Clavicle Fracture

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

Overview

Patients with medial clavicle fractures who survive the initial trauma generally achieve good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [1]. Non-unions and malunions remain the most common complications following clavicle fractures, whether treated operatively or non-operatively [5]. Complication rates following surgical clavicle fracture care averaged 8.1% [12]. Close follow-up of nonoperatively treated fractures is warranted due to the risk of progressive displacement in the peri-injury period [2].

Specific treatment should be individualized based on fracture characteristics and patient expectations rather than broadly applied [4]. Most mid-shaft clavicle fractures can be treated effectively by non-operative means [35]. However, 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 [35]. Patient selection for surgery may influence functional outcome after midshaft clavicle fracture [43], and there may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation for displaced midshaft clavicle fractures [44].

In the adolescent population, the majority of clavicular fractures can and should be treated nonoperatively [39]. Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment [27]. Operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected cases of adolescent clavicular fractures [39]. Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications [40]. Despite this, 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 [72], though definitive indications for fixation in the adolescent population with markedly displaced midshaft clavicle fractures remain unclear [72].

Anatomy & Pathophysiology

Osseous Anatomy and Epidemiology

Clavicle fractures constitute 2% to 5% of all fractures in adults and 35% to 44% of all fractures in the shoulder [38], with an annual incidence of 50 to 64 per 100,000 persons [38]. The majority occur in males and are associated with vehicular trauma, falls, or sporting injuries [3]. Most (85%) fractures occur in the midshaft where the bone is narrowest and soft tissue coverage is scarce [23], comprising approximately 69% to 81% of all clavicle fractures [38]. Lateral third fractures account for 17% to 28% [38], while medial third fractures constitute the remaining 2% to 3% [38]. The risk for fracture is increased in men aged 30 years or younger and all patients older than 70 years [38].

Mechanisms of Injury

The most common mechanism is a direct blow to the shoulder, whether from a fall or direct trauma [16], with a direct blow to the point of the shoulder being the commonest cause of midshaft fractures [23]. Falls on an outstretched hand are less common [16], while motor vehicle/motorcycle accidents, bicycling, skiing/snowboarding, and sports injuries are the most common mechanisms for completely displaced midshaft fractures [23]. Sternoclavicular injuries are rare and typically associated with posteriorly directed blows against the medial clavicle or distal shoulder girdle [23]. Simple falls from standing height are unlikely to produce displaced fractures in healthy young persons but can injure elderly, osteoporotic individuals [23]. Fractures from trivial mechanisms in the distal third should prompt investigation for a pathologic fracture [23]. High-energy trauma rarely results in open fractures [16], though penetrating trauma from projectiles, blasts, or sharp objects can occur [22]. A large abrasion or contusion on the posterior shoulder is typical in displaced midshaft fractures, especially from bicycle or motorcycle falls [23].

Kinematics and Deforming Forces

The clavicle acts as the main strut maintaining shoulder girdle position under lateral compression; failure occurs via AC articulation failure, clavicle fracture, or SC joint dislocation [23]. The direction of the initial deforming force, along with gravitational and muscular forces, results in the distal fragment being translated inferiorly, anteriorly, and medially (shortened), and rotated anteriorly [23]. The distal fragment is translated anteriorly, medially, and inferiorly, and rotated anteriorly due to muscular and gravitational forces, resulting in scapular protraction [23]. The outer fragment in distal fractures is pulled downward and forward by the weight of the arm [34]. The pectoralis major, pectoralis minor, and latissimus dorsi draw the distal segment downward and medially, causing overriding [34]. The trapezius muscle attaches to the entire outer two-thirds of the clavicle, while the sternocleidomastoid muscle attaches to the medial third, drawing the segments superiorly and posteriorly [34].

Classification Systems

Edinburgh Classification: Divides fractures by anatomic location into type I (medial third), type II (middle third), and type III (lateral third) [16]. Subgroup A indicates displacement less than 100% and subgroup B indicates displacement more than 100% [16]. Subgroup 1 indicates no articular involvement and subgroup 2 indicates intra-articular extension [16]. Neer Classification: Type I distal fractures have intact coracoclavicular (CC) ligaments [36]. Type II distal fractures have CC ligaments detached from the medial fragment, with the trapezoidal ligament attached to the distal fragment [36]. Type III distal fractures involve extension into the AC joint [36]. Craig Classification: Best predicted nonunion or delayed union of lateral third clavicle fractures in a 2011 study [16]. Robinson Classification: Had the best prognostic potential for middle third clavicle fractures in a 2011 study [16]. AO/OTA Classification: Designates the clavicle as segment 15 [36], where metaphyseal fractures are shorter segments than one-third of the bone length [36]. Lateral Third Subtypes: Type I fractures occur lateral to the CC ligaments and are usually stable [16]. Type II fractures are medial to the CC ligaments, usually unstable, and require surgical management [16]. Type IIA fractures have the fracture medial to intact conoid and trapezoid ligaments [16]. Type IIB fractures have the fracture lateral to the torn conoid ligament but medial to the intact trapezoid ligament [16]. Type III fractures are intra-articular through the AC joint with intact CC ligaments [16]. Type IV fractures involve disruption of the clavicular periosteal sleeve in pediatric patients, where the epiphysis and physis remain with the AC joint and displacement occurs at the junction of the metaphysis and physis [16]. Type V fractures involve a small, inferior cortical bone fragment remaining attached to the CC ligaments, with proximal and distal fragments not connected to the coracoid process [16].

Pediatric and Neonatal Fractures

Pediatric clavicle fractures represent 8% to 15% of all pediatric fractures [70], with approximately 76% to 85% occurring in the middle third [70]. The mechanism is usually a fall onto an outstretched arm, a direct fall on or blow to the lateral shoulder, or a direct blow to the clavicle itself [70]. The clavicle is the most commonly fractured bone during neonatal delivery, occurring in 0.035% to 3.2% of live births [70]. Risk factors for birth-related fractures include high birth weight (>4,000 g), shoulder dystocia, and increased maternal age [70]. Cesarean section reduces the risk but still occurs in 0.05% of live births via cesarean section with high birth weight and increased maternal age [70]. Up to 20% of birth-related fractures are identified after discharge from the hospital [70]. The clavicle reaches 80% of its length at age 9 in girls and age 12 in boys [70], growing at a rate of 2.6 mm per year in girls and 5.4 mm per year in boys [70].

