classification of distal clavicle fractures, Type 3A includes cortical alignment fractures, with 1 being extra-articular and 2 being intra-articular [63]. Type 3B includes displaced fractures, with 1 being extra-articular and 2 being intra-articular [63].

Other Considerations: The modified Neer classification remains the predominantly cited system for distal clavicle fractures [102]. However, its intra- and interobserver reliability has been demonstrated to be inconsistent [102], with interrater agreement for lateral clavicle fractures rated as fair [119]. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice [119]. A new simple classification system for lateral clavicle fractures showed substantial inter- and intraobserver reliability [98]. Another new classification system for distal clavicle fractures demonstrated moderate interobserver and substantial intraobserver reliability [104]. According to the classifications of Neer and Jäger/Breitner, a clear therapeutic strategy for lateral clavicular fractures can be defined [141].

Pediatric Lateral Clavicle Injuries

Dameron and Rockwood: This classification is used for injuries involving the lateral end of the clavicle and acromioclavicular joint in children [55]. In children, displacement of the lateral clavicle occurs through the periosteal sleeve rather than through the coracoclavicular ligaments [55]. Most injuries to the lateral end of the clavicle in the immature skeleton are fractures involving the metaphyseal or physeal regions, specifically Salter-Harris type I or II fractures [55]. The lateral epiphysis of the clavicle does not ossify until the age of 18 or 19 years [55]. Type I involves low-energy trauma with mild strain of the acromioclavicular ligaments and no disruption of the periosteal tube [55]. Type II involves complete disruption of the acromioclavicular ligaments with partial damage to the superolateral aspect of the periosteal sleeve [55]. Type III involves complete disruption of the acromioclavicular ligaments and greater disruption of the periosteal sleeve, resulting in gross instability [55]. Type IV involves posterior displacement of the lateral clavicle, which can pierce the trapezius muscle and/or fascia [55]. Type V involves complete disruption of the superior aspect of the periosteal sleeve, resulting in displacement of the distal clavicle through the trapezial fascia into the subcutaneous tissues [55]. Type VI involves inferior displacement of the distal clavicle below the coracoid process [55].

Adolescent Lateral-End Fractures: In adolescent lateral-end clavicle fractures, Type I is an undisplaced extra-articular fracture lateral to the intact coracoclavicular ligaments [21]. Type IIA is a displaced fracture occurring medial to the intact coracoclavicular ligaments [21]. Type IIB is a displaced fracture with disruption of the coracoclavicular ligaments [21]. Type IV is a physeal fracture pattern in skeletally immature patients [21]. Type V is a comminuted fracture pattern with a separate inferior fragment of the clavicle attached independently to the coracoclavicular ligaments [21].

Clinical Presentation

Mechanism and Epidemiology

Clavicle fractures most commonly affect young, active, working individuals, with the majority occurring in males younger than 30 years [34]. The injury typically results from a fall onto the shoulder or a direct blow to the shoulder [8, 34]. In the United States, football injuries represent the most common etiology [39]. While vehicular trauma, falls, and sporting injuries are primary associations [8], adolescent clavicle fractures occur more frequently in males during sports, secondary to a direct blow, and on the nondominant side [120]. For adolescent lateral-end clavicle fractures, contact sport is the most common mechanism, followed by cycling, falls, road traffic accidents, and direct blows [21]. Midshaft fractures constitute approximately 80% of all clavicle fractures [34]. Open clavicle fractures are rare [22], and bilateral clavicle fractures are extremely rare, associated with polytrauma [78]. The differential diagnosis for a fractured clavicle should include idiopathic nontraumatic fractures [9].

Physical Examination

Inspection often reveals a displaced fracture producing a lump along the collar-bone [13]. A dropped shoulder on the affected side, swelling, and haematoma at the middle third of the clavicle are usually observed [136]. When displacement occurs, the medial fragment typically displaces posterosuperiorly due to the pull of the sternocleidomastoid muscle, while the lateral fragment displaces inferomedially due to the pull of the pectoralis major and the weight of the arm, resulting in a “Z” deformity [34]. Palpation often identifies fracture elements [136]. Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms [57].

A distal neurovascular examination is essential because of the proximity of the brachial plexus and subclavian vessels to the zone of injury [26]. Although vascular and neurological complications are rare [13], assessment of possible skin compromise and neurovascular status is important [136]. Tenting of the skin should be evaluated carefully as it can indicate an impending open fracture [26].

Imaging

X-rays typically show the fracture in the middle third of the bone, with the lateral fragment lying below the medial fragment [13]. Outer-third injuries require special views to define any fracture [13]. For accurate assessment, 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 [26]. A bilateral panoramic view of both shoulders is necessary to measure clavicular shortening [26]. Diagnosis verification may also be made from a single AP chest radiograph, which is commonly available in urgent trauma settings [156]. Two incidence radiographs taken in the upright position, a Zanca view (a 10- to 15-degree cephalic tilt of the standard view), and the Velpeau axillary view help characterize fractures [156]. The Zanca view helps delineate lateral clavicle fractures by removing the overlap of the thoracic cage [156].

