38 ClaviCle FraCtures

Transcription

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Clavicle Fractures
Michael D. McKee
•• Introduction 1427
•• Assessment 1429
Mechanisms of Injury 1429
Associated Injuries 1430
Signs and Symptoms 1432
Imaging and Other Diagnostic Studies 1435
Classification 1437
Outcome Measures 1437
•• Pathoanatomy
and
Applied Anatomy 1440
Bony Anatomy 1440
Ligamentous Anatomy 1441
Muscular Anatomy 1441
Neurovascular Anatomy 1441
•• Treatment Options 1442
Nonoperative Treatment 1443
Operative Treatment 1444
Introduction
to
Clavicle Fractures
Clavicle fractures are common injuries in young, active individuals, especially those who participate in activities or sports
where high-speed falls (bicycling, motorcycles) or violent
collisions (football, hockey) are frequent, and they account
for approximately 2.6% of all fractures.29–32,46,112,116,122,123,126
In contrast to most fractures, Robinson155 reported in an
epidemiologic study that the annual incidence in males was
highest in the under 20 age group, decreasing with each
subsequent age cohort (Fig. 38-1). The incidence in females
was more constant, with peaks seen in the teenager (sports,
motor vehicle accidents) and the elderly (osteoporotic fractures from simple falls). The annual incidence of fractures in
their Scottish population was 29 per 100,000 persons per
year.155
•• Management of Expected Adverse Outcomes
Unexpected Complications 1459
and
Infection 1459
Nonunion 1459
Malunion 1461
Neurovascular Injury 1464
Hardware Failure 1465
Hardware Prominence 1466
Refracture 1467
Scapular Winging 1467
•• Author’s Preferred Method
•• Controversies
and
of
Treatment 1469
Future Directions 1469
Patient Selection for Operative Intervention 1469
Method of Fixation 1469
Timing of Surgical Intervention 1470
•• Summary 1470
The majority of clavicular fractures (80% to 85%) occur in
the midshaft of the bone, where the typical compressive forces
applied to the shoulder and the narrow cross section of the
bone combine and result in bony failure.7–16,18–24,26–32,107,155,179
Distal third fractures are the next most common type (15% to
20%), and, although they can result from the same mechanisms
of injury as that seen with midshaft fractures, they tend to
occur in more elderly individuals from simple falls.56,153,156,157,193
Medial third fractures are the rarest (0% to 5%), perhaps due to
the difficulty in accurately imaging (and identifying) them.167,185
One recent study of 57 such fractures reported that patients
were typically men in their fifth decade and the usual mechanism of injury was from a motor vehicle accident.185 These
authors also noted a relatively high (20%) associated mortality
from concomitant head and chest injuries.
1427
1428 Section two Upper Extremity
160
Incidence/100,000 population/yr
140
120
Male
Female
100
80
60
40
20
0
13–20 yrs
20–29 yrs
30–39 yrs
40–49 yrs
50–59 yrs
60–69 yrs
70–79 yrs
>80 yrs
Age cohorts
Older studies suggested that a fracture of the shaft of the
clavicle, even when significantly displaced, was an essentially benign injury with an inherently good prognosis when
treated nonoperatively.112–116 In a landmark 1960 study
Neer115 reported nonunion in only three of 2,235 patients
with middle third fractures of the clavicle treated by a sling
or a figure-of-eight bandage. Rowe160 showed an overall incidence of nonunion of 0.8% in 566 clavicle fractures treated
in a similar fashion. Thus, what was felt to be the most serious complication following clavicular fracture, nonunion,
appeared to be extremely rare. Also, malunion of the clavicle
(which occurred radiographically on a predictable basis in
displaced fractures), was described as being of radiographic
interest only, with little or no functional consequences. This
thinking dominated the approach to clavicle fractures for
decades.
More recently, there has been increasing evidence that the
outcome of the nonoperatively treated (especially displaced
or shortened) midshaft fracture is not as optimal as was once
thought.14,42,59,68,85,99,103,123–125 In 1997, Hill et al.68 were the
first to use patient-oriented outcome measures to examine
66 consecutive patients with displaced midshaft clavicle fractures
and they found an unsatisfactory outcome in 31%, as well as a
nonunion rate of 15%. In a meta-analysis of the literature from
Table 38-1
Figure 38-1 The epidemiology of clavicle
fractures in Edinburgh, Scotland. (Adapted
from Robinson CM, Court-Brown CM,
McQueen MM, et al. Estimating the risk
of nonunion following nonoperative treatment of a clavicle fracture. J Bone Joint
Surg Am. 2004;86-A(7):1359–1365.)
1975 to 2005, Zlowodzki et al.209 found that the nonunion rate
for nonoperatively treated displaced midshaft clavicle fractures
was 15.1%, exponentially higher than that previously described
(Table 38-1). Other recent epidemiologic and prospective studies have supported these findings.14,42,68,99,121,123,124,153–155 In addition, the malunion of the clavicle has been clearly shown by
multiple authors to be a distinct clinical entity with characteristic signs and symptoms that can be significantly improved by
corrective osteotomy.7,9,21,24,41,84,102,103 Potential explanations for
the increased complication rate seen following the nonoperative
care of these fractures may be due to changing injury patterns
(especially from “extreme” sports such as mountain bicycling,
snowboarding, and all-terrain vehicle riding), increased expectations of the modern patient, comprehensive follow-up (including patient-oriented outcome measures) and focusing on adults
(eliminating children with their inherently good prognosis and
remodeling potential).71,76,96,101,125,143,154,181,195,205
Good results with a high union rate and a low complication rate have been reported from a variety of techniques for
primary fixation of displaced fractures of the clavicle, dispelling
some of the pessimism that surrounded prior studies where a
poor understanding of soft tissue handling, a selection bias of
patients, and inadequate implants combined to produce inferior results.2,15,23,41,53,63,82,91,119,140–142 Zlowodzki’s209 systematic
A Meta-Analysis of Nonoperative Treatment, Intramedullary Pinning, and Plate
Fixation for Displaced Midshaft Fractures of the Clavicle (Published 1975–2005)
Treatment Method
Nonoperative (n = 159)
Percentage with Nonunion
Infections (Total)
Infections (Deep)
Fixation Failures
15.1
0
0
0
Plating (n = 460)
2.2
4.6
2.4
2.2
Intramedullary pinning (n = 152)
2.0
6.6
0
3.9
Adapted from Zlowodzki M, Zelle BA, Cole PA, et al. Treatment of midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the Evidence-Based
Orthopaedic Trauma Working Group. J Orthop Trauma, 2005;19(7):504–507.
Chapter 38 Clavicle Fractures 1429
Study or Subgroup
COTS 2007
Judd 2009
Smekal 2009
Smith 2000
Virtanen 2010
Witzel 2007
Operative
Nonoperative
Events Total Events
Total
49
16
62
2
28
1
29
1
30
5
30
0
35
16
30
0
25
8
26
0
33
0
35
0
Weight
Risk Ratio
IV, Random, 95% Cl
49.0%
13.4%
12.2%
12.9%
12.6%
0.10 [0.02, 0.41]
0.97 [0.06, 14.70]
0.09 [0.01, 1.57]
0.04 [0.00, 0.56]
0.06 [0.00, 0.93]
Not estimable
Total (95% CI)
212
200
100.0%
Total events
3
46
Heterogeneity: Tau2 = 0.00; Chi2 = 3.35, df = 4 (p = 0.50); I2 = 0%
Test for overall effect: Z = 4.38 (p < 0.0001)
0.11 [0.04, 0.29]
Risk Ratio
IV, Random, 95% CI
0.01
0.1
1
10
100
Favors experimental
Favors control
Figure 38-2 A forest plot comparing the nonunion rate between nonoperative (control) and operative
(experimental) groups from multiple randomized trials of clavicle fracture fixation for displaced midshaft fractures. Operative intervention results in a significantly decreased nonunion rate compared to
nonoperative treatment (p = 0.002). The size of the squares is proportionate to the size of the study,
and the diamond is the pooled data. (Adapted from: McKee RC, Whelan DB, Sche mitsch EH, et al.
Operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675–684, with permission.)
review showed a relative risk reduction of 86% (from 15.1%
to 2.2%) for nonunion with primary plate fixation compared
to nonoperative treatment. In addition, a recent meta-analysis
by McKee et al. of six randomized clinical trials of operative
versus nonoperative care for displaced midshaft clavicle fractures demonstrated a reduction of nonunion and symptomatic
malunion from 46/200 cases (23%) in the nonoperative group
to 3/212 cases (1.4%) in the operative group (Fig. 38-2).105
While there is increasing interest in, and enthusiasm for,
primary fixation of clavicle fractures, it is vital to remember
that the majority of these fractures can and should be treated
nonoperatively. The current research in this area should not
provoke a swing of the operative pendulum into indiscriminate fixation of all clavicle injuries. Clinical and basic science
research in this field adds objective information to this topic
and is directed at prompting a thoughtful assessment of each
injury based on these data and each case’s individual merits
such as the function and expectations of the patient, the location of the fracture, and the degree of displacement or comminution. Treatment is then based upon this assessment, the
evidence-based facts now available, and a rational balance
of the potential risks and benefits of surgery, rather than an
extreme operative or nonoperative approach.