Associated Injuries and Prognosis

Associated injuries are increasingly common compared to older studies [22]. Patients with 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 [22]. Several Level 1 trauma center studies note a high mortality rate (20% to 34%) from associated chest and head traumas in polytrauma patients [22]. Multiple ipsilateral rib fractures may be significant as the degree of disruptive energy imparted to the chest and shoulder girdle may be associated with higher rates of poor outcome in the associated clavicle fracture [22]. If a vascular repair has been performed for a clavicle injury, clavicular fixation provides an optimally stable environment for healing [22]. The prognostic index (PI) becomes more negative with increasing age, increasing comminution, increasing displacement, and female sex [10]. Most clavicle fractures do not increase the occurrence of later subacromial pain syndrome [7], and results do not suggest protraction of the scapula as a major risk factor for its development [7].

Classification

Allman: Proposed in 1967, this system classifies clavicle fractures by anatomic location in descending order of incidence [16]. Type I fractures involve the middle third [16]. Type II fractures involve the lateral third [16]. Type III fractures involve the medial third [16].

Neer (Modified): In 1968, Neer subclassified Type II (lateral third) fractures based on coracoclavicular (CC) ligament integrity and fracture line relationships to the CC ligaments and acromioclavicular (AC) joint [16]. Type I lateral fractures occur lateral to the CC ligaments and are usually stable [16]. Type II lateral fractures occur medial to the CC ligaments, are usually unstable, and require surgical management [16]. Type IIA fractures occur medial to the intact conoid and trapezoid ligaments [16]. Type IIB fractures occur lateral to the torn conoid ligament but medial to the intact trapezoid ligament [16]. Type III lateral fractures are intra-articular through the AC joint with intact CC ligaments; they are usually stable but can result in AC joint arthritis [16]. Type IV fractures involve disruption of the clavicular periosteal sleeve in pediatric patients, where the epiphysis and physis remain with the AC joint and displacement occurs at the metaphysis-physis junction [16]. Type V fractures involve a small, inferior cortical bone fragment remaining attached to the CC ligaments, with proximal and distal fragments not connected to the coracoid process; these are rare and generally require surgical intervention [16]. The Modified Neer classification remains the predominantly cited system for distal clavicle fractures [55], though its intra- and interobserver reliability is inconsistent [55], leading to incorrect treatment choices and misclassifications in research [55]. Interrater agreement for lateral clavicle fractures using this system is fair [64], and additional 3D CT does not improve interrater or intrarater agreement or associated treatment choice [64].

Craig: Introduced in 1990, this classification details fracture patterns within the three broad groups of Allman's system [34]. Group I fractures, or middle third fractures, are the most common in adults and children, occurring where the clavicle changes from prismatic to flattened cross-section; they account for 80% of clavicle fractures [34]. Group II fractures account for 12% to 15% of all clavicle fractures and are subclassified by the location of CC ligaments relative to fracture fragments [34]. Type I distal clavicle fractures are the most common by a 4:1 ratio; they are interligamentous fractures between the conoid and trapezoid or between the coracoclavicular and AC ligaments where ligaments remain intact to prevent rotation, tilting, or displacement [34]. Type II distal clavicle fractures involve detachment of CC ligaments from the medial segment; in Type IIA, both conoid and trapezoid ligaments may be on the distal fragment, while in Type IIB, the conoid is ruptured but the trapezoid remains attached to the distal segment [34]. There is no functional difference between Type IIA and Type IIB fractures [34]. These fractures are equivalent to a serious AC separation with loss of normal constraints to anteromedial scapular rotation [34]. Four forces impair healing: the weight of the arm pulls the outer fragment downward and forward when erect [34]; the pectoralis major, pectoralis minor, and latissimus dorsi draw the distal segment downward and medially causing overriding [34]; scapular rotation moves the distal segment during arm movement [34]; and the trapezius (attaching to the outer two-thirds) and sternocleidomastoid (attaching to the medial third) draw the clavicular segments superiorly and posteriorly [34]. Type III distal fractures involve the AC joint articular surface alone, characterized by a break in the articular surface without ligamentous injury; they may be subtle, confused with first-degree AC separation, require special views to visualize, and may manifest as late degenerative joint arthrosis [34]. Type IV fractures occur in children and may be confused with complete AC separation [34]. Weightlifter's clavicle, or distal end resorption, may occur from increased vascularity secondary to microtrauma or microfractures [34]. A 2011 study reported that the Craig classification best predicted nonunion or delayed union of lateral third clavicle fractures [16].

Edinburgh: Proposed in 1998, this system divides clavicular fractures by anatomic location into Type I (medial third), Type II (middle third), and Type III (lateral third) [16]. Subgroup A indicates displacement less than 100%, while subgroup B indicates displacement more than 100% [16]. Subgroup 1 indicates no articular involvement, while subgroup 2 indicates intra-articular extension [16]. Type II fractures are subdivided into subgroup 1 (simple or wedge-type) and subgroup 2 (comminuted or segmented) [16].

Robinson: A 2011 study reported that the Robinson classification had the best prognostic potential for middle third clavicle fractures [16]. Surgical treatment with locked plate fixation in Type IIB2 clavicle fractures according to this classification can be the first treatment choice, offering better cosmetics, lower complication rates, and better outcomes [68].

Other Considerations: Most clavicle fractures result from a fall onto the shoulder or a direct blow [3], with the most common mechanism being a direct blow to the shoulder following a fall or direct trauma [16]. Less commonly, a fall on an outstretched hand results in a clavicle fracture [16]. Clavicle fractures are rarely open despite high-energy trauma [16]. The prevalence of clavicle fractures in the US population has been relatively stable over the past 10 years [29], with football injuries being the most common etiology [29]. A presented classification system for lateral clavicle fractures showed substantial inter- and intraobserver reliability [54].

Clinical Presentation

Most clavicle fractures result from a fall onto the shoulder or a direct blow [3]. The majority of these injuries occur in males [3], with adolescent fractures specifically affecting male patients [28]. Etiologies include vehicular trauma, falls, or sporting injuries [3], with football injuries representing the most common cause of pediatric clavicular fractures in the United States [29]. Adolescent fractures typically occur during sports [28], secondary to a direct blow to the shoulder [28], and affect the nondominant side [28]. Bilateral clavicle fractures are extremely rare [19] but are associated with polytrauma [19].