For lateral clavicle fractures, AP radiographs using the Zanca view provide good visualization [163]. To accurately delineate the degree of fracture displacement, radiographs should be taken with the patient standing and the arm unsupported by slings, braces, or the uninjured arm [163]. 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 the integrity of the coracoclavicular ligaments [163]. CT scanning of lateral clavicle fractures is rarely required clinically but can be useful in selected cases to determine intra-articular extension or displacement [163].

Fractures of the medial clavicle, especially those involving the sternoclavicular (SC) joint, are notoriously difficult to accurately assess with plain radiographs due to superimposed cervical and thoracic spine structures [163, 133]. Additional imaging, usually in the form of a CT scan, may be required to diagnose certain medial end clavicle fractures [133]. CT scanning is the radiographic procedure of choice when the anatomy of a medial clavicle fracture is unclear [163]. CT scans can help distinguish between a medial epiphyseal fracture and true SC dislocations [163]. Some radiograph projections, such as the serendipity and Hobbs views, could be performed as the initial investigation for medial clavicle fractures [156]. For medial clavicle fractures, CT scanning is the procedure of choice [156]. CT is the most accurate modality for determining fracture shortening and morphology but is not typically obtained [26]. Additional CT scanning is useful for intra-articular fractures [156].

Classification

The Robinson classification describes medial fractures as Type I, middle third fractures as Type II, and distal third fractures as Type III [163]. The AO/OTA Fracture and Dislocation Classification Compendium designates the clavicle as segment 15 and divides it into medial metaphyseal, diaphyseal, and lateral metaphyseal fractures [163]. In the AO/OTA classification, metaphyseal fractures are not one-third of the length of the bone but are shorter segments [163].

Lateral clavicle fracture types include: * Type I: Undisplaced extra-articular fractures lateral to the intact coracoclavicular ligaments [21]. * Type IIA: Displaced fractures occurring medial to the intact coracoclavicular ligaments [21]. * Type IIB: Displaced fractures with disruption of the coracoclavicular ligaments [21]. * Type IV: Physeal fracture patterns in skeletally immature patients [21]. * Type V: Comminuted fracture patterns with a separate inferior fragment of clavicle attached independently to the coracoclavicular ligaments [21].

Investigations

Plain radiography: Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture [60]. In urgent trauma settings, the diagnosis may be made from a single AP chest radiograph, which may be the only available film [60]. This view allows evaluation of deformity relative to the normal side and identification of associated skeletal injuries, including rib, glenoid, and scapular fractures [60]. To best delineate a clavicular fracture, the radiograph should be taken in the upright position, as gravity demonstrates maximal deformity [60]. Upright radiographs better demonstrate displacement and predict the position at healing if nonoperative treatment is selected [201]. An upright chest radiograph specifically evaluates midshaft displacement, representing the physiologic stress across the fracture when considering nonoperative management [208]. Ideally, the AP beam is angled 20 degrees superiorly to eliminate thoracic cage overlap and show the clavicle in profile [60]. If the torso is internally rotated 20 degrees, the scapula and shoulder girdle are placed parallel to the cassette for a true AP film [60]. Standard plain unilateral radiographs are insufficient to reliably determine the degree of shortening and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons [214]. Consequently, plain radiograph-based measurements are not recommended when clavicle shortening is considered in the decision to pursue operative management [211]. Outer-third clavicle injuries require special views to define any fracture [13].

CT: CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting [60]. However, CT is the most accurate modality for determining fracture shortening and morphology, though it is not typically obtained [26]. CT imaging demonstrates the complex three-dimensional deformity affecting the shoulder girdle, including significant scapular angulation and protraction [60]. It 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]. Medial clavicle injuries in the pediatric population must be evaluated both clinically and radiographically using chest, clavicle, and serendipity views as well as CT scan [194].

Other Considerations: A small percentage of clavicular fractures are associated with more severe injuries, including scapulothoracic dissociation, scapular fractures, rib fractures, pneumothorax, and neurovascular compromise [26]. Segmental fractures of the clavicle are easily missed [77]. Delayed diagnosis is likely if careful examination of the patient's radiographs is not performed [213]. A measurement of length can be made on the chest radiograph comparing the injured to the uninjured side, where shortening of 2 cm or more represents a relative indication for primary fixation [60]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [7]. 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 [95].