Assessment
of
A
Clavicle Fractures
Mechanisms of Injury for Clavicle Fractures
A direct blow on the point of the shoulder is the commonest
reported mechanism of injury that produces a midshaft fracture
of the clavicle.15,107,155,179 This can occur in a number of ways,
including being thrown from a vehicle or bicycle, during a sports
event, from the intrusion of objects or vehicle structure during
a motor vehicle accident, or falling from a height (Fig. 38-3).
A recent prospective trial of over 130 completely displaced
midshaft fractures of the clavicle identified motor vehicle/
motorcycle accidents, bicycling accidents, skiing/snowboarding
B
Figure 38-3 A: Mechanism of injury. Clavicle fractures are usually
produced by a fall directly on the involved shoulder. B: Corresponding clinical photograph demonstrating posterior skin abrasion following displaced midshaft clavicle fracture.
falls or collisions, sports injuries, and falls as the most commonly
involved mechanisms.15 As the shoulder girdle is subjected to
compression force directed from laterally, the main strut maintaining position is the clavicle and its articulations (Fig. 38-4).
As the force exceeds the capacity of this structure to withstand it,
failure can occur in one of the three ways. The acromioclavicular
(AC) articulation may fail, the clavicle may break, or the sternoclavicular (SC) joint may dislocate. SC injuries are rare and typically associated with more posteriorly directed blows against the
medial clavicle (posterior dislocations) or posteriorly directed
blows to the distal shoulder girdle (levering the proximal clavicle into an anterior dislocation).90,177 Presumably there are subtle
nuances in the direction and magnitude of applied forces and
local anatomy that dictate whether the failure occurs in the AC
joint, or in the clavicle, and the magnitude of displacement that
occurs. Most (85%) clavicle fractures occur in the midshaft of
the bone where, as can be seen in a cross section, the bone
is narrowest and enveloping soft tissue structures (which may
help dissipate injury force) are most scarce.29–32,153,155 It is typical
to see a large abrasion or contusion on the posterior aspect of
the shoulder in patients with displaced midshaft clavicular fractures, especially those who fall from bicycles, motorcycles, or
other vehicles. This force vector may also contribute to the location of the injury: Midshaft fracture, distal fracture, or AC joint
injury. The direction of the initial deforming force, and both
gravitational and muscular forces on the clavicle are significant
and result in the typical deformity seen after fracture, with the
distal fragment being translated inferiorly, anteriorly, and medi-
Sternocleidomastoid
Trapezius
Sternoclavicular
ligaments
Pectoralis
and latissimus
Weight
of arm
Figure 38-5 Muscular and gravitational forces acting on the fractured clavicle with resultant deformity. The distal fragment is translated anteriorly, medially, and inferiorly, and rotated anteriorly. This
results in the scapula being protracted.
ally (shortened), and rotated anteriorly (Fig. 38-5). With recent
advances in imaging techniques, there is an increasing level of
information available regarding the complex three-dimensional
deformity that can result from a displaced midshaft fracture of
the clavicle (Fig. 38-6).152
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: These
fractures are typically seen in the distal third of the clavicle. If the mechanism of injury is trivial and does not seem
commensurate with the fracture depicted, then a careful
investigation for a pathologic fracture should be performed
(Fig. 38-7).32,176
Associated Injuries with
Clavicle Fractures
Figure 38-4 The strut function of the clavicle, the only bony articulation between the axial skeleton and the upper limb.
Associated injuries are increasingly common in patients with
fractures of the clavicle, compared to the incidence reported
in older traditional studies.39,43,44,101,181,207 There may be s everal
reasons for this, including more liberal use of improved

A
B
Figure 38-6 A: Preoperative three-dimensional CT scan of a patient with a displaced clavicle fracture
and ipsilateral flail chest. This injury pattern represents a severe injury with significant instability of the
entire forequarter. B: Following plate fixation of both the clavicle and multiple ipsilateral ribs, the flail
segment became stable.
diagnostic techniques (i.e., CT scanning), the greater speed
and violence of many modern sports (such as motocross and
snowboarding) and the improved survivorship of patients with
significant chest trauma who would have succumbed prior
to the institution of comprehensive treatment of the trauma
patient. In fact, several studies from Level 1 trauma centers
have examined the characteristics of polytrauma patients
with clavicle fractures, and have noted a high mortality rate
(20% to 34%) from associated chest and head traumas.101,181
Presumably these series of critically injured patients contain
survivors who live to require treatment for the complications
of their clavicle fractures who may not have survived without
modern trauma care.
Patients who have sustained high-energy vehicular trauma
are more likely to have associated injures to the thoracic cage,
including ipsilateral rib fractures, scapular and/or glenoid fractures, proximal humeral fractures, and hemo/pneumothoraces
(Fig. 38-8).29,101,181 In addition to simply being good medicine,
identification of these injuries is important for multiple reasons.
Patients may require urgent treatment directed specifically at
the associated injury (i.e., tube thoracostomy for pneumothorax), their presence may influence the treatment of the clavicle
fracture (i.e., an associated displaced glenoid neck fracture, the
so-called “floating shoulder,” see below), or (as objective information on this entity increases) they may give an indication of
the likelihood of a negative outcome for the clavicle fracture
Figure 38-7 A 45-year-old previously well woman presented to the fracture clinic with shoulder pain
following an episode of minor trauma. Radiographs revealed a fracture through a lytic lesion of the
clavicle. This was the presentation of what subsequent investigation revealed to be a widely disseminated metastatic adenocarcinoma of unknown source.
Figure 38-8 Anteroposterior radiograph of the clavicle in a 42-year-old man involved in a motor
vehicle collision. Associated injuries include multiple ipsilateral upper rib fractures, an ipsilateral pneumothorax (arrows outlining collapsed lung), and multiple lower extremity fractures. This patient has
four relative indications for operative fixation; (1) the severe displacement of the clavicle fracture,
(2) the multiple upper rib fractures, which tend to destabilize the shoulder girdle, (3) the associated
lower extremity fractures and the resultant need for immediate upper extremity use, and (4) the pneumothorax, which is indicative of the degree of trauma applied to the shoulder.
(malunion, nonunion) that may have implications regarding primary fixation (Fig. 38-9). There is also some evidence that multiple ipsilateral rib fractures are significant for a number of reasons:
The degree of disruptive energy imparted to, and the resultant
deformity and instability of, the chest and shoulder girdle may
be associated with higher rates of poor outcome in the associated
clavicle fracture. In addition, there is increasing interest in the
primary fixation of mechanically unstable chest wall segments
(or “flail chest”) as a means of improving the respiratory outcome
and ventilatory care of such patients (Fig. 38-6).62,183
The clavicle can also be injured from penetrating trauma
including projectiles, blasts, and sword or machete blows
(Fig. 38-10). In this situation, diagnosing and treating underlying chest and/or vascular injuries is critically important, and the
clavicle can be treated on its own merits.30,32,36,69,78,111,148,187 However, if a vascular repair has been performed, clavicular fixation
(if possible) provides an optimally stable environment for healing.
Signs and Symptoms of Clavicle Fractures
History
The history should delineate a number of aspects to optimize
the patient’s care. In addition to the standard demographic
data, the details of the mechanism of injury are important. A
clavicle fracture caused by a simple low-energy fall is unlikely
to be associated with other fractures or intrathoracic injuries,
while a fracture that occurs as a result of severe vehicular trauma
or a fall from a height should prompt a search for other injuries.
In my experience, clavicle fractures that result from falls while
bicycling often have multiple ipsilateral upper rib fractures. At
a Level 1 trauma center, we studied 105 polytrauma patients
(multiple system injury and injury severity score greater than 16)
with fractures of the clavicular shaft and found a mortality rate
of 32%, mainly due to associated head and chest injuries.101 This
high incidence of associated head/chest injuries mandates careful
clinical and radiographic investigation. The physical mechanism
of injury is important: While the majority of fractures will result
from a blow to the shoulder, failure of the bone can also occur
from a traction-type injury. This usually occurs in an industrial
or dockyard injury in which the involved arm is forcefully pulled
away from the body as it is caught in machinery. It can also occur
in vehicular trauma when the arm is pinned against or strikes
a fixed object as the torso continues past it. This can lead to
scapulothoracic dissociation, as the shoulder girdle fails in tension at the SC joint, the clavicle or the AC joint. This is evident
on the radiographs when a c ompletely d
isplaced, distracted fracture site is seen (as opposed to the typical overlapping fracture
fragments) (Fig. 38-11). The high incidence of neurologic and
vascular traction injuries seen in this setting mandates further
investigation (i.e., angiography), because they can be limb threatening.30,39,58,111,136,207
If the clavicular fracture has occurred with minimal trauma,
one must be alert to the possibility of a pathologic fracture
(Fig. 38-7). Metabolic processes that weaken bone (i.e., renal
disease, hyperparathyroidism), benign or malignant tumors (i.e.,
myeloma, metastases), or pre-existing lesions (i.e., congenital
pseudarthrosis of the clavicle) can result in pathologic fracture.