Inspection and palpation must account for the mechanism of injury. Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms [24]. Segmental fractures of the clavicle are easily missed [32]. Lateral clavicle fractures can be well visualized with AP radiographs [36]. Centering the radiograph on the AC joint and angling the beam in a cephalic tilt of approximately 15 degrees (the Zanca view) helps delineate lateral clavicle fractures by removing the overlap of the upper portion of the thoracic cage [36]. Radiographs to accurately delineate the degree of lateral clavicle fracture displacement should be taken with the patient standing and the arm unsupported by slings, braces, or the uninjured arm [36].

Imaging Modalities: * Stress Views: A stress view may be useful to determine the integrity of the coracoclavicular ligaments in lateral clavicle fractures [36]. A 2.26- to 4.53-kg (5- to 10-lb) weight is suspended from the wrist of the affected arm for this view [36]. * CT Scanning: CT scanning of lateral clavicle fractures is rarely required clinically but can be useful in selected cases to determine intra-articular extension or displacement [36]. Fractures of the medial clavicle, especially those involving the SC joint, are notoriously difficult to accurately assess with plain radiographs [36]. CT scanning is the radiographic procedure of choice when the anatomy of a medial clavicle fracture is unclear [36]. CT scanning can help distinguish between a medial epiphyseal fracture and true SC dislocations [36]. Medial epiphyseal fractures are common in individuals up to 25 years of age [36].

Classification Systems: * Allman Classification: Divides clavicle fractures into proximal (Group I), middle (Group II), and distal (Group III) third fractures [36]. * Neer Classification: Divides distal clavicle fractures into three subgroups based on ligamentous attachments and degree of displacement [36]. * Type I: The coracoclavicular ligaments are intact [36]. * Type II: Coracoclavicular ligaments are detached from the medial fragment, with the trapezoidal ligament attached to the distal fragment [36]. * Type III: Fractures have extension into the AC joint [36]. * Rockwood Subtypes (Neer Type II): * Type IIA: Both conoid and trapezoid ligaments are attached to the distal fragment [36]. * Type IIB: The conoid ligament is detached from the medial fragment [36]. * Robinson Classification: Divides the clavicle into thirds, describing medial fractures as Type I, middle third fractures as Type II, and distal third fractures as Type III [36]. This classification includes variables of proven diagnostic value such as intra-articular extension, displacement, and comminution [36]. * AO/OTA Classification: Designates the clavicle as segment 15 [36]. It divides the clavicle into medial metaphyseal, diaphyseal, and lateral metaphyseal fractures [36]. In this system, metaphyseal fractures are shorter segments than one-third of the length of the bone [36].

Outcomes and Complications: Most clavicle fractures have an excellent outcome using conservative management [14]. Most patients with clavicle fractures can expect good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [1]. Patients who survive the initial trauma of a medial clavicle fracture can expect good clinical and functional outcomes [1]. However, a high proportion of patients with medial clavicle fractures will die within 3 years of the injury [18]. Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma [18]. Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively [17].

Operative Considerations: Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates [33]. Shoulder function remains excellent following nonoperative management of displaced distal clavicle fractures [33]. The risk of complications and delayed surgery is low following nonoperative management of displaced distal clavicle fractures [33]. Initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed [8]. There is a subset of patients, especially those with shortened, displaced fractures, who would benefit from primary operative repair of clavicular injuries [11]. Patients with displacement of greater than 2 cm may heal promptly with minimal symptomatology and full function of the involved shoulder despite prognostic factors for a poor outcome [11]. Patient noncompliance, especially when associated with substance abuse, is a clear contraindication for surgery [11]. Patient noncompliance with the postoperative regimen could be suspected to have a major cause of failures in acute, displaced midshaft fractures of the clavicle [11]. Active adolescents with badly displaced fractures may benefit from primary surgical repair [11]. Nonunions and symptomatic malunions do occur in active adolescents with badly displaced fractures treated nonoperatively [11]. Plate fixation of clavicle fractures is associated with a high success rate and a minimal complication rate [11].

Red Flags and Follow-up: Effective management of lateral clavicular fractures remains an ongoing challenge [6]. The most common complications following clavicle fractures, whether treated operatively or non-operatively, are non-unions and malunions [5]. Patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern [9]. Close follow-up of nonoperatively treated clavicle fractures is warranted [2]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [13]. The results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome [7]. Clavicle fractures do not increase the occurrence of later subacromial pain syndrome [7]. The prevalence of clavicle fractures in the United States population has been relatively stable over the past 10 years [29].

Investigations

Plain radiography: Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture [26], which may also be made from a single AP chest radiograph [26]. To best delineate a fracture, the radiograph should be taken in the upright position where gravity demonstrates maximal deformity [26]. Ideally, the AP beam should be angled 20 degrees superiorly to eliminate thoracic cage overlap and show the clavicle in profile [26]; if the torso is internally rotated 20 degrees, the scapula and shoulder girdle align parallel to the cassette for a true AP film [26]. A chest radiograph evaluates deformity relative to the normal side and screens for associated skeletal injuries such as rib, glenoid, and scapular fractures [26]. Shortening of 2 cm or more on a chest radiograph represents a relative indication for primary fixation [26]. Standard plain unilateral radiographs are insufficient to reliably determine the degree of shortening or the need for surgery among fellowship–trained orthopaedic surgeons [91]. Medial third clavicular fractures are often not fully appreciated on plain radiography [76], and segmental fractures are easily missed [32].

CT: CT scanning is the radiographic investigation of choice for medial third clavicular fractures given the difficulty of clear visualization with plain radiography [76]. In a case series, 22% of patients had medial third clavicle fractures that could only be identified on CT [76]. CT scanning can demonstrate the complex three-dimensional deformity affecting the shoulder girdle with midshaft fractures, including significant scapular angulation and protraction [26]. 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" [26]. Despite these capabilities, CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting [26].

MRI: Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to distal clavicle fractures should be recommended [81].