Treatment

General Principles

Clavicle fractures are a common injury, accounting for 2.6 to 4% of all fractures in adults [34]. Historically, most clavicle fractures have been managed nonoperatively [46], and nonsurgical management remains the preferred initial mode of treatment for most cases [47]. However, the risk for persistent symptoms following nonoperative treatment is higher than expected [2]. Close follow-up of nonoperatively treated fractures is warranted due to the potential for progressive displacement in the peri-injury period [5]. When displacement occurs in midshaft clavicle fractures, the medial fragment typically displaces posterosuperiorly due to the pull of the sternocleidomastoid muscle, and the lateral fragment typically displaces inferomedially due to the pull of the pectoralis major and the weight of the arm [34]. Treatment should be tailored to each patient, considering the type of fracture, amount of displacement and comminution, age and level of activity, and aesthetic appearance [47]. There is considerable disagreement between surgeons regarding the recommendation for surgery for midshaft clavicle fractures [183]. In one study year, 8.6% of clavicle fractures were managed by primary surgery [46], with the majority of operatively treated cases in a Swedish study being OTA type B diaphyseal fractures [46].

Non-Operative

Nonoperative care is the treatment of choice for most fractures of the clavicle shaft, especially those that are minimally displaced or undisplaced [118]. It is also the treatment of choice for clavicle shaft fractures in elderly, ill, noncompliant, or sedentary individuals where surgical risk is high or benefit is low [118]. For undisplaced middle-third clavicle fractures, accurate closed reduction is neither possible nor essential [13]. The primary treatment is support of the arm in a sling until pain subsides, usually within 1–3 weeks [13]. Active shoulder exercises should be encouraged after pain subsides, particularly in older patients [13]. Nondisplaced clavicle fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment [129]. The management of undisplaced clavicular fractures remains primarily nonsurgical [152].

For displaced midshaft fractures, there is little or no convincing evidence that any significant improvement can be made to the original position using nonoperative techniques [118]. A randomized trial found no significant difference between a figure-of-eight bandage and a simple sling in radiographic or functional outcome for displaced midshaft clavicle fractures [118]. Patients preferred the simple sling over the figure-of-eight bandage, with fewer patients dissatisfied with the sling [118]. Comparative studies have shown no advantage of the figure-of-eight bandage over a simple sling for nonoperative management of clavicle fractures [46]. Historical management strategies including the figure-of-eight bandage and plaster have largely been abandoned because they are associated with increased pain and discomfort with no functional or radiographic benefit over the use of a simple sling [152]. A simple sling should be worn for about 2 weeks followed by a physical therapy regimen for nonoperative management of clavicle fractures [46].

In the adolescent population, nonoperative management of mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up [29]. Shortened midshaft clavicular fractures in adolescents had excellent outcomes after both operative and nonoperative treatments [40]. Comparably excellent outcomes of severe clavicular fractures in older adolescent athletes can be achieved with nonoperative treatment [105, 108]. Nonsurgical treatment of complete displaced clavicle fractures in adolescents can achieve a good prognosis [132]. Nonoperative treatment remains the primary treatment for acute nondisplaced midclavicular fractures in the pediatric population [138]. More than 90% of Pediatric Orthopaedic Society of North America members favor nonoperative treatment for nondisplaced and angulated midshaft clavicle fractures in the 12–19-year-old adolescent population [138]. Common nonoperative treatment options in adolescents include 2 to 4 weeks of shoulder immobilization with a simple sling [138].

For distal clavicle fractures, nondisplaced fractures (Neer types I, III, and IV) can be treated with nonoperative management [80]. Nondisplaced fractures of the distal end of the clavicle are best treated with a sling [86]. If the conoid ligament is intact in a distal clavicle fracture, the fracture can be expected to heal with sling treatment [86]. The earliest return to sports activity for nondisplaced distal clavicle fractures is generally around 2 months after the injury [86]. In collision sports, extra padding or a fiberglass shell may be necessary to protect the distal end of the clavicle after nondisplaced fracture [86]. 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 [25]. The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment [70]. Initial nonsurgical management with delayed surgery for patients who develop a symptomatic nonunion appears to be a viable treatment strategy for lateral third clavicle fractures [162]. Most lateral third clavicle fractures, particularly in middle-aged or elderly populations, should be managed nonsurgically [162].

For medial third clavicle fractures, management is usually nonsurgical, with satisfactory outcomes and low nonunion rates of 4% to 8% [176]. Treatment consists of an arm sling for comfort, with shoulder immobilization for 2 to 6 weeks [176]. Shoulder range of motion is started as soon as pain subsides or becomes tolerable [176]. Contact sports should be avoided for at least 2 to 3 months to allow complete fracture healing and shoulder rehabilitation [176]. 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 [125].