In this setting, nonoperative treatment of the clavicle fracture
is recommended initially, while intervention is directed toward
diagnosis and treatment of the underlying condition. Once the
primary diagnosis has been made and treatment initiated, the
clavicle fracture is treated based on its individual aspects. Also,
D
E
A
B
F
C
G
Figure 38-9 A “floating shoulder” injury. This patient was injured in a motor vehicle accident. A: An
anteroposterior radiograph demonstrates a displaced, shortened left clavicle fracture. B: A CT scan
of the shoulder reveals a comminuted glenoid neck fracture. C: There is significant clinical deformity.
D: Intraoperatively, the fracture is reduced with the aid of reduction clamps, and an anterior fixation
plate is applied (E, F). Symmetry of the shoulder was restored by clavicle fixation alone, and it was not
necessary to repair the glenoid fracture. G: There was an excellent clinical result with full restoration
of motion and a Constant score of 95.
A
B
Figure 38-10 A: A comminuted clavicle fracture resulting from a low-velocity gunshot wound with
an associated hemopneumothorax and a retained intrathoracic bullet, treated with tube thoracostomy. The degree of clavicular deformity and the associated injuries represent a relative indication for
operative repair. B: Severe injuries in a 25-year-old soldier struck by a high-velocity bullet fired by an
insurgent in Afghanistan. The AK-47 bullet fractured the humerus, struck the clavicle, shattering the
midportion, lacerated the subclavian vein and artery (causing life-threatening hemorrhage) and came to
rest in the soft tissues of the neck. In an austere operating environment, the clavicle fragments were
resected and a vascular repair was performed.
repetitive or unusual loads may induce a stress fracture of the
clavicle, typically in bodybuilders or w
eightlifters.134,159,169
In the past, when treatment of all clavicular shaft fractures was
consistently nonoperative, a detailed history of lifestyle, occupation, and medical conditions was usually perfunctory at best,
since these factors did little to influence decision making. However, there is now increasing evidence that operative intervention
is superior in carefully selected cases of displaced clavicular shaft
fracture, such that additional information gleaned from the history contributes to the risk/benefit analysis regarding possible
surgery. Compliant patients in the 16 to 60 age group, who have
active recreational lifestyles and/or physically demanding occupations (especially those that require throwing, repetitive overhead
work, or recurrent lifting) are candidates for primary operative
repair if they are medically fit and have completely displaced
fractures with good bone q
uality.15,108,140,190,209 Factors associated
with noncompliance and a high rate of fixation failure, such as
drug and alcohol abuse, untreated psychiatric conditions, homelessness, or uncontrolled seizure disorders are contraindications
for primary operative repair of clavicle fractures.10
Physical Examination
Figure 38-11 Emergency angiogram of a patient with a scapulothoracic dissociation and wide distraction of a very distal clavicle fracture. There is an associated axillary artery avulsion, a complete brachial
plexus injury, and multiple ipsilateral upper extremity fractures.
When nonoperative treatment was chosen for the vast majority
of clavicle fractures, there was little emphasis placed on a careful physical examination of the shoulder girdle. However, there
are a number of findings that are important in surgical decision making. There is usually swelling, bruising, and ecchymosis at the fracture site, as well as deformity with displaced
fractures. Visible deformity of the shoulder girdle, best seen
when the patient is standing, is an important feature to recognize. The usual position seen with a completely displaced
midshaft fracture of the clavicle has been described as shoulder
“ptosis,” with a droopy, medially driven, and shortened shoulder (Fig. 38-12).64,74,136,150 In addition, the shoulder translates
and rotates forward: This is a deformity that can best be seen
by viewing the patient from above. Due to this malposition of
the shoulder girdle, inspection of the patient from behind may
reveal a subtle prominence of the inferior aspect of the scapula
from scapular protraction as it moves with the distal fragment.
A
B
Figure 38-12 A: The “scout” portion of a CT scan in a polytrauma patient with a displaced clavicle
fracture demonstrates the typical deformity which occurs with these injuries. B: The corresponding
clinical photograph demonstrates blanching of the skin over the medial fragment (arrow).
Shortening of the clavicle should be measured clinically with a
tape measure. A mark is made in the midline of the suprasternal notch and another is made at the palpable ridge of the AC
joint: Measuring this length gives the difference between the
involved and normal shoulder girdle.172 The degree of shortening at the fracture site is very important in the decision making
of operative versus nonoperative care, as it has been reported
in multiple studies to be of prognostic significance (greater
shortening, especially more than 1.5 to 2 cm, is associated with
a worse prognosis). Radiographs, especially of long oblique
fractures, tend to overestimate the degree of shortening which
emphasizes the importance of a proper clinical examination.
A careful neurologic and vascular examination of the
involved limb is mandatory, especially if surgical intervention
is contemplated. If a deficit is not noted preoperatively, then it
may be incorrectly attributed to the surgery which has prognostic, medical–legal, and treatment implications.29–32
Open Fractures
Surprisingly, given its subcutaneous nature and exposed position, open fractures of the clavicle are relatively rare. Most open
fractures are associated with high-energy vehicular trauma, and
recognition is important for a number of reasons: The fracture itself will require irrigation, debridement, and fixation,
and there is a high incidence of associated injuries. Two large,
recent series focused on open fractures of the clavicle. Taitsman
et al.181 described 20 patients with this injury; 15 had pulmonary injuries, 13 had head injuries, 8 had scapular fractures, 11
had facial trauma, and there was a variety of other injuries. In
the largest published series to date, Gottschalk et al.61 identified
53 open clavicle fractures from an active Level 1 trauma center
over a 16-year period (roughly three cases per year, illustrating the rarity of this condition). They also reported many associated serious injuries, with the 26 patients with penetrating
injuries having a high incidence of great vessel injury, while
the 21 patients with blunt trauma had a 52% rate of serious
head injury. They stated that an open clavicle fracture should
immediately raise suspicion for a serious concomitant injury,
and that a prompt and thorough evaluation should be initiated.
As far as treatment of the clavicle fracture itself is concerned,
no specific recommendations are available in the literature, but
general principles should be followed. Prophylactic antibiotics
should be administered, and in general the instability associated with such a fracture will warrant operative stabilization as
promptly as the patient’s general condition permits.
Imaging and Other Diagnostic Studies for
Clavicle Fractures
Simple anteroposterior (AP) radiographs are usually sufficient
to establish the diagnosis of a clavicle fracture. The diagnosis
may also be made from a single AP chest radiograph, which
may be the only available film in an urgent trauma setting. The
chest radiograph can also be used to evaluate the deformity of
the involved clavicle relative to the normal side, and to look for
associated skeletal injuries such as rib, glenoid, and scapular
fractures. A measurement of length can be made on the chest
radiograph comparing the injured to the uninjured side: Shortening of 2 cm or more represents a relative indication for primary fixation. To best delineate a clavicular fracture, as when
one is determining whether operative intervention is warranted,
a radiograph should be taken in the upright position (where
gravity will demonstrate maximal deformity). Ideally, the radiographic beam for the AP radiograph of the clavicle should be
angled 20 degrees superiorly to eliminate the overlap of the thoracic cage and show the clavicle in profile.29–32,149,194 In addition,
if the torso is internally rotated a similar 20 degrees (rotating
internally when standing or by bumping up the opposite side
while supine), the scapula and shoulder girdle are placed parallel
to the cassette for a true AP film. CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting, although
A
B
C
D
Figure 38-13 Fractures of the medial end of the clavicle are difficult to visualize with conventional
radiography. This 32-year-old female equestrian sustained a medial clavicle fracture following a riding
accident when her horse fell on her. The anteroposterior radiograph (A) reveals some asymmetry of
the clavicles but it is difficult to define the exact nature of the injury due to the overlap of bony axial
structures and the spinal column. B: A CT scan clearly demonstrates the medial fracture with a small
residual medial fragment (small arrow) and posterior displacement of the shaft (big arrow), (C) impinging on the mediastinal structures. D: Plate fixation was performed, with extension of the plate onto
the sternum due to the small size of the medial fragment. Once bony union has occurred (between 3
and 6 months), such a plate should be removed. (Case courtesy of Dr. Jeremy A. Hall.)
this imaging modality can demonstrate the complex threedimensional deformity that affects the shoulder girdle with these
injuries, including significant scapular angulation and protraction.64 It is also 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.”45,145,158
Lateral clavicle fractures can be well visualized with
AP radiographs. Centering the radiograph on the AC joint
and angling the beam in a cephalic tilt of approximately
15 degrees (the Zanca view) helps delineate the fracture well,
by removing the overlap of the upper portion of the thoracic cage.30,32 To accurately delineate the degree of fracture
displacement, these radiographs should be taken with the
patient standing and the arm unsupported by slings, braces,
or the uninjured arm. On occasion, it may be useful to obtain
a stress view to determine the integrity of the coracoclavicular ligaments (as this can influence the choice of fixation):
A 2.26- to 4.53 kg (5- to 10-lb) weight is suspended from the
wrist of the affected arm and then radiographs are taken. CT
scanning of lateral clavicle fractures is rarely required clinically; but can be useful in selected cases to determine intraarticular extension or displacement.