Other Considerations: Most clavicle 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 [3]. The most common mechanism is a direct blow to the shoulder, whether following a fall or due to direct trauma [16], though less commonly a fall on an outstretched hand can result in a fracture [16]. Clavicle fractures are rarely open despite high-energy trauma [16]. Associated injuries are increasingly common compared to older studies, with high mortality rates (20% to 34%) from associated chest and head traumas in polytrauma patients [22]. Patients with 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 [22]. Multiple ipsilateral rib fractures may be associated with higher rates of poor outcome [22]. Bilateral clavicle fractures are extremely rare and associated with polytrauma [19]. Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in compression mechanisms [24]. Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables accurate prediction of patients likely to have union with nonoperative management [48]. Once healed, further radiographic imaging provides no notable information [13]. Close follow-up of nonoperatively treated fractures is warranted due to displacement related to patient position and progressive displacement in the peri-injury period [2]. Most patients have an excellent outcome with conservative management [14], and initial nonsurgical management is reasonable as functional outcomes are similar even with delayed surgery [8]. Teenage patients with completely displaced fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively [17]. Significant remodeling occurs in adolescent patients with displaced fractures, particularly in older adolescents followed for longer intervals [95, 96]. Patients with medial clavicle fractures who survive initial trauma can expect good clinical and functional outcomes regardless of surgical or nonsurgical management [1]. The results do not suggest scapular protraction as a major risk factor for subacromial pain syndrome (SAPS) following clavicle fractures, nor do clavicle fractures increase the occurrence of later SAPS [7].

Treatment

Non-Operative

Most mid-shaft clavicle fractures are effectively managed non-operatively, with the majority of patients achieving excellent functional outcomes [35]. While initial nonsurgical management is reasonable even when surgery is delayed, close follow-up is warranted due to the risk of progressive displacement in the peri-injury period [2, 8]. A sling is preferred over a figure-of-eight bandage as it causes less discomfort, fewer complications, and lower pain scores without increasing clavicular shortening [83]. A sling should be worn for approximately 2 weeks followed by a physical therapy regimen [83]. Recent evidence indicates that proportional shortening of 8% is not associated with impaired function or patient dissatisfaction in healed displaced midshaft fractures [83]. However, a pain score exhibiting no or minimal change from 2 to 4 weeks after nonoperative treatment of a displaced midshaft fracture is associated with a high risk of symptomatic nonunion [88].

Operative

Indications: Operative treatment for midshaft clavicle fractures is indicated for displacement greater than 2 cm, shortening greater than 2 cm, increasing comminution with more than 3 fragments, segmental fractures, open fractures, and impending open fractures with soft tissue compromise [10]. Obvious clinical deformity, usually associated with displacement or shortening greater than 2 cm, also warrants surgery [10]. Scapular malposition and winging on initial examination are specific indications for operative treatment [10]. Associated injuries requiring operative management include vascular injury requiring repair, progressive neurologic deficit, ipsilateral upper extremity injuries or fractures, multiple ipsilateral upper rib fractures, "floating shoulder," and bilateral clavicle fractures [10]. Patient factors indicating surgery include polytrauma requiring early upper extremity weight-bearing or arm use, and patient motivation for rapid return of function such as in elite sports or self-employed professionals [10]. Operative repair should be reserved for medically well, physically active patients who stand to benefit most from rapid restoration of normal anatomy and stable fixation [10]. Adolescent patients with significantly displaced midshaft fractures may develop symptomatic malunion following nonoperative treatment, although nonunion remains rare [10]. A subset of patients, especially those with shortened and displaced fractures, would benefit from primary operative repair [11]. Active adolescents with badly displaced fractures may also benefit from primary surgical repair as nonunions and symptomatic malunions do occur with nonoperative care [11]. There may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation for displaced midshaft clavicle fractures in the adolescent population [44].

Surgical Approach / Technique: Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications [40]. Clavicle plating under WALANT (wide-awake local anesthesia no tourniquet) is a reliable and effective alternative option to general anesthesia in selected patients or settings with limited anesthetic facilities [87]. A real-size 3D-printed model can be used as a preoperative and intraoperative tool for minimally invasive plating of comminuted midshaft clavicle fractures when it is difficult to achieve anatomic reduction by open reduction technique [66]. A simple surgical technique for correcting malunion after midshaft clavicle fracture seems to be a good option in the treatment of clavicle malunion [61].

Implant Selection: Plate fixation is a safe and reliable fixation method with a low complication rate for adolescent patients with significantly displaced midshaft clavicle fractures [10]. Distal radial locking plates provided stable fixation with minimal early complications and no disturbance to the acromioclavicular joint, subacromial space, or rotator cuff for unstable distal clavicle fractures [30]. Both distal anatomic locking plate fixation and arthroscopic coracoclavicular button fixation provide satisfactory functional and radiological outcomes for unstable distal clavicular fractures [15]. A locking plate combined with titanium cable is an effective method for treating unstable distal clavicle fractures (Neer type II) [63]. A modified method of augmented distal clavicle fracture osteosynthesis with a Fibertape coracoclavicular cerclage is effective, produces good clinical outcomes, and has minimal complications [58]. Rigid clavicular fixation is a safe and effective treatment option for anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in adolescents [49]. Understanding clavicle anatomy, appropriate patient selection, and implant design differences is critical to successful application of intramedullary fixation and avoiding complications [80].

Alignment / Balancing Strategy: Future studies are needed to determine whether there is an optimal approach for clavicle plating (anteroinferior versus superior) [62].

Pain Management: No specific analgesic regimens are detailed in the provided evidence base for this section.

Adjuncts: No specific adjuncts such as tourniquet, tranexamic acid, drains, navigation, or robotics are detailed in the provided evidence base for this section.

Revision: Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures [41]. 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 [56]. Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures [47].