Operative

Indications: There is a growing trend towards internal fixation of acute clavicular fractures associated with severe displacement, fragmentation or shortening [13]. 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) [67]. Current evidence-based indications for surgical fixation of midshaft clavicular fractures include radiographic shortening of greater than or equal to 2 cm, displacement in a caudal/cephalad plane by equal to or greater than 100% or one bone width, and significant comminution [152]. Additional indications for surgical intervention for midshaft clavicle fractures include open fractures, fractures with underlying neurovascular injury, and fractures that result in significant scapular malposition or winging [152]. Most mid-shaft clavicle fractures can be treated effectively by non-operative means, but a select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications benefit from surgical fixation which has been shown to result in improved outcomes compared with non-operative measures [72]. Operative repair of clavicle fractures should be reserved for medically well, physically active patients who stand to benefit the most from a rapid restoration of normal anatomy and stable fixation [24]. In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment [122]. Surgical management of displaced midshaft clavicular fractures is well supported by high-quality clinical studies [67].

Surgical Approach / Technique: Fixation of displaced fractures of the clavicle can be accomplished by either open plating or intramedullary pinning [152]. An advantage of internal fixation for displaced middle-third clavicle fractures is that the patient can mobilize the arm and return to work and independence more quickly [13]. Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30–65 years old [139]. Plate fixation of clavicle fractures: comparison between early and delayed surgery indicates that most patients have an excellent outcome using conservative management, but surgery is an option [10]. Carefully indicated adolescent patients undergoing ORIF of clavicle fractures can return to play more quickly than previously thought [93]. ORIF of displaced midshaft clavicle fractures may be warranted at initial presentation in additional circumstances beyond absolute indications for surgical intervention in the adolescent population [87]. Treatment of clavicle fractures in adolescents remains controversial; while younger adolescents have excellent remodeling potential and can be treated non-operatively, older adolescents with less growth remaining may require operative management similar to adults [145]. The consensus is that operative intervention for adolescent clavicle fractures should be reserved for older, larger adolescents with severely displaced fractures [24]. Plate fixation is a safe and reliable fixation method with a low complication rate in adolescent patients with significantly displaced midshaft clavicle fractures [24].

Implant Selection: Specific contoured locking plates are available for the internal fixation of clavicle fractures [13]. The use of a pre-contoured plate facilitates surgical care of clavicular fractures, reducing hardware prominence and secondary surgical procedures [67]. The development of precontoured clavicular plates has resulted in a significant reduction in hardware prominence compared with the prior standard use of straight compression or reconstruction plates [152]. Precontoured 2.7-mm plates have demonstrated biomechanical superiority to reconstruction plates in both load to failure and bending failure stiffness [152]. Dual plating may be used as an adjuvant in highly comminuted cases of clavicle fractures [67]. Dual plating with 2.4- or 2.7-mm plates may additionally have a benefit of decreased hardware prominence [67]. Dual plating of the clavicle, usually superiorly and anteriorly, has shown similar outcomes to single plating [152]. Dual plating may be useful in cases of complex comminution or fragment containment where a bridging technique is required [152]. Hardware prominence and secondary surgery for hardware removal has been suggested as a potential benefit of dual plating over single plating [152].

Intramedullary fixation resulted in fewer complications such as prominent hardware and superficial infection compared to plating, whereas there were similar Constant scores [152]. However, intramedullary fixation has been shown to be inferior to plating in terms of rotational control and axial rigidity and may not be the best choice in comminuted fracture patterns requiring increased rotatory control and axial stability [152]. There is a higher rate of removal of intramedullary pins or nails compared to plates [152]. These 2 methods (plate versus intramedullary fixation) were comparable and safe in the treatment of displaced midshaft clavicle fractures [121]. A randomized study found that the percentage of patients reporting implant irritation was no different between plate (70%) and intramedullary nail (66%) fixation for displaced midshaft clavicular fractures [17]. The percentage of patients reporting implant irritation was 39 of 56 patients (70%) for plate fixation and 41 of 62 patients (66%) for intramedullary nail fixation [17]. Intramedullary fixation was associated with a higher likelihood of implant removal (82%) compared to plate fixation (50%) in a randomized study [17]. The likelihood of implant removal was 51 of 62 patients (82%) for intramedullary fixation versus 28 of 56 patients (50%) for plate fixation [17].

Outcomes and Complications: A meta-analysis of six randomized controlled trials found that plate fixation significantly reduced nonunion, although not having a significant effect on final functional outcomes [17]. Secondary surgical procedures were performed less often in the surgically treated group when excluding planned hardware removals in a meta-analysis of six randomized controlled trials [17]. When plate removal was included, revision surgeries were not different between surgical and nonoperative groups in a meta-analysis of six randomized controlled trials [17]. A systematic review including 22 randomized controlled trials showed decreased nonunion in surgically treated patients with a number needed to treat of 10 [17]. Risk of revision surgery across all treatment arms when including plate removal was the same in a systematic review of 22 randomized controlled trials [17]. Surgical management outperformed nonsurgical management in both Disabilities of the Arm, Shoulder and Hand and Constant scores, although averages do not reach minimally clinically important difference at a minimum of 1-year posttreatment follow-up [17]. In a study comparing operative and nonoperative care, the operative group had significantly better Constant and DASH scores at all time points and were significantly more likely to be satisfied with their shoulder [68]. A comprehensive review article outlined that primary internal fixation has advantages including a decreased delayed- and nonunion rate, a lower symptomatic malunion rate, and earlier return to function when compared to nonoperative treatment [42]. Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment [53].