Fractures of the medial clavicle, especially those involving
the SC joint, are notoriously difficult to accurately assess with
plain radiographs. CT scanning is the radiographic procedure
of choice when the anatomy of the fracture is unclear. This
investigation can help distinguish between a medial epiphyseal
fracture (common in individuals up to 25 years of age) and true
SC dislocations (Fig. 38-13).30,167,185,206
Classification of Clavicle Fractures
A number of classification schemes have been proposed for
fractures of the clavicle. These have traditionally been based on
the position of the fracture, with the groups originally divided
by Allman into proximal (Group I), middle (Group II), and
distal (Group III) third fractures. This general grouping has the
advantage of corresponding to the clinical approach to these
fractures of most orthopedic surgeons.30 Recognizing that this
basic scheme does not take into effect factors that influence
treatment and outcome, such as fracture pattern, displacement,
comminution, and shortening, various authorities have refined
the classification to include other variables. Due to their high
rate of delayed union and nonunion, Neer divided distal clavicle
fractures into three subgroups, based on their ligamentous
attachments and degree of displacement (Type II was subsequently modified by Rockwood).30,113
Type I: Distal clavicle fracture with the coracoclavicular ligaments intact
Type II: Coracoclavicular ligaments detached from the medial
fragment, with the trapezoidal ligament attached to the distal fragment
IIA (Rockwood): Both conoid and trapezoid attached to the
distal fragment
IIB (Rockwood): Conoid detached from the medial fragment
Type III: Distal clavicle fracture with extension into the AC joint.
Ideally, a classification scheme should be reproducible with
a low rate of inter- and intra-observer variability, should help
direct treatment, can be used to predict outcome, should be
useful in both the clinical and research realms, and should be
simple enough to be practically useful yet robust enough to
include all fracture patterns. While at the present time there
is no classification scheme that has been rigorously tested to
meet all these objectives, modern schemes based on prospective, comprehensive population-based studies are available.
Nordqvist et al.123 examined over 2,035 fractures of the clavicle over a 10-year period and essentially expanded on Allman’s original scheme by adding subtypes based on fracture
displacement, including a comminuted category for midshaft
fractures. In a similar population-based study in Edinburgh,
Robinson155 evaluated over 1,000 consecutive fractures of the
clavicle, and developed a classification scheme based on prognostic variables from the analysis of their data (Fig. 38-14). It
continues the traditional scheme of dividing the clavicle into
thirds, and adds variables that are of proven diagnostic value
(intra-articular extension, displacement, and comminution).
However, a feature of this scheme is that it reverses the traditional numbering scheme, describing medial fractures as Type
I, middle third fractures as Type II, and distal third fractures
as Type III. Since distal third fractures are firmly entrenched in
the orthopedic lexicon as “Type II” fractures, this can lead to
significant confusion. Despite this drawback, the Robinson classification is based on an extensive database that includes prospectively gathered, objective clinical data. For this reason, it is
the classification I prefer to use clinically as it can help predict
outcome and hence guide treatment, including the decision to
operate and the fixation methods chosen. The AO/OTA Fracture and Dislocation Classification Compendium was updated
in 2007 to include recent developments including a unified
numbering scheme and measures to improve observer reliability (Fig. 38-15). The clavicle is designated as segment 15, and is
divided into the standard medial metaphyseal, diaphyseal, and
lateral m
etaphyseal fractures.95 An important difference is that
the metaphyseal fractures in this scheme are not one-third of the
length of the bone but are shorter segments, according to the
AO “rule of squares.” For the all-important diaphysis, there are
simple (15-B1), wedge (15-B2), and complex (15-B3) subtypes.
Outcome Measures for Clavicle Fractures
It has become apparent that outcome measures previously used
for fractures in general, and clavicle fractures in particular, have
not reliably demonstrated significant residual deficits following
injury.115,160 Gauging success or failure based on the isolated
finding of the presence or absence of union on a post-injury
radiograph was shown to be inadequate by Gossard.59 They used
patient-based questionnaires that revealed a 32% rate of patient
dissatisfaction following the nonoperative treatment of displaced midshaft clavicle fractures, a significantly higher rate than
expected from traditional (i.e., radiographic or surgeon-based)
outcome measures. In addition, they showed that a significant
proportion of patients (15%) were dissatisfied despite radiographic union, confirming the existence of symptomatic clavicular malunion for the first time in a large series. McKee et al.99 used
Robinson Cortical Alignment
Fracture (Type 2A)
Robinson Displaced Fractures (Type 2B)
Undisplaced (Type 2A1)
Simple or single butterfly (Type 2B1)
Allman Group I
Craig Group I
Angulated (Type 2A2)
Segmental or comminuted (Type 2B2)
Robinson Cortical Alignment
Fracture (Type 3A)
Extra-articular (Type 3B1)
Neer Type II
Craig Type II, IV
Extra-articular (Type 3A1)
Neer Type I
Craig Type I
Allman Group II
Craig Group II
Intra-articular
(Type 3B2)
Craig Type V
Intra-articular (Type 3A2)
Neer Type III
Craig Type III
Robinson Undisplaced Fractures (Type 1A)
Extra-articular (Type 1A1)
Craig Type I
Craig Type II
Intra-articular (Type 1A2)
Craig Type III
Craig Type V
Figure 38-14 Robinson classification scheme of clavicle fractures.
Allman Group III
Craig Group III
Location: Medial end (15-A)
Location: Diaphysis (15-B)
Location: Lateral end (15-C)
Type:
A. Clavicle, medial end (15-A)
Type:
B. Clavicle, diaphysis (15-B)
Type:
C. Clavicle, lateral end (15-C)
Group:
Clavicle, medial end (15-A)
1. Extra-articular (15-A1)
Clavicle, diaphysis (15-B)
1. Simple (15-B1)
Clavicle, lateral end (15-C)
1. Extra-articular (15-C1)
2. Intra-articular (15-A2)
2. Wedge (15-B2)
2. Intra-articular (15-C2)
3. Comminuted (15-A3)
3. Complex (15-B3)
Figure 38-15 AO/OTA classification scheme of clavicle fractures.
machine-based objective strength measurements on patients
with clavicular malunion to demonstrate strength deficits of up
to 30% that were not apparent on the traditional manual strength
testing against the physicians resisting arm.
Similar findings in other areas have prompted extensive
research into the evaluation of outcome. A number of modern,
validated, responsive, consistent outcome measures are now
available for the evaluation following shoulder girdle injuries.
Most clinical research studies examining patient outcome in this
anatomic area use a comprehensive set of outcome measures
including a patient-oriented general health status measurement
such as the SF-36 or MFA, a patient-oriented limb-specific outcome measure such as the Disabilities of the Arm, Shoulder, and
Hand (DASH), a surgeon-based outcome score such as the Constant shoulder score or UCLA shoulder score, and a radiographic
measure. With regard to the radiographic measurements, there is
Group
Nonoperative
Operative
100
Constant score
90
80
70
60
6
12
24
52
Time (week)
104
Figure 38-16 Constant shoulder scores of patients following operative versus nonoperative treatment of a displaced midshaft fracture
of the clavicle at 2 years are similar to 1-year scores, indicating that
function plateaus after 1-year post injury. (Adapted from: Schemitsch
LA, Schemitsch EH, Veillette C, et al. Function plateaus by one year in
patients with surgically treated displaced midshaft clavicle fractures.
Clin Orthop Relat Res. 2011;469(12:3351–3355, with permission.)
increasing focus on standardizing technique so as to obtain consistent results. There are now data available from multiple studies
on the effect of a clavicle fracture on these outcome measures
that help the attending surgeon with treatment and prognostication (see below).15,85,103,143,155
Another previously unanswered yet important question
regarding outcome following clavicle fracture was the length
of follow-up required to determine the time of maximal recovery, or when a patient “plateaued” following injury. While most
scientific journals require a minimum follow-up of 2 years for
outcome studies, this can be extremely difficult to obtain in the
“trauma population,” which tends to be predominantly young,
male, and transient. A recent study by Schemitsch et al.164 demonstrated that outcome measures such as the DASH or Constant score do not change appreciably after 1 year in patients
with midshaft clavicle fractures (Fig. 38-16). This finding has
important implications. Clinically, following either operative or
nonoperative treatment, patients can be told that their functional outcome is unlikely to change significantly from their
status at 1 year post injury. Researchers can plan for a single
year of follow-up post-intervention, with the knowledge that
the expense and effort of longer monitoring is unnecessary as
changes in outcome measures past this point are minimal. In
addition, economists can use the 1-year data from such studies
for definitive calculations of the long-term cost-effectiveness of
various treatment methods.137
Pathoanatomy and Applied Anatomy Relating
to Clavicle Fractures
Bony Anatomy of the Clavicle
The clavicle is a relatively thin bone, widest at its medial and
lateral expansions where it articulates with the sternum and
acromion, respectively (Fig. 38-17). It has two distinct curves:
The larger, obvious curve is in the coronal plane giving the bone
its characteristic S shape (medial end convex anterior and lateral end concave anterior).107 There is also a more subtle superior curve delineated in a cadaver study by Huang et al.70 This
milder superior bow had its apex laterally a mean of 37 mm
from the acromial articulation, with a mean magnitude of 5 mm.