Other Considerations: Medial clavicle fractures often represent physeal injury–subluxations or fracture–dislocations in younger individuals due to the medial clavicular epiphysis fusing last (until 25 to 30 years of age) [77]. Preoperative CT scans are important for defining the anatomy of medial clavicle fractures as they are difficult to visualize with plain radiographs [77]. Fractures that are significantly displaced, especially with posterior displacement of the shaft fragment, may warrant operative repair for medial clavicle fractures [77]. Fixation of medial clavicle fractures using smooth wires or pins alone is contraindicated due to the potential for migration and visceral injury [77]. If patients with medial clavicle fractures survive the initial trauma, good clinical and functional outcomes are expected regardless of whether surgical or nonsurgical management is chosen [1]. A high proportion of patients with medial clavicle fractures die within 3 years of the injury [18]. Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among survivors [18]. Specific treatment of clavicle fractures should be individualized based on fracture characteristics and patient expectations rather than broadly applied [4]. The most common complications following clavicle fractures, whether treated operatively or non-operatively, are non-unions and malunions [5]. Effective management of lateral clavicular fractures remains an ongoing challenge [6]. Patient noncompliance, especially when associated with substance abuse, is a clear contraindication for surgery [11]. Complication rates following surgical clavicle fracture care averaged 8.1% [12]. Women are 4 times more likely than men to have hardware removed following operative treatment of clavicle fractures [42]. Patients undergoing clavicle hardware removal report worse long-term outcomes than patients with hardware retained [42]. The overall incidence of clavicular hardware removal was 12.6% [46]. Only 7.7% of patients required hardware removal for symptomatic hardware with pre-contoured titanium anterior plating of midshaft clavicle fractures [84]. Considerable disagreement between surgeons exists regarding recommendation for surgery for midshaft clavicle fractures [86]. Historically, most clavicle fractures have been managed nonoperatively, with 8.6% managed by primary surgery in the study year [83]. The highest prevalence of primary surgery was in OTA type B diaphyseal fractures where 10.4% were managed surgically [83]. 7.2% of OTA type C lateral fractures were treated with primary surgery [83]. Comparative studies have shown no advantage of the figure-of-eight bandage over a simple sling for nonoperative management of clavicle fractures [83]. There is consistent evidence that the rates of malunion and nonunion are less with primary surgery for midshaft clavicle fractures [83]. There is essentially no evidence that primary surgical treatment improves final patient function for midshaft clavicle fractures [83]. Tamaoki et al. reported no difference in DASH scores at 6 weeks, 6 months, and 1 year between operative and nonoperative management of midshaft clavicle fractures [83]. Tamaoki et al. reported no difference in pain levels, time to return to previous activities, and dissatisfaction with the cosmetic result between operative and nonoperative management of midshaft clavicle fractures [83]. Analysis of DASH scores in a review of published evidence favored operative management for midshaft clavicle fractures [83]. Proportional shortening of 8% did not significantly correlate with the DASH score, Constant score, or SF-12 score at any time during follow-up in nonoperatively treated patients [83]. Patients with displaced clavicle fractures benefit clinically and financially from stabilization, experiencing less chronic pain, deformity, and weakness with better range of motion and earlier return to work [37]. Most patients with clavicle fractures have an excellent outcome using conservative management [14]. Nonsurgical and surgical management provide similar results for distal clavicle fractures [59]. In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment [60]. Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up [25]. Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment [27]. Carefully indicated adolescent patients undergoing ORIF of clavicle fractures can return to play more quickly than previously thought [50].

Complications

Non-union and Malunion: Non-unions and malunions represent the most common complications following clavicle fractures, irrespective of operative or non-operative management [5]. High-quality evidence confirms that surgical treatment of displaced midshaft clavicle fractures in adults yields significantly higher union rates than non-surgical treatment [108]. In prospective randomized trials, non-union rates were markedly lower in surgical groups compared to non-surgical cohorts: 2.4% vs 23% in the Netherlands [20], 0% vs 15% in Brazil [20], and 0.8% vs 11% at nine months in the United Kingdom [20]. A systematic review of 1,352 patients across 14 randomized trials corroborated a lower risk of non-union with surgical intervention [20]. Conversely, non-unions occur more frequently with non-surgical treatment of displaced midshaft fractures [20]. In adolescents, five patients in a nonoperative group with a mean of 26 mm of shortening developed symptomatic malunion, with four requiring corrective osteotomy [10].

Infection and Wound Complications: The most common complication following surgery for midshaft clavicle fracture nonunion is wound infection [20]. Patients undergoing surgical fixation for midshaft clavicle nonunion face an increased risk of short-term complications compared to those treated for acute fractures [41], with a retrospective cohort study confirming higher total complication rates in the nonunion group [20]. The prognosis for bony union in infected clavicle fractures is poor, with only two of six patients achieving union [116]. While precontoured locking plates achieved satisfactory clinical results with low complication rates [107], and dual mini-fragment plating showed a low rate of implant removal for soft-tissue irritation (3.7%) [20], general complication rates following surgical clavicle fracture care average 8.1% [12]. Specifically, the overall complication rate following ORIF of displaced midshaft clavicle fractures was 27.3%, with 9.1% requiring reoperation [112].

Hardware Removal and Refracture: The overall incidence of clavicular hardware removal is 12.6% [46], with women being four times more likely than men to undergo removal [42]. Following clavicle ORIF, one in four patients underwent reoperation [109]. Major re-intervention and refracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures [47]. Severe comminution and unsatisfactory reduction during primary surgery are risk factors for refracture after implant removal [115]. The incidence of refracture following implant removal after bone union is likely underestimated [115]. Patients undergoing hardware removal report worse long-term outcomes than those with retained hardware [42].

Scapular Dysfunction and Pain: Scapular winging results from residual clavicular malposition due to malunion or nonunion [82], a risk lessened by primary fixation [82]. Clavicle fractures do not increase the occurrence of later subacromial pain syndrome [7], and scapular protraction is not a major risk factor for its development [7].

Thromboembolism and Chest Wall Injury: Subclavian vein thrombosis following clavicle fracture fixation is rare [104]. Chest wall injury (CWI) does not affect surgery-related complications after clavicle fracture repair [105].

Other Considerations: High-quality evidence indicates that while surgical treatment results in better early patient-reported outcomes, long-term outcomes between surgical and non-surgical treatments for displaced clavicle fractures are similar [108]. Functional gains from operative treatment at three and six months are lesser and not clinically relevant [52]. In adolescents, surgery demonstrated no benefit in quality of life, satisfaction, shoulder-specific function, or complication prevention at two years [53]. Patient selection influences functional outcomes after midshaft clavicle fracture [43]. Operative management of extra-lateral distal clavicle fractures yields very good outcomes [9], with both distal anatomic locking plate fixation and arthroscopic coracoclavicular button fixation providing satisfactory results for unstable distal fractures [15]. Plate fixation in adolescents is safe with a low complication rate [10, 11], though patient noncompliance, especially with substance abuse, is a clear contraindication for surgery [11]. Implant removal rates are low with precontoured locking plates compared to traditional plates [107], and limited incision approaches achieve outcomes comparable to standard techniques [113]. Fixation using locking or hook plates is safe with very low reoperation rates [110]. Bilateral clavicle fractures are rare and associated with polytrauma; high-energy vehicular trauma often involves thoracic cage injuries (rib, scapular, glenoid, humeral fractures, hemo/pneumothoraces) and carries a high mortality rate (20% to 34%) from associated chest and head traumas [22]. Multiple ipsilateral upper rib fractures are significant as they indicate higher disruptive energy associated with poorer outcomes [22]. The incidence of medial end clavicle fractures is higher than previously considered [103]. The rate of open treatment has increased dramatically since 1999, with the mean number of ORIFs per candidate rising from 0.13 to 0.89 by 2010 [114], including in patients older than 65 years [106]. This increase has occurred with a low complication rate [117]. The COVID-19 pandemic altered trauma mechanisms but did not affect the rate of operative versus non-operative management [118].