Non-Union and Specific Fracture Types: Non-union of middle-third clavicle fractures is treated by bone graft and plating [13]. 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 [124]. Bone marrow injection for the treatment of clavicle nonunion is promising, with low morbidity and preliminary success justifying further trials [106]. 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 [107]. Outer-third clavicle fractures are quite troublesome and may need open reduction and internal fixation [13]. Surgical techniques for management of displaced lateral clavicle fractures have been summarized in meta-analyses demonstrating no statistically significant difference between coracoclavicular stabilization and locking plate fixation in either functional outcome scores or union rate [162]. Tension band wiring has been found to be associated with poorer Constant scores and has a higher complication rate for lateral clavicle fractures [162]. The hook plate was found to be useful for very lateral fractures with limited bone stock for distal fragment fixation, although acromial osteolysis and the requirement for removal of hardware remain a concern [162]. Careful review of the injury, specifically deciding on the integrity of the coracoclavicular ligaments and fracture pattern, should be taken into account when deciding between hook plate, locking plate, coracoclavicular fixation, and a combination for lateral clavicle fractures [162]. In a specific unit, there is no clearly favoured method of internal fixation of lateral clavicle fractures [85].

Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome [28]. Surgical management of medial third clavicle fractures is usually reserved for fractures associated with injury to the mediastinal structures secondary to fracture displacement [176]. Fractures associated with mediastinal injury should be reduced fairly emergently, with an attempt at closed reduction [176]. Open reduction and internal fixation (ORIF) is sometimes necessary to maintain reduction of an unstable medial third clavicle fracture [176]. Techniques used for ORIF of displaced medial third clavicle fractures include wire fixation, plate-and-screw constructs, or interosseous sutures [176]. A recent study reported a 100% union rate and excellent DASH functional outcome scores following surgical management of medial third clavicle fractures in 27 patients [176].

Other Considerations: There is mounting evidence that the incidence of clavicle fracture repair is increasing worldwide [42]. A study of the Swedish Hospital Discharge Register demonstrated an increase in the overall incidence of clavicle fractures from 36 per 100,000 person-years in 2001 to 59 per 100,000 person-years in 2012 [42]. The rate of surgical fixation for clavicle fractures increased by 705% from 2001 to 2012 in a Swedish study [42].

Complications

Non-Operative Management

Malunion: Displaced middle-third clavicle fractures treated with simple splintage carry a risk of symptomatic malunion, primarily manifesting as pain and reduced power during shoulder movements [13]. While malunion is inevitable in displaced clavicle fractures [13], the resulting slight deformity in adults is generally accepted unless it causes a very unsightly bump with skin irritation [13]. In children, bone remodels rapidly following malunion of displaced clavicle fractures [13].

Non-Union: Simple splintage of displaced middle-third fractures with shortening exceeding 2 cm is associated with an increased incidence of non-union [13]. In a prospective study of 222 patients, non-union developed in 5% of cases, occurring evenly between the middle and acromial parts of the clavicle [84]. A multicenter, prospective, randomized clinical trial reported a 14% non-union rate in the non-operative group for completely displaced middle-third fractures [68]. Nonoperative management of displaced distal clavicle fractures also results in higher nonunion rates [25]. Risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures are multifactoric [83]. When non-union occurs in middle-third fractures, it is treated by bone graft and plating [13].

Functional Outcomes: Complications including non-union and symptomatic malunion were more frequent in the non-operative group compared to the operative group in a multicenter, prospective, randomized clinical trial [68]. A direct relationship exists between increased displacement and worse DASH scores in the non-operative group [68]. When midshaft clavicle fractures are treated conservatively, the affected shoulder side remains more symptomatic than the unaffected side 10 to 30 years after trauma [89].

Operative Management

General Complication Rates: Surgical treatment of midshaft clavicle fractures is associated with a slightly higher incidence of complications compared to the nonoperative approach [71]. Patients undergoing surgical fixation for a midshaft clavicle nonunion face an increased risk of short-term complications compared with those treated for acute fractures [113].

Hardware-Related Issues: There is a highly variable complication profile associated with each fixation method for distal clavicle fractures [92]. In a randomized study of 56 patients with plate and 62 patients with intramedullary nails, 70% of plate fixation patients and 66% of intramedullary nail patients reported implant irritation [17]. Intramedullary fixation was associated with a higher likelihood of implant removal (82%) compared to plate fixation (50%) in a randomized study of displaced midshaft clavicular fractures [17]. In a comparative study of operative versus nonoperative care, 11 of 62 operative patients reported hardware irritation or prominence [42].