The medial superior surface of the clavicle was found to be flat.
This article also described the fit of a precontoured clavicular
plate to 100 pairs of cadaver clavicles. The authors found that
there were significant sex and racial differences in the fit of the
plate from best (black male clavicles) to worst (white female
clavicles). This article helps explain why intraoperatively it often
Figure 38-17 The cross-sectional and topographic anatomy of the clavicle. The clavicle is narrowest in its midportion, explaining the high incidence of fractures in this area.
is necessary to adjust or contour even “anatomic” plates for the
clavicle to achieve an optimal fit.70 The bone in the relatively
thin diaphysis is typically hard cortical bone best suited for
cortical screws, whereas the medial and lateral expansions are
softer cancellous bone where larger pitch cancellous screws can
be inserted without tapping.
Ligamentous Anatomy of the Clavicle
Sternocleidomastoid
Trapezius
Pectoralis major
Medial
There is relatively little motion at the SC joint, and the supporting
soft tissue structures are correspondingly thick. Medially the clavicle is secured to the sternum by the SC capsule, and although
there are not easily demonstrable “ligaments,” the thickening
of the posterior capsule has been determined to be the single
most important soft tissue constraint to anterior or posterior
translation of the medial clavicle. There is also an interclavicular
ligament which runs from the medial end of one clavicle, gains
purchase from the superior aspect of the sternum at the sternal
notch, and attaches to the medial end of the contralateral clavicle.
Acting as a tension wire at the base of the clavicle, this ligament
helps prevent inferior angulation or translation of the clavicle. In
addition, there are extremely stout ligaments that originate on the
first rib and insert on the undersurface or the inferior aspect of
the clavicle.19 A small fossa inferomedially, the rhomboid fossa,
has been described as an attachment point for these ligaments,
which primarily resist translation of the medial clavicle.
Lateral
The coracoclavicular ligaments are the trapezoid (more lateral)
and conoid (more medial) which are stout ligaments that arise
from the base of the coracoid and insert onto the small osseous ridge of the inferior clavicle (trapezoid) and the clavicular
conoid tubercle (conoid). These ligaments are very strong and
provide the primary resistance to superior displacement of the
lateral clavicle. Their integrity, or lack thereof, plays an important role in the decision making and fixation selection in the
treatment of displaced lateral third clavicle fractures. Clavicle
fractures in this location will often have an avulsed inferior
fragment to which these ligaments are attached, especially in
younger individuals. Inclusion of these fragments in surgical
fixation selection enhances the stability of the operative repair.
The capsule of the AC joint is thickened superiorly and is primarily responsible for resisting AP displacement of the joint. It
is important to repair this structure, which is usually reflected
surgically as part of the deep myofascial layer, when operating
on the lateral end of the clavicle. If one is inserting a hook plate
for fixation of a very distal fracture, a small defect can be made
in the posterolateral aspect of the capsule for insertion of the
hook portion into the posterior subacromial space.23,42,83,98,193
Muscular Anatomy of the Clavicle
The clavicle is not as important as the scapula in terms of muscle origin, but still serves as the attachment site of several large
muscles. Medially, the pectoralis major muscle originates from
the clavicular shaft anteroinferiorly, and the sternocleidomastoid originates superiorly. The pectoralis origin merges with
the origin of the anterior deltoid laterally, while the trapezius
Scalenus anterior
Subclavius
Brachial plexus
Subclavian artery
Subclavian vein
First rib
Pectoralis minor
Figure 38-18 Applied anatomy of the clavicle. Anterosuperiorly,
the pectoralis major muscle and fascia envelope the medial 60%
of the clavicle while the lateral 40% is covered by the deltoid muscle and its fascia. Posterosuperiorly, the trapezius muscle attaches
to the clavicle.
insertion blends superiorly with the deltoid origin at the lateral margin (Fig. 38-18). Muscle attachment plays a significant
role in the deformity which results after fracture: The medial
clavicular fragment is elevated by the unopposed pull of the
sternocleidomastoid muscle, while the distal fragment is held
inferiorly by the deltoid and medially by the pectoralis major.
The undersurface of the clavicle is the insertion site of the subclavius muscle, which is of little significance functionally but
serves as a soft tissue buffer in the subclavicular space superior
to the brachial plexus and subclavian vessels. The platysma or
“shaving m
uscle” is variable in terms of thickness and extent,
but 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. It is divided
during the surgical approach, and is typically included in the
closure of the superficial, or skin/subcutaneous layer.
Neurovascular Anatomy of the Clavicle
The supraclavicular nerves originate from cervical roots C3
and C4 and exit from a common trunk behind the posterior
border of the sternocleidomastoid muscle. There are typically
three major branches (anterior, middle, and posterior) that
cross the clavicle superficially from medial to lateral, and are
at risk during surgical approaches. If they are divided, an area
of numbness is typically felt inferior to the surgical incision,
although this tends to improve with time. A more difficult problem can be the development of a painful neuroma in the scar
which, although rare, can negatively affect an otherwise good
surgical outcome. For this reason, some authorities recommend
identification and protection of these nerves during operative
repair.75,76,174 More vital neurovascular structures lie inferior to
the clavicle. The subclavian vein runs directly below the subclavius muscle and above the first rib, where it is readily accessible (for central venous access) and vulnerable (to inadvertent
injury). More posteriorly lie the subclavian artery and the brachial plexus, separated from the vein and clavicle by the additional layer of the scalenus anterior muscle medially. The plexus
is closest to the clavicle in its midportion, where the greatest
care needs to be taken in not violating the subclavicular space
with drills, screws, or instruments. A recent study by Sinha
et al.171 used reconstructed three-dimensional CT arteriograms
of the head, neck, and shoulder to better define the relationship
between these vascular structures and the clavicle. Their goal
was to define “safe zones,” in terms of distance and direction, for
potential drill penetration during plate and screw fixation of the
clavicle. They divided the clavicle into medial, middle, and distal thirds, and found that the subclavian vessels were closest at
the medial end, with the vein directly apposed to the posterior
cortex of the medial clavicle in some cases. In the middle third,
the artery and vein were a mean of 17 and 13 mm from the clavicle, respectively, at an approximate angle of 60 degrees to the
horizontal (i.e., the vessels were posterior-inferior to the clavicle,
Figs. 38-19 and 38-20). Laterally, the distances were greater,
with the artery and vein a mean of 63 and 76 mm, respectively
form the clavicle. Using these findings, the authors made a number of recommendations regarding surgical technique: Extreme
caution must be used when manipulating medial clavicular fracture fragments, and superior plating may be safer than anterior plating in this area. Also, they felt that anterior plating had
less potential for vessel injury from drill or screw penetration,
as compared to superior plating, in the more common middle
third fractures. They felt the risk of iatrogenic vessel injury was
Anterior
Posterior
12.7 mm (3D)
Clavicle
SV SA
Scapula
6.0 mm (3D)
70°
Anterior
50°
Posterior
Horizontal
Clavicle
SV
SA
Average angle of artery and vein
middle one third (point ‘B’)
Figure 38-20 Schematic illustration indicating the location of the
subclavian artery and vein in relation to the middle third of the clavicle, and the angle from the horizontal of potential drill/screw penetration to be avoided. (Adapted from: Sinha A, Edwin J, Sreeharsha B,
Bhalaik V, Brownson P. A radiological study to define safe zones
for drilling during plating of clavical fractures. J Bone Joint Surg Br.
2001;93-B:1247–1252, with permission.)
much less in the fixation of distal third fractures. Despite the
proximity of these vital structures, iatrogenic injury is surprisingly rare in clavicle fracture fixation (see below).
Clavicle Fracture
Treatment Options
A recent review article focusing on evidence-based medicine
outlined treatment approaches to displaced midshaft fractures
of the clavicle.104 This resource summarizes the available objective evidence about recommendations for the optimal treatment
of these injuries (Table 38-2). The grades of recommendation
are as follows.
Grade A: Good evidence (high-quality prospective, randomized
clinical trials (RCTs) with consistent findings) recommending for or against intervention
Grade B: Fair evidence (lesser quality RCTs, prospective comparative studies, case-control series) recommending for or
against intervention
Grade C: Poor-quality evidence (case series or expert opinions)
recommending for or against intervention
Lungs
Figure 38-19 The relationship of the subclavian artery (SA) and vein
(SV) to the midshaft of the clavicle. (Adapted from: Sinha A, Edwin J,
Sreeharsha B, Bhalaik V, Brownson P. A radiological study to define
safe zones for drilling during plating of clavical fractures. J Bone
Joint Surg Br. 2001;93-B:1247–1252, with permission.)
Grade I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention
While there is an abundance of manuscripts detailing the
treatment of clavicle fractures, most tend to be retrospective
reviews, although there are an increasing number of prospective
and/or randomized trials being published.15,59,74,154 My personal
recommendations for treatment must be considered in light of
the evidence available in Tables 38-1 and 38-2.