Recovery

Light activity (weeks): Patients may resume desk work and driving within the initial peri-injury period, though close follow-up is warranted due to the risk of progressive displacement in nonoperatively treated fractures [2]. For adolescents, return to play can occur more quickly than previously thought with carefully indicated ORIF [50], while those treated non-operatively can expect excellent outcomes at 5 years post-injury [17].

Full activity (months): Surgical stabilization offers an accelerated return to work compared with nonsurgical management, with working populations under injury compensation returning sooner after ORIF of displaced middle-third fractures [73]. Specifically, TEN fixation in adolescent athletes engaged in high-demand sports significantly accelerates return to sport and reduces season loss [51]. Conversely, workers' compensation patients treated surgically or nonoperatively return to work at roughly the same time, despite surgery being three times more expensive [65]. Adolescents undergoing surgery for diaphyseal non-union, impending non-union, or symptomatic mal-union typically return to sports within 2 to 4 months [99].

Complete recovery / outcome plateau (months): Functional outcomes and pain relief for medial clavicle fractures are favorable at a minimum of 1-year follow-up, though a high proportion of these patients may die within 3 years of the injury [18]. While fixation with pre-contoured plates and locking screws results in faster functional recovery, there is no difference in function after six months and one year compared to nonoperative treatment [111]. Similarly, surgery demonstrated no benefit in patient-reported quality of life, satisfaction, or shoulder-specific function at 2 years after injury for completely displaced clavicle shaft fractures in adolescents [53].

Rehabilitation protocol: Initial nonsurgical management is reasonable as patients achieve similar functional outcomes even when surgery is delayed [8]. Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables accurate prediction of patients likely to achieve union with nonoperative management [48]. Conservative management is supported for uncomplicated displaced fractures, but a lower threshold for early surgery should be considered where optimal shoulder function is required [45].

Functional milestones: Patients with extra-lateral distal clavicle fracture patterns achieve very good clinical outcomes following operative management [9]. Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, yet shoulder function remains excellent with a low risk of complications [33]. Nonoperative management of adolescent mid-shaft fractures results in excellent functional outcomes at long-term follow-up [25], and comparably excellent outcomes for severe fractures in adolescent athletes can be achieved with non-operative treatment [98].

Other Considerations: Patients with medial clavicle fractures who survive the initial trauma can expect good clinical and functional outcomes regardless of whether surgical or nonsurgical management is chosen [1]. However, patients with displaced clavicle fractures benefit clinically and financially from stabilization, experiencing less chronic pain, deformity, and weakness with better range of motion [37]. Effective management of lateral clavicular fractures remains an ongoing challenge [6], and specific treatment should be individualized based on fracture characteristics and patient expectations rather than broadly applied [4]. Informing patients about their injury, treatment options, and expectations for recovery is paramount for overall patient satisfaction after treatment for a displaced midshaft clavicle fracture [69].