Wound and Nerve Complications: In the same comparative study, 18 of 62 operative patients reported incisional numbness [42], and 9 of 62 reported a sensitive or painful fracture site [42]. A limited incision approach for plating of acute midshaft clavicle fractures achieved a low complication rate comparable to standard incision techniques [61].

Adolescent Populations: Operative treatment with plate and screw application has a low complication rate in selected cases of adolescent clavicular fractures [38]. In a retrospective study of 43 adolescent patients with displaced midshaft clavicle fractures, complications in the plate group were minor [24].

Associated Injuries and Trauma

High-Energy Trauma: Patients with clavicle fractures who have sustained high-energy vehicular trauma are more likely to have associated injuries to the thoracic cage, including ipsilateral rib fractures, scapular and/or glenoid fractures, proximal humeral fractures, and hemo/pneumothoraces [48]. Studies from Level 1 trauma centers have noted a high mortality rate of 20% to 34% from associated chest and head traumas in polytrauma patients with clavicle fractures [48].

Specific Injury Patterns: Ipsilateral clavicle fracture and acromioclavicular joint injury has an overall incidence of 6.8% [173]. Women reported higher rates of distal clavicle fracture in the postoperative period following acromioclavicular joint reconstruction, with a fracture rate of 19.6% at 90 days in the female cohort [131].

Long-Term and Specific Outcomes

Glenohumeral Kinematics: Glenohumeral internal rotation deficit after operative treatment of mid-shaft clavicle fractures is a subclinical, scapula-related phenomenon associated with a tendency toward scapular protraction [12].

Mortality and Osteolysis: Medial clavicle fractures have a high proportion of patients who will die within 3 years of the injury [31]. In a case report of Type VI acromioclavicular separation with middle-third clavicle fracture, follow-up radiographs at 10 months demonstrated minimal distal clavicle osteolysis [6].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range-of-motion and strength recovery.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling/brace removal timing.

Functional milestones: Functional results after distal clavicle fractures are excellent following either conservative or surgical treatment [70]. Patients report good quality of life and functional outcomes after plating for midshaft clavicular fractures [135]. The improvement in DASH and CSS scores observed with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of follow-up [143].

Other Considerations: Medial clavicle fractures demonstrate favorable functional outcomes and pain relief at minimum 1-year follow-up among trauma survivors [31]. However, a high proportion of patients with medial clavicle fractures die within 3 years of the injury [31]. In a cohort of 68 patients identified over a 5-year period, excellent functional results were achieved following conservative management of medial clavicle fractures [44]. Generally, 95% of clavicle fractures heal uneventfully, while non-union develops in 5% of cases [84].

For adolescent and pediatric populations, teenage patients with completely displaced clavicle fractures treated non-operatively can expect excellent radiographic and clinical outcomes 5 years post-injury [23]. Displacement in adolescent mid-shaft clavicular fractures does not predict nonunion or inferior functional outcome at long-term follow-up [29]. Shortened midshaft clavicular fractures in adolescents yield excellent outcomes after both operative and nonoperative treatments [40]. Carefully indicated adolescent patients undergoing open reduction and internal fixation (ORIF) can return to play more quickly than previously thought [93]. A more prolonged surveillance period is recommended for children with recurrent clavicle fractures [43].

Regarding operative treatment, surgical management of midshaft clavicle fractures significantly reduces the nonunion rate and shortens the time to union compared with the nonoperative approach [71]. This surgical approach leads to better shoulder functional scores at short- and long-term follow-up, despite a slightly higher incidence of complications [71]. Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, yet shoulder function remains excellent with a low risk of complications and delayed surgery [25]. Patients have very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern [58]. Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela, healing at an average of 8.8 weeks [226]. 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 [61]. The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union [190].

In non-operative management, proportional shortening of 8% in nonoperatively treated displaced midshaft clavicular fractures is not associated with impaired function or patient dissatisfaction [46]. There is essentially no evidence that primary surgical treatment improves final patient function compared to nonoperative management [46]. The results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome (SAPS) following clavicle fractures [11]. The observed association between glenohumeral internal rotation deficit and a tendency toward scapular protraction may provide insight into this phenomenon after operative treatment of mid-shaft clavicle fractures [12].