Table 38-2
Recommendations for the Optimal
Treatment of Displaced Midshaft
Fractures of the Clavicle
Gradea
References
Young active patients with completely displaced midshaft fractures of the clavicle will have
superior results with primary
fracture fixation.
B
15,174,209
Anteroinferior plating may reduce
the risk of symptomatic hardware compared to superior
plating.
C
27,91
There is no difference in outcome between a regular sling
and a figure-of-eight bandage
when nonoperative treatment
is selected.
B
3,178
There is no difference in outcome
between plating and intramedullary nailing of displaced midshaft clavicle fractures.
I
7,26,63,73,
140,209
Factors associated with poor outcome following nonoperative
treatment of displaced midshaft clavicle fractures include
shortening, and increasing
fracture comminution.
A
14,59,102,125,
154,174,209
Statement
patients. They could demonstrate no functional or radiographic
difference between the two groups, and in general the patients
preferred the sling (2/27 dissatisfied with the sling compared
to 9/34 dissatisfied with the figure-of-eight bandage, p = 0.09).
In a retrospective review of 140 patients treated nonoperatively,
Stanley and Norris did not find any difference between a standard sling and a figure-of-eight bandage, a finding confirmed
by other authors.138,139,178 Also, a figure-of-eight bandage that is
over-tightened can result in a temporary lower trunk brachial
plexus palsy and for this reason my practice, if nonoperative
care is selected, is to apply a simple, conventional sling with a
padded neckpiece, and no attempt at reduction is made.
Outcomes—Nonoperative Treatment
a
Grade of recommendation.
Nonoperative Treatment of
Clavicle Fractures
The earliest reported attempt at closed reduction of a displaced
midshaft fracture of the clavicle was recorded in the “Edwin
Smith” papyrus dating from the 30th century BC. Hippocrates
described the typical deformity resulting from this injury, and
emphasized the importance of trying to correct it.1 It is usually
possible to obtain an improvement in position of the fracture
fragments by placing the patient supine, with a roll or sandbag behind the shoulder blades to let the anterior displacement
and rotation of the distal fragment correct with gravity, followed
by superior translation and support of the affected arm. Unfortunately, it is difficult or impossible to maintain the reduction
achieved. For this reason, over the millennia that followed the
first description of treatment of this fracture, there have been
hundreds of descriptions of different devices designed to maintain the reduction, including splints, body jackets, casts, braces,
slings, swathes, and wraps.1,3,16,31,59,97 At the present time, there
is no convincing evidence that any of these devices reliably
maintains the fracture reduction or improves clinical, radiographic, or functional outcomes. For many years the standard
of care in North America was the “figure-of-eight” bandage:
Andersen et al.3 examined its utility in a prospective, randomized, controlled clinical trial comparing it to a simple sling in 60
Traditionally, clavicle fractures have been treated nonoperatively
but recent studies have shown that the union rate for displaced
midshaft fractures of the clavicle may not be as favorable as
previously described. In a prospective series of 868 patients
with clavicle fractures treated nonoperatively, Robinson et al.154
reported a significantly higher nonunion rate (21%) in displaced
comminuted midshaft fractures. An analysis of this paper by
Brinker et al.14 suggested a nonunion rate varying between 20%
and 33% for displaced comminuted fractures in males. Hill
et al.68 studied 66 consecutive displaced midshaft clavicle fractures and found a 15% nonunion rate and a 31% rate of patient
dissatisfaction with nonoperative care. Based on their data,
they concluded that displacement of the fracture fragments of
greater than 2 cm was associated with an unsatisfactory result. A
meta-analysis of studies of clavicle fractures from 1975 to 2005
revealed that displaced midshaft clavicle fractures treated nonoperatively had a nonunion rate of 15.1%. This meta-analysis
also showed that primary plate fixation was, contrary to prevailing opinion, a safe and reliable procedure.209 Nowak et al.125,126
examined the late sequelae in 208 adult patients with clavicle
fractures at 10 years post injury. Interestingly, 96 (46%) still had
symptoms despite the fact that only 15 (7%) had an established
nonunion. McKee et al.99 reported on a series of patients who has
nonoperative treatment of a displaced midshaft clavicle fracture
a mean of over 4 years earlier. Objective muscle strength testing revealed significant strength deficits, especially of shoulder
abduction and flexion which help explain some of the patient
dissatisfaction seen despite bony union.
While it is unclear why such a dramatic difference exists
in outcome between previous reports on clavicle fractures and
contemporary studies, one possibility may be the inclusion of
children in the older reports, which, due their inherent healing
abilities and remodeling potential, may artificially improve the
overall results. Also, patient-oriented outcome measures, as used
by Hill et al. and McKee et al. have been shown to reveal functional deficits in the upper extremity that have not been detected
traditionally.15,68,99 A focus on radiographic outcomes would not
reveal such problems. Patient expectations and injury patterns
are changing. Several studies that examined clavicular shaft fractures in polytrauma patients found that the presence of a clavicle
fracture was associated with a 20% to 30% mortality rate (mainly
from concomitant chest and head injuries), and that survivors
displayed a significant level of residual disability in the involved
Table 38-3
osmesis Following Operative
C
Versus Nonoperative Care of
Clavicular Fractures
Complaint
Operative
(n = 62)
Nonoperative
(n = 49)
p Value
“Droopy” shoulder
0
10
0.001
Bump/Asymmetry
0
22
0.001
Scar
3
0
0.253
Sensitive/painful
fracture site
9
10
0.891
Hardware irritation/
prominence
11
0
0.001
Incisional numbness
18
0
0.001
Satisfied with
appearance of
shoulder
52
26
0.001
shoulder.101,184 Thus, there is a surviving patient population
(with clavicle fractures) that has an intrinsically worse prognosis
where long-term sequelae may be more common.
Although it is not typically an orthopedic priority, cosmesis is important to patients, and an unsightly scar has been a
traditional deterrent to operative treatment of clavicular fractures.29,30,32,115,118,128,142 However, to a body image conscious
patient (predominantly young, male population), a droopy
shoulder is also of significant cosmetic concern. In a recent
RCT comparing operative and nonoperative treatments, despite
the incidence of hardware prominence and incisional complications (numbness, sensitivity) in the operative group, more
patients in this group answered “yes” to the question “Are you
satisfied with the appearance of your shoulder?” than in the
nonoperative group (52/62 vs. 26/49, p = 0.001, Table 38-3).
This study also showed superior surgeon-based (Constant score)
and patient-based (DASH) upper extremity outcomes.15
In contradistinction to older case series, recent studies on
the primary plate fixation of acute midshaft clavicle fractures
have reported high success rates with union rates ranging from
94% to 100% and low rates of infection and surgical complications. A recent meta-analysis of plate fixation for 460 displaced fractures revealed a nonunion rate of only 2.2%. With
improved implants, prophylactic antibiotics, and better soft tissue handling one can conclude that plate fixation is reliable and
reproducible.15,82,140,141,209
Operative Treatment of Clavicle Fractures
Indications/Contraindications
There are numerous large series that describe relatively good
results following nonoperative treatment of clavicle fractures,
and it is my opinion that the majority of clavicle fractures can,
and should, be treated in this fashion.3,43,49,78,115,160 However,
there are serious deficiencies in these papers including the
inclusion of children (who have an intrinsically good result and
remodeling potential), large numbers of patients lost to followup, and radiographic and/or surgeon-based outcomes that are
insensitive to residual deficits. Recent evidence from prospective and randomized clinical trials has suggested that there is a
subset of individuals who benefit from primary operative care
(Fig. 38-21).15,59,74,105,140,154,169,173,192,201 Operative repair in this
setting 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. There are multiple
potential indications for primary operative fixation, outlined
in Table 38-4. The majority of modern prospective studies
examining the potential benefits of primary clavicle fracture
fixation have been in adult patients, with 16 years of age the
typical (arbitrary) lowest age of inclusion. Thus, it is unclear if
adolescent patients, in general, would benefit from operative
repair to a similar degree as adult patients. However, adolescent
patients can develop symptomatic malunion following nonoperative treatment of displaced midshaft fractures of the clavicle,
although nonunion remains rare as one would expect. Vander
Have et al.189 performed a retrospective study on 43 adolescent patients (mean age: 15.4 years) with displaced midshaft
clavicle fractures, 17 of whom underwent primary plate fixation, and 25 of whom were treated nonoperatively. They found
that complications in the plate group were minor, and a more
rapid return to function with a shorter time to union resulted.