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. (10.1097/corr.0000000000001916)
• [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. (10.1016/j.jse.2018.01.004)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. (10.1016/j.jse.2011.08.053)
• [L2] Effective management of lateral clavicular fractures remains an ongoing challenge. (10.1016/j.xrrt.2024.11.002)
• [L4] The results do not suggest protraction of the scapula as a major risk factor for the development of SAPS. (10.1016/j.xrrt.2024.01.008)
• [L3] Initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. (10.5435/jaaos-d-16-00130)
• [L4] The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. (10.1016/j.jse.2020.10.006)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. (10.1186/s12891-022-05075-5)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. (10.5435/jaaos-d-17-00598)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. (10.1016/j.jse.2019.06.022)
• [L3] Both distal anatomic locking plate fixation and arthroscopic coracoclavicular button fixation provide satisfactory functional and radiological outcomes. (10.1016/j.jseint.2021.05.007)
• [L2] Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. (10.1177/2325967123s00041)
• [L4] Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. (10.1097/corr.0000000000001839)
• [L4] Bilateral clavicle fractures are extremely rare and associated with polytrauma. (10.1186/s12891-023-06228-w)
• [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. (10.1177/03635465000280062301)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L2] Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment. (10.1177/2325967119s00428)
• [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. (10.1177/2325967120921344)
• [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. (10.1016/j.xrrt.2025.05.023)
• [L4] The use of distal radial locking plates provided stable fixation with minimal early complications and no disturbance to the acromioclavicular joint, subacromial space, or rotator cuff. (10.1016/j.jse.2007.04.012)
• [Case_report] The case highlights that segmental fractures of the clavicle are easily missed. (10.1177/1758573214564496)
• [L4] Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. (10.1016/j.jse.2023.12.006)
• [L3] Patients with displaced clavicle fractures benefit clinically and financially from stabilization, experiencing less chronic pain, deformity, and weakness with better range of motion and earlier return to work. (10.1016/j.jse.2012.06.006)
• [L4] Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively, although operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected cases. (10.2106/jbjs.22.01036)
• [L4] Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications. (10.1177/2325967119s00056)
• [L3] Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. (10.1016/j.jse.2016.01.028)
• [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. (10.1016/j.jse.2015.09.029)
• [L1] This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. (10.1177/1758573218777996)
• [Case_report] Although ORIF of displaced midshaft clavicle fractures remains controversial in the adolescent population, there may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation. (10.1016/j.xrrt.2023.03.004)
• [L3] We support the conservative management of uncomplicated displaced clavicle fractures but recognize that a lower threshold for early surgery should be considered where optimal shoulder function is required. (10.1016/j.jse.2014.09.037)
• [L4] The overall incidence of clavicular hardware removal was 12.6%. (10.1016/j.jse.2020.06.034)
• [L1] Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures. (10.1016/j.jse.2016.01.018)
• [L1] Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. (10.2106/jbjs.19.00955)
• [Case_report] This case adds to the limited literature and supports the role of rigid clavicular fixation as a safe and effective treatment option in similar presentations. (10.1016/j.xrrt.2026.100697)
• [L3] These data suggest that carefully indicated adolescent patients undergoing ORIF of clavicle fractures can RTP more quickly than previously thought. (10.1177/23259671251374299)
• [L3] For adolescent athletes engaged in structure- or kinetic-dependent sports with high clavicle functional demand, TEN fixation significantly accelerates return to sport, reduces season loss, and enhances early functional and psychological recovery, while achieving long-term functional outcomes equivalent to conservative treatment. (10.1186/s13018-026-06708-4)
• [L1] At three and six months, the functional gain is lesser and not clinically relevant. (10.1016/j.jseint.2023.12.011)
• [L2] Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. (10.1177/03635465221114420)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. (10.1016/j.jse.2025.04.021)
• [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. (10.1097/corr.0000000000001456)
• [L3] Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management. (10.1177/1758573221990367)
• [L4] The described technique of augmented fixation of the distal clavicle is effective, produces good clinical outcomes, and has minimal complications. (10.5397/cise.2022.00913)
• [L4] Nonsurgical and surgical management provide similar results for distal clavicle fractures. (10.5435/00124635-201107000-00002)
• [L2] In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. (10.1016/j.jse.2013.06.025)
• [L4] The surgical technique described seems to be a good option in the treatment of clavicle malunion. (10.1177/1758573220933247)
• [L3] Future studies are needed to determine whether there is an optimal approach for clavicle plating. (10.1016/j.jse.2015.09.005)
• [L4] This combined surgical strategy can be considered an effective method for treating unstable distal clavicle fractures. (10.1186/s12891-021-04137-4)
• [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. (10.1177/0363546515593949)
• [L2] Workers' compensation patients treated for clavicle fractures return to work at roughly the same time whether they are treated surgically or nonoperatively, with surgery being roughly 3 times more expensive. (10.1016/j.jse.2016.02.004)
• [L5] This technique can be used for a unilateral displaced comminuted midshaft clavicle fracture when it is difficult to achieve anatomic reduction by open reduction technique. (10.1186/s13018-015-0233-5)
• [L3] Surgical treatment with locked plate fixation in type IIB2 clavicle fractures according to Robinson Classification can be the first treatment choice with better cosmetics, lower complication rate, and better outcomes. (10.1177/2325967114s00265)
• [L5] Our study shows that informing patients about their injury, treatment options and expectations for recovery is paramount for overall patient satisfaction after treatment for a displaced midshaft clavicle fracture. (10.1186/s12891-020-03557-y)
• [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. (10.5435/00124635-201301000-00002)
• [L1] Surgical treatment with ORIF of displaced middle-third clavicular fractures resulted in good and excellent functional results, shorter time to complete return to work, earlier bone healing, and fewer cases of nonunions in a working population under injury compensation. (10.1016/j.jse.2014.11.041)
• [L1] Surgical treatment of midshaft clavicle fractures results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. (10.1177/0363546516673615)
• [L5] Understanding clavicle anatomy, appropriate patient selection, and implant design differences is critical to successful application and avoiding complications. (10.5435/jaaos-d-16-00576)
• [L1] Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to distal clavicle fractures should be recommended. (10.1186/s13018-022-02919-7)
• [L4] Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates. (10.1016/j.jse.2021.05.021)
• [L4] Considerable disagreement between surgeons exists regarding recommendation for surgery for midshaft clavicle fractures. (10.1016/j.jse.2025.06.023)
• [L4] Clavicle plating under WALANT is a reliable and effective alternative option to general anesthesia in selected patients or settings with limited anesthetic facilities. (10.1016/j.jse.2020.03.003)
• [L3] A pain score that exhibits no or minimal change from 2 to 4 weeks after nonoperative treatment of a displaced midshaft fracture of the clavicle is associated with a high risk that symptomatic nonunion will develop. (10.1097/corr.0000000000001411)
• [L3] These data suggest that adolescent patients undergoing anatomic ORIF of midshaft clavicle fractures may be able to return to play more quickly than previously thought. (10.1177/2325967125s00119)
• [L3] 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. (10.1177/0363546514523926)
• [L3] Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. (10.1177/2325967121s00494)
• [L3] Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. (10.1177/2325967121s00626)
• [L2] Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment. (10.1177/2325967121s00214)
• [L4] Adolescents who underwent surgery for diaphyseal clavicle fracture non-union, impending non-union or symptomatic mal-union demonstrated bony healing and returned to sports within 2-4 months, with a comparable post-operative course and rate of subsequent hardware removal to patients treated with plate fixation for their primary clavicle fracture. (10.1177/2325967115s00078)
• [L4] The results of this study suggest that the incidence of medial end clavicle fractures in the general population is higher than had previously been considered. (10.1177/1758573220923122)
• [L4] Subclavian vein thrombosis following fixation of clavicle fracture is rare. (10.1111/sae.12006)
• [L3] CWI did not affect surgery-related complications after clavicle fracture repair. (10.1186/s12891-021-04148-1)
• [L2] Our analysis demonstrates an overall increase in the proportion of surgically treated clavicle shaft fractures, including in the male and female population older than 65 years. (10.1016/j.jhsa.2017.06.099)
• [L4] Satisfactory clinical results with a low rate of complications were achieved with precontoured locking plates for displaced midshaft clavicular fractures and a low rate of hardware removal compared with traditional plates. (10.1016/j.jse.2014.12.013)
• [L1] High-quality evidence shows that surgical treatment of displaced clavicle fractures in adults results in higher union rates and better early patient-reported outcomes compared with nonsurgical treatment, though long-term outcomes are similar. (10.5435/jaaos-d-23-00472)
• [L4] Following clavicle ORIF, one in four patients underwent reoperation. (10.2106/jbjs.m.00607)
• [L3] Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision. (10.1016/j.jseint.2021.11.001)
• [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. (10.1302/0301-620x.100b10.bjj-2017-1137.r3)
• [L2] The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. (10.1016/j.jse.2022.03.016)
• [L5] In this large cohort with long-term follow-up, a limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to the reported rate for standard incision techniques. (10.1016/j.jse.2025.06.002)
• [L4] The rate of open fixation treatment for clavicular fractures has increased since 1999, with the mean number of clavicle ORIFs per candidate rising significantly from 0.13 in 1999 to 0.89 in 2010. (10.1016/j.jse.2015.11.065)
• [L3] The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. (10.1186/s12891-023-06391-0)
• [L4] The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union. (10.1097/01.blo.0000183088.60639.05)
• [Abstract] Based on the dataset of the ABOS, the rate of open treatment for clavicle fractures has increased dramatically since 1999 with a low complication rate. (10.1016/j.jse.2013.07.031)
• [L3] The COVID-19 pandemic was associated with substantial changes in the epidemiology of clavicle fractures, particularly in trauma mechanisms, but did not affect the rate of operative versus non-operative management. (10.1186/s13018-025-06634-x)