Key Evidence

• [L5] If patients with medial clavicle fractures can survive the initial trauma, there is every reason to expect good clinical and functional outcomes, regardless of whether surgical or nonsurgical management is chosen. [1] (10.1097/corr.0000000000001916)
• [L2] The risk for persistent symptoms following nonoperative treatment of clavicular fractures was far higher than expected. [2] (10.1080/17453670510041475)
• [L3] Initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. [3] (10.5435/jaaos-d-16-00130)
• [L4] Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury. [4] (10.1177/03635465241228818)
• [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. [5] (10.1016/j.jse.2018.01.004)
• [L5] Follow-up radiographs at 10 months demonstrated a healed clavicle fracture with improvement in the degree of angulation and minimal distal clavicle osteolysis. [6] (10.1097/00042752-200209000-00011)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. [7] (10.5435/jaaos-d-17-00598)
• [L5] The authors suggest the differential diagnosis of a fractured clavicle should be expanded to include idiopathic nontraumatic fractures. [9] (10.1097/01.blo.0000203465.12690.db)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. [10] (10.1016/j.jse.2019.06.022)
• [L4] The results do not suggest protraction of the scapula as a major risk factor for the development of SAPS. [11] (10.1016/j.xrrt.2024.01.008)
• [L4] The observed association with a tendency toward scapular protraction may provide insight into this phenomenon. [12] (10.1186/s13018-026-06856-7)
• [L2] Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment. [14] (10.1177/2325967119s00428)
• [L4] [16] (10.3109/17453674.2010.480939)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. [18] (10.1186/s12891-022-05075-5)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. [19] (10.1016/j.jse.2011.08.053)
• [L4] [21] (10.1177/17585732221131922)
• [L4] Open clavicle fractures are rare injuries. [22] (10.1097/bot.0b013e31821c0b7f)
• [L2] Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. [23] (10.1177/2325967123s00041)
• [L4] Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. [25] (10.1016/j.jse.2023.12.006)
• [L4] Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome. [28] (10.1007/s00068-018-1024-6)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. [29] (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L4] Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications. [30] (10.1177/2325967119s00056)
• [L4] Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. [31] (10.1097/corr.0000000000001839)
• [L1] This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. [33] (10.1186/1471-2474-12-196)
• [L1] [34] (10.5435/jaaos-d-23-00472)
• [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. [38] (10.2106/jbjs.22.01036)
• [L3] The prevalence of clavicle fractures in the United States population has been relatively stable over the past 10 years, with football injuries being the most common etiology. [39] (10.1016/j.xrrt.2025.05.023)
• [L3] Shortened midshaft clavicular fractures had excellent outcomes after both operative and nonoperative treatments. [40] (10.1097/bpo.0000000000000627)
• [L5] The authors recommend a more prolonged surveillance period in children with recurrent fractures of the clavicle. [43] (10.1097/bpb.0000000000000231)
• [Paper] Sixty eight patients with medial clavicle fractures were identified over a 5 year period, with excellent functional results seen following conservative management. [44] (10.1016/j.injury.2016.06.011)
• [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. [49] (10.1016/j.injury.2014.04.032)
• [L3] Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. [53] (10.1016/j.otsr.2017.03.021)
• [L4] These findings do not support routine operative reduction and fixation of shortened midshaft clavicular fractures based on the argument of functional outcome. [56] (10.3109/17453674.2015.1040982)
• [L4] Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms. [57] (10.1177/03635465000280062301)
• [L4] The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. [58] (10.1016/j.jse.2020.10.006)
• [L5] In this large cohort with long-term follow-up, a limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to the reported rate for standard incision techniques. [61] (10.1016/j.jse.2025.06.002)
• [L4] [63] (10.5435/00124635-201107000-00002)
• [L3] Displaced midshaft clavicular fractures with the intent of achieving 'good' outcome must be managed non-operatively. [66] (10.1016/j.injury.2020.10.019)
• [L4] The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment. [70] (10.1016/j.injury.2010.09.036)
• [L1] Surgical treatment of midshaft clavicle fractures significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. [71] (10.1177/0363546519826961)
• [Case_report] The case highlights that segmental fractures of the clavicle are easily missed. [77] (10.1177/1758573214564496)
• [L4] Bilateral clavicle fractures are extremely rare and associated with polytrauma. [78] (10.1186/s12891-023-06228-w)
• [L4] The question of stability is preoperatively less relevant than the question of whether the dislocated fragments lead to compromised shoulder function. [79] (10.1007/s00068-018-0946-3)
• [Paper] Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). [80] (10.2106/jbjs.rvw.25.00260)
• [L3] The risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures are multifactorial. [83] (10.1016/j.otsr.2014.11.018)
• [L3] Ninety-five percent of fractures healed uneventfully, while non-union developed in 5% of cases, evenly distributed between the middle part and the acromial part of the clavicle. [84] (10.1016/s0020-1383(99)00312-5)
• [L4] In our unit there is no clearly favoured method of internal fixation of lateral clavicle fractures. [85] (10.1007/s00590-021-03173-z)
• [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. [87] (10.1016/j.xrrt.2023.03.004)
• [L4] The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. [89] (10.1186/s13018-023-04450-9)
• [L4] [90] (10.1007/s00068-019-01122-4)