Five patients in the nonoperative group, with a mean of 26
mm of shortening, developed a symptomatic malunion, with
four patients choosing corrective osteotomy. It is clear that
some adolescent patients with significantly displaced midshaft
clavicle fractures have suboptimal results following closed
Table 38-4
Relative Indications for Primary
Fixation of Midshaft Clavicle
Fractures
Fracture-Specific
1.Displacement >2 cm
2.Shortening >2 cm
3.Increasing comminution (>3 fragments)
4.Segmental fractures
5.Open fractures
6.Impending open fractures with soft tissue compromise
7.Obvious clinical deformity (usually associated with 1 and
2 above)
8.Scapular malposition and winging on initial examination
Associated Injuries
1.Vascular injury requiring repair
2.Progressive neurologic deficit
3.Ipsilateral upper extremity injuries/fractures
4.Multiple ipsilateral upper rib fractures
5.“Floating shoulder”
6.Bilateral clavicle fractures
Patient Factors
1.Polytrauma with requirement for early upper extremity
weight-bearing/arm use
2.Patient motivation for rapid return of function (e.g., elite
sports or the self-employed professional)
Figure 38-21 Probability of nonunion
at various time points following a midshaft clavicle fracture. The PI (Prognostic index) becomes more negative with
each of the following factors: Increasing
age, increasing comminution, increasing
displacement, and female sex. (Adapted
from Robinson CM, Court-Brown CM,
McQueen MM, et al. Estimating the risk
of nonunion following nonoperative treatment of a clavicle fracture. J Bone Joint
Surg Am. 2004;86-A(7):1359–1365.)
Estimated proportion of fractures remaining ununited
1
0.9
0.8
0.7
6 weeks
12 weeks
24 weeks
0.6
0.5
0.4
0.3
0.2
0.1
0
–2.5
treatment, and that plate fixation is a safe and reliable fixation
method with a low complication rate in this group. Prospective,
randomized studies of operative versus nonoperative treatment
in this specific group are required to determine the exact role, if
any, for primary operative repair of these fractures. At present,
the consensus is that operative intervention should be reserved
for older, larger adolescents with severely displaced fractures.17
External Fixation
There are reports in the literature of various techniques of
external fixation for clavicle fractures.35,165,186 This method takes
advantage of the intrinsic healing ability of the clavicle and
allows restoration of length and translation without the scarring or morbidity of a surgical approach. In addition, there is
no retained hardware at the conclusion of treatment. Schuind165
reported on a series of 20 patients treated with external fixation for clavicular injuries, many of whom had local soft tissue
compromise; union occurred in all. Tomic et al.186 described
the treatment of 12 patients with nonunion of the clavicular
shaft by application of a modified Ilizarov device. Union was
achieved in 11 of 12 patients with an increase in the mean
Constant score from 30 preoperatively to 69 postoperatively.
It is clear that this technique is technically possible to perform, and may be useful in certain specific situations. Unfortunately, the practical difficulties associated with the position and
prominence of the fixation pins, coupled with a lack of patient
acceptance in the North American population, has resulted in
minimal use of this technique (Table 38-5).
Intramedullary Pinning
Preoperative Planning. Intramedullary (IM) pinning
of fractures of the shaft of the clavicle has several advantages.
These are similar to the benefits seen with IM fixation of long
bone fractures in other areas, although this technique had not
–2
–1.5
–1
–0.5
0
Prognostic index (PI)
been as consistently successful in the clavicle as series in the
femur or tibia have reported.8,30,48,51,63,73,106 Advantages include a
smaller, more cosmetic skin incision, less soft tissue stripping at
the fracture site, decreased hardware prominence following fixation, technically straightforward hardware removal, and a possibly lower incidence of refracture or fracture at the end of the
implant. Recently, modifications to the technique have included
a radiographically guided completely “closed” technique.26 Since,
at the present time, there is no consistently reliable way to “lock”
an IM clavicle pin, complications include those common to all
unlocked IM devices, namely failure to control axial length and
rotation, especially with increasing fracture comminution and
decreasing intrinsic fracture stability. In addition, a biomechanical study of clavicular osteotomies by Golish et al.57 comparing
3.5-mm compression plates to 3.8- or 4.5-mm IM pins showed
that the plated constructs were superior in resisting displacement
in a number of different testing modes (maximal load, cyclical
Table 38-5
External Fixation of Clavicle
Fractures: Preoperative Planning
Checklist
OR table
Radiolucent table
Position
Semisitting with small pad between
scapulae
Fluoroscopy location
C-arm is placed ipsilateral and enters
from the side
Equipment
External or ring fixator of surgeon’s
choice
Special considerations
This is a complex technique requiring
a subspecialty skill level and is not
well tolerated by some patients
Intramedullary Fixation of Clavicle
Fractures: Preoperative Planning
Checklist
Table 38-6
OR table
Radiolucent table
Position
scapulae
Fluoroscopy
location
C-arm is placed ipsilateral, and enters
from the side
Equipment
Intramedullary pins, reamers, inserters,
and any attachment guides or jigs
Special considerations
At present, this technique is reserved for
simple fractures such as transverse or
short oblique patterns without significant comminution
stress) compared to both IM pin constructs. Therefore, based
on clinical and biomechanical evidence, at the present time this
technique is, in general, reserved for simple fracture patterns
(transverse and short oblique fractures) (Table 38-6).
Patient Positioning. The technique includes positioning
the patient in a semisitting position on a radiolucent table, with
an image intensifier on the ipsilateral side. By rotating the image
45 degrees caudal and 45 degrees cephalad orthogonal views of
the clavicle can be obtained. A small pad is placed between the
scapulae to allow the shoulder to “fall back,” aiding in reduction, as the typical clavicle fracture deformity results in protraction of the shoulder girdle. The arm may be free-draped
if a difficult reduction is anticipated (i.e., as with significant
shortening), but in general this is not necessary. The head is
turned to the opposite side and taped in place.
A
C
Surgical Approach/Technique. A small incision is then
made over the posterior-lateral corner of the clavicle 2 to 3 cm
medial to the AC joint (Fig. 38-22). The posterior clavicle at this
point is identified and the canal breached with a drill consistent
with the planned fixation device. A reduction of the fracture is
then performed, either through a small open incision or, as experience increases, in a completely closed fashion using a percutaneous reduction clamp on the medial fragment and a “joystick”
in the distal fragment. Alternatively, the fixation device can be
inserted using a “retrograde” technique where it is passed out
from the fracture site through the lateral fragment. The fracture
is then reduced and the IM device is inserted into the medial
fragment under direct vision. It is important to accurately reduce
length and rotation, although the latter can be quite difficult if
done closed and no visual clues from the fracture configuration
are available. A small incision may be necessary to reduce vertically oriented comminuted fragments and “tease” then back into
alignment. Following this, the canal is drilled to the appropriate
size to accept the planned IM device. Options include headed
pins, partially threaded pins or screws, cannulated screws, and
smooth wires. Although some series report favorable results with
smooth wires, the North American experience with small diameter smooth pin fixation includes breakage and migration and is,
in general, dismal.87,93,109,120 Smooth wires are contraindicated for
fracture fixation about the shoulder in general and the clavicle in
particular. It is important not to distract the fracture site with the
fixation device, which can occur as the pin is inserted into the
unyielding opposite cortex as the S-shaped clavicle comes into
contact with the end of the straight pin. If this occurs, the pin
must be withdrawn slightly or a shorter pin is used. The head of
the pin or screw can be left prominent to facilitate early removal
through a small posterior incision, or can be left flush with the
bone to decrease soft tissue irritation (Fig. 38-23).
B
Figure 38-22 Intramedullary fixation with a headed, distally
threaded pin (modified Hagie pin). (A) Retrograde drilling of the
distal fragment, (B) reduction and fixation of the fracture, (C) addition of bone graft or bone graft substitute.
A
E
B
F
G
C
D
Figure 38-23 A: A comminuted, displaced, midshaft fracture of
the clavicle. B: Photograph showing the operative set-up with the
image intensifier in place. C: A small incision is made and the fracture
reduced in an open fashion followed by retrograde insertion of the
pin. D: Postoperative radiograph revealing reduction of the fracture.
E: Skin irritation over prominent pin. F: Radiograph demonstrating
bony union. G: Follow-up radiograph following uneventful union and
pin removal. (Case courtesy of, and copyright by, Dr. David Ring).
A
B
Figure 38-24 A: A completely displaced transverse fracture of the midshaft of the clavicle treated
with a lockable, large diameter intramedullary nail. B: While this device represents an advance in the
treatment of these injuries, more outcome data is required prior to implementation in unstable fracture
patterns. (Case courtesy of Dr. Aaron Nauth).
Postoperative Protocol. Some authors advocate leaving
the pin in a prominent position subcutaneously for easy access
in the clinic at the time of early (7 to 8 weeks postoperative)
hardware removal. This step depends on the type of fixation
device used and the philosophy of the treating surgeon. The
incisions are closed in a fashion similar to that used for plate
fixation, although they are typically smaller. If the surgeon is
confident with the stability of the repair, early motion is instituted similar to that performed following plate fixation.
of implants that, in general, are essentially unlocked, have poor
rotational or axial control, and are not suitable for unstable or
comminuted fractures. Newer devices are now available that
have the potential to improve on traditional IM implants with
locking capability (Fig. 38-24): Further studies will elucidate if
their theoretical advantages are borne out in clinical practice.
See also “Controversies: Method of Fixation,” below.