See Also

• Fractures
• Clavicle Fracture Fixation
• Rotator Cuff

References

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[40] INCREASING VALUE: CAN MIDSHAFT CLAVICLE FRACTURES BE SURGICALLY TREATED AS AN OUTPATIENT?. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00056

[41] Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.01.028

[42] Plate fixation of midshaft clavicular fractures: patient-reported outcomes and hardware-related complications. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.09.029

[43] Does candidate for plate fixation selection improve the functional outcome after midshaft clavicle fracture? A systematic review of 1348 patients. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218777996

[44] Consequences of delayed surgical intervention of a displaced midshaft clavicle fracture: a case report. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.03.004

[45] The long-term outcome of displaced mid-third clavicle fractures on scapular and shoulder function: variations between immediate surgery, delayed surgery, and nonsurgical management. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.09.037

[46] Risk factors for hardware removal following operative treatment of middle- and distal-third clavicular fractures. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.034

[47] Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.01.018

[48] Displaced Midshaft Clavicle Fracture Union Can Be Accurately Predicted with a Delayed Assessment at 6 Weeks Following Injury. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.00955

[49] Anterior sternoclavicular joint disruption with ipsilateral medial clavicle fracture in an adolescent: case report and literature review. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100697

[50] Safety of Accelerated Return to Play After Anatomic Open Reduction and Internal Fixation of Adolescent Clavicle Fractures. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251374299

[51] Titanium elastic nail fixation versus conservative treatment for displaced mid-shaft clavicle fractures in adolescent athletes stratified according to sport function: a multicenter retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06708-4

[52] Minimal early functional gains after operative treatment of midshaft clavicular fractures: a meta-analysis of 10 randomized controlled trials including 1333 patients. JSES International. 2024. DOI: 10.1016/j.jseint.2023.12.011

[53] Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221114420

[54] Differentiating and treating lateral clavicle fractures: a new simple classification system. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.021

[55] Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001456

[56] Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up. Shoulder & Elbow. 2021. DOI: 10.1177/1758573221990367

[58] A modified method of augmented distal clavicle fracture osteosynthesis with a Fibertape coracoclavicular cerclage. Clinics in Shoulder and Elbow. 2022. DOI: 10.5397/cise.2022.00913

[59] Management of Distal Clavicle Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201107000-00002

[60] Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a meta-analysis of randomized controlled trials. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.06.025

[61] A simple surgical technique for correcting malunion after midshaft clavicle fracture. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220933247

[62] Anteroinferior versus superior plating of clavicular fractures. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.09.005

[63] Locking plate combined with titanium cable for Neer type II distal clavicle fractures. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04137-4

[64] The Interrater and Intrarater Agreement of a Modified Neer Classification System and Associated Treatment Choice for Lateral Clavicle Fractures. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515593949

[65] Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers' compensation cases. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.02.004

[66] Use of a real-size 3D-printed model as a preoperative and intraoperative tool for minimally invasive plating of comminuted midshaft clavicle fractures. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0233-5

[68] Comparison of Short Term Results of Type IIB2 Middle Third Clavicular Fractures Treated with Figure of Eight Bandage and Locked Plate Fixation. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00265

[69] Exploring patient satisfaction after operative and nonoperative treatment for midshaft clavicle fractures: a focus group analysis. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03557-y

[70] Orthopaedic Knowledge Update. Pediatric Clavicle, Shoulder, and Humerus Trauma > Shoulder > Clavicle Fractures.

[72] Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201301000-00002

[73] Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.11.041

[75] Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516673615

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[80] Intramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00576

[81] Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02919-7

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[84] Results of pre-contoured titanium anterior plating of midshaft clavicle fractures. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.05.021

[86] Current clinical practice among orthopedic surgeons in Australia for treatment of midshaft clavicle fractures. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.06.023

[87] Plating of clavicle fracture using the wide-awake technique. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.03.003

[88] Minimal Pain Decrease Between 2 and 4 Weeks After Nonoperative Management of a Displaced Midshaft Clavicle Fracture Is Associated with a High Risk of Symptomatic Nonunion. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001411

[89] Poster 5: Safety of an Accelerated Return to Play Strategy Following Anatomic Open Reduction Internal Fixation of Adolescent Clavicle Fractures. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00119

[91] Intraobserver and Interobserver Agreement in the Classification and Treatment of Midshaft Clavicle Fractures. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514523926

[95] Remodeling of Adolescent Displaced Clavicle Fractures: A Facts Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00494

[96] Paper 63: Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00626

[98] Operative Versus Non-Operative Treatment of Severely Shortened or Comminuted Clavicle Fractures in Older Adolescent Athletes: Results from A Prospective, Multicenter, Level 2 Cohort Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00214

[99] Outcomes of Operatively Treated Non-unions and Symptomatic Mal-unions of Adolescent Diaphyseal Clavicle Fractures. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00078

[103] The incidence of medial end clavicle fractures is higher than had previously been considered. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220923122

[104] Subclavian Vein Thrombosis following Acute Internal Fixation of a Clavicular Fracture. Shoulder & Elbow. 2013. DOI: 10.1111/sae.12006

[105] Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04148-1

[106] Treatment Trends in Older Adults With Midshaft Clavicle Fractures. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.099

[107] Surgical treatment of displaced midshaft clavicular fractures with precontoured plates. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.013

[108] American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary on the Treatment of Clavicle Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00472

[109] Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00607

[110] A review of outcomes after operative fixation of clavicular fractures over a 10-year period—a single tertiary trauma unit experience. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.001

[111] Plate fixation compared with nonoperative treatment of displaced midshaft clavicular fractures: a randomized clinical trial. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b10.bjj-2017-1137.r3

[112] Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.03.016

[113] Limited incision plating of midshaft clavicle fractures: a case series of 1,038 patients. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.06.002

[114] Frequency and complications after operative fixation of clavicular fractures. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.065

[115] Refracture after plate removal of midshaft clavicle fractures after bone union—incidence, risk factors, management and outcomes. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06391-0

[116] Infection after Clavicle Fractures. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000183088.60639.05

[117] Frequency and Complications after Operative Fixation of Clavicle Fractures. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.07.031

[118] Epidemiological changes in clavicle fractures during the COVID-19 pandemic: a six-year analysis from a large single-center cohort. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06634-x