• [L3] While most distal clavicle fracture fixation methods can achieve stable union, there is a highly variable complication profile associated with each fixation method. [92] (10.1016/j.otsr.2019.03.012)
• [L3] These data suggest that carefully indicated adolescent patients undergoing ORIF of clavicle fractures can RTP more quickly than previously thought. [93] (10.1177/23259671251374299)
• [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. [95] (10.2106/jbjs.19.00955)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. [98] (10.1016/j.jse.2025.04.021)
• [L5] The modified Neer classification remains the predominantly cited classification system for distal clavicle fractures, yet its intra- and interobserver reliability has been demonstrated to be inconsistent, which can lead to incorrect treatment choices and misclassifications in research. [102] (10.1097/corr.0000000000001456)
• [L3] The study demonstrated moderate interobserver and substantial intraobserver reliability of the new classification system and the associated treatment choice for distal clavicle fractures. [104] (10.1016/j.otsr.2018.05.015)
• [L2] Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment. [105] (10.1177/03635465231219248)
• [L4] Bone marrow injection for the treatment of clavicle nonunion is promising, with low morbidity and preliminary success justifying further trials. [106] (10.1016/j.jse.2006.05.001)
• [L3] Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management. [107] (10.1177/1758573221990367)
• [L2] Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment. [108] (10.1177/2325967121s00214)
• [L3] Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. [113] (10.1016/j.jse.2016.01.028)
• [L4] [118] (10.1016/j.ocl.2009.12.005)
• [L3] The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair, and additional 3D CT did not improve the overall level of interrater or intrarater agreement of the classification system or associated treatment choice. [119] (10.1177/0363546515593949)
• [L4] Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. [120] (10.1177/2325967120921344)
• [L1] These 2 methods were comparable and safe in the treatment of displaced midshaft clavicle fractures. [121] (10.1097/md.0000000000001792)
• [L2] In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. [122] (10.1016/j.jse.2013.06.025)
• [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. [124] (10.1016/j.otsr.2013.09.011)
• [L5] A targeted approach to the management of mid-shaft clavicle fractures is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union. [125] (10.1016/j.injury.2020.11.066)
• [L4] Nondisplaced clavicle fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment. [129] (10.3810/psm.2011.09.1930)
• [L3] Women reported higher rates of distal clavicle fracture in the postoperative period, and the high fracture rate in the female cohort (90 days, 19.6%) highlights a potentially under-recognized clinical consideration. [131] (10.1002/ars2.70063)
• [L4] Nonsurgical treatment of complete displaced clavicle fractures in adolescents can achieve a good prognosis. [132] (10.1177/03635465241275671)
• [L4] [133] (10.1177/1758573220923122)
• [L3] Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures. [135] (10.1016/j.injury.2017.10.032)
• [L4] [136] (10.1302/2058-5241.3.170033)
• [L5] [138] (10.5397/cise.2025.00500)
• [L4] [139] (10.4103/tcmj.tcmj_25_18)
• [L4] According to the classifications of Neer and Jäger/Breitner, a clear therapeutic strategy for lateral clavicular fractures can be defined. [141] (10.1016/0020-1383(95)00156-5)
• [L1] The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup. [143] (10.1007/s11999-011-1915-x)
• [L4] Midshaft clavicular fractures should be classified according to the Robinson classification on two-plane radiography to optimize treatment decisions. [146] (10.1016/j.clinimag.2014.07.012)
• [L4] [148] (10.1302/0301-620x.95b7.31316)
• [L5] There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents due to concerns about symptomatic malunion and poor functional outcomes with nonsurgical management, though definitive indications for fixation in this population remain unclear. [161] (10.5435/00124635-201301000-00002)
• [L2] [164] (10.1016/j.jse.2022.03.016)
• [L1] This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. [165] (10.1177/1758573218777996)
• [L5] [167] (10.1007/s10140-018-1586-y)
• [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. [170] (10.1016/j.jseint.2021.05.007)
• [L3] Ipsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall. [173] (10.1016/j.injury.2016.12.021)
• [L4] Considerable disagreement between surgeons exists regarding recommendation for surgery for midshaft clavicle fractures. [183] (10.1016/j.jse.2025.06.023)
• [L5] [186] (10.1016/s0020-1383(15)30035-8)
• [L4] The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union. [190] (10.1097/01.blo.0000183088.60639.05)
• [L5] Medial clavicle injuries in the pediatric population must be evaluated both clinically and radiographically using chest, clavicle, and serendipity views as well as CT scan. [194] (10.1097/bot.0b013e3181aa7d3d)
• [L4] This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected. [201] (10.1097/bot.0000000000000129)
• [L4] An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management. [208] (10.1097/bot.0000000000000727)
• [L4] When clavicle shortening is considered in the decision to pursue operative management, the use of plain radiograph-based measurements is not recommended. [211] (10.4055/cios.2016.8.4.367)
• [L5] Delayed diagnosis is likely if careful examination of the patient's radiographs is not performed. [213] (10.1177/2054270414527281)
• [L3] Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons. [214] (10.1177/0363546514523926)
• [L4] Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. [226] (10.1177/0363546510372795)

See Also

• Fractures
• Clavicle Fracture Fixation
• Internal Fixation
• Soft Tissue Structures
• Distal Clavicle Osteolysis

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