Potential Pitfalls and Preventative Measures
Outcome. While there are many theoretical advantages to
IM fixation, it would appear that the results of this method with
currently available implants are more unpredictable than the
results reported for plate fixation. Biomechanically, IM devices
appear to be inferior in resisting displacement when compared
to plate fixation.60 Two clinical studies comparing IM fixation
to nonoperative treatment failed to show any advantage in the
IM fixation group. Grassi et al. described a high complication
rate with IM fixation including eight infections, three “refractures,” two delayed unions and two nonunions with hardware
failure in 40 patients.63 Judd et al.,74 in a randomized trial,
failed to show an advantage of IM fixation over nonoperative
care in 57 patients, with nearly half the operative group losing
some degree of reduction. A recent study by Strauss et al.180
described a complication rate of 50%, (including three cases
of skin necrosis) in 16 patients treated with Hagie pin fixation.
They recommended against the continued use of this device. A
meta-analysis by Zlowodzki et al.209 did not reveal any significant differences between plate and IM fixation, although this
analysis was hampered by the lack of any direct comparative
studies. Conversely, Chuang et al.26 described 100% union with
no significant complications in a group of 34 patients with an
acute midshaft fractures of the clavicle treated with an IM cannulated screw. Also, these studies examine the clinical outcomes
Preoperative Planning. While this section will describe
the author’s technique of operative repair of a midshaft clavicle
fracture, it is important to remember that the majority of midshaft fractures can be treated nonoperatively. A careful physical
examination (see above) is mandatory to rule out other injuries, which may influence the anesthetic choice (i.e., an ipsilateral pneumothorax), or the surgery itself (compromised skin
or deficient soft tissue, neurovascular injury). The skin in this
area is typically bruised, with extensive swelling, following a
displaced midshaft fracture. Since the difficulty of reduction
and fixation does not increase until approximately 2 weeks following injury, it may be prudent to delay operative intervention (as one would in other areas) until the soft tissue in the
vicinity of the planned surgical approach is more robust. Radiographs of the injured clavicle are usually sufficient. The surgeon
should observe the severity of the displacement, the number
of fracture fragments, and the location of the main fracture
line (Fig. 38-25). There is often a vertically oriented anterosuperior fragment, which may benefit from lag screw fixation
and minifragment screws should be available as this fragment
may be quite narrow. Also, the number of screws that potentially can be placed into the distal fragment can be determined
preoperatively, so that the appropriate size of plate can be
available. Older series describing fixation of clavicle fractures
have described poor results when inadequate fixation such as
Open Reduction and Plate Fixation
A
B
C
D
Figure 38-25 A: Anteroposterior radiograph of a displaced midshaft clavicle fracture. Note the difference in diameter of the proximal and distal fragments at the fracture site, suggesting that a significant
degree of rotation has occurred. B: Intraoperative photograph of a displaced fracture, (C) reduced
anatomically with small fragment reduction forceps. D: Postoperative radiograph after open reduction
and internal fixation with an anterior to posterior lag screw followed by fixation with an anatomic plate.
cerclage wires alone or plates of inadequate size or length are
used (Figs. 38-26 and 38-27).114,115,142,160 A fixation set that
includes plates which are precontoured, or “anatomic,” to fit
the S shape of the clavicle is ideal. Although these plates may
require some intraoperative adjustments, they typically save significant time associated with the extensive contouring required
to make a straight plate fit the bone. They help to decrease the
soft tissue irritation that occurs when the end of a straight plate
protrudes past the end of the bone as the clavicle curves away.
Currently, there are two common surgical approaches applicable to the fixation of clavicle fractures, each with its own
advantages and disadvantages. They are as follows.
Anteroinferior. Several groups have published large series
on the advantages of anteroinferior plating of acute clavicle
fractures.27,82,170 Advantages of this technique include an easier
screw trajectory with less likelihood of serious neurovascular
injury with inadvertent overpenetration of the drill (although
obscure the fracture site radiographically. Also, although there
remains some controversy on the matter, biomechanical studies
have in general shown that the most advantageous position for
plate placement is the superior surface.
Figure 38-26 Cerclage wiring in isolation is inadequate to control
the deforming forces at the site of a displaced clavicle fracture. It
results in all of the risks of surgical intervention with few of the
benefits, and is to be avoided.
the incidence of iatrogenic nerve injury is very low), and the
ability to insert longer screws in the wider AP dimension of the
clavicle, and decreased hardware prominence. It is also technically easier to contour a small-fragment compression plate
along the anterior border as opposed to the superior surface.
However, the advent of precontoured plates has largely negated
this particular advantage. Collinge et al.27 reported on the use of
this technique in 58 patients and described 1 fixation failure, 1
nonunion, 3 infections, and only 2 hardware removals. Potential disadvantages of this technique include the lack of general familiarity with the approach, and that the plate tends to
Anterosuperior. Anterosuperior plating can reasonably be
considered the most popular operative method for fixation of
the clavicle.11,12,15,26,33 Its advantages include a general familiarity with this approach in most surgeons’ hands, the ability to extend it simply to both the medial and lateral ends of
the clavicle, and the benefit of clear radiographic views of the
clavicle postoperatively. Its disadvantages include the trajectory
of screw placement (from superior to inferior) that can be difficult, and inadvertent “plunging” with the drill can place the
underlying lung and neurovascular structures at risk. Also, the
clavicle is fairly narrow in its superoinferior dimension, and
typically the length of screws inserted range from 14 to 16 mm
in females to 16 to 18 mm in males (Table 38-7).
Patient Positioning. The patient is positioned in the
“beach-chair” semisitting position on a regular operating room
(OR) table with an attached foot piece to support the legs. It has
not been routinely necessary to use special tables or positioners.
The head is placed on a round support and, if general anesthesia is to be used, the endotracheal tube is taped to the opposite
side. The arm does not need to be free-draped for isolated injuries and is usually padded and strapped to the patients’ side. It
is helpful to place a small pad behind the involved shoulder to
elevate it and then check to ensure that the anticipated superior
drill trajectory is free from obstruction. This is less of a concern
if an anterior-inferior plate application is chosen.
Surgical Approach (Anterosuperior). A superior
approach and plating is my preferred technique because of its
simplicity, the well-proven clinical record of superior plate application, and several biomechanical studies that have suggested
that the optimal location for plate placement is superior.60,72
Table 38-7
Figure 38-27 Anteroposterior radiograph of a 35-year-old man who
weighed over 200 pounds (200 lb), whose clavicle nonunion was fixed
with a 3.5-mm pelvic reconstruction plate. Early mechanical failure
occurred through deformation of the plate. This type of plate may
be suitable for smaller, low-demand individuals but has a higher failure rate when used in larger, more physically active patients, especially given the current availability of stronger, precontoured plates.
pen Reduction and Plate Fixation
O
of Clavicle Fractures: Preoperative
Planning Checklist
OR table
A regular or radiolucent table may be used
at the surgeon’s discretion
Position
scapulae—this aids in reduction of
the fracture
Fluoroscopy
location
Fluoroscopy is not mandatory, and is used
at the discretion of the surgeon if a difficult reduction is anticipated. If used, the
C-arm is place ipsilaterally, and enters
from the side
Equipment
Precontoured plates, small fragment
fixation set, drill
Special
considerations
Most fractures are amenable to plate fixation, and this procedure is within the
skill set of most orthopedic surgeons
It is possible that anterior–inferior plating leads to less plate irritation than placement of the plate on the superior surface of the
clavicle. In the one direct comparison (nonrandomized) between
the two techniques, Lim et al.91 reported a significantly better
pain visual analog scale for patients in the anterior/inferior fixation group (p = 0.05). This finding awaits confirmation from further studies.
An oblique skin incision is made centered superiorly over
the fracture site. The subcutaneous tissue and platysma muscle are kept together as one layer and extensively mobilized,
especially proximally and distally. As experience with the technique increases, a smaller incision using “minimally invasive”
principles can be employed. Care is taken to identify, isolate,
and protect any visible, larger branches of the supraclavicular nerves; smaller ones may need to be divided. It is usually
wise to warn patients that they may experience some numbness
inferior to the incision which will typically improve with time.
The myofascial layer over the clavicle is incised and elevated
in one continuous layer. Therefore, at the conclusion of the
procedure, fracture site and plate coverage are enhanced by
having two soft tissue layers (skin/subcutaneous tissue, myofascial layer) to close. Care is taken to preserve the soft tissue
attachments to any major fragments, especially the vertically
oriented fragment of the anterosuperior clavicle that is often
seen. It is not necessary to completely denude these fragments
in order to reduce them.
Technique. The main fracture line and major fragments
are clearly identified and cleaned of debris and hematoma, and
a fixation strategy is formulated. If there is a free fragment of
sufficient size to be structurally important (one-third of the
clavicle circumference or greater), it can be reduced to the
proximal or distal clavicle that it arose from and fixed with a lag
screw, simplifying the fracture to a simple pattern (Fig. 38-28).
The proximal and distal fragments are then reduced with the
aid of reduction forceps; they can be held temporarily with a
K-wire or, ideally, with a lag screw. A precontoured plate of
sufficient length is then applied to the superior surface. If a
lag screw has been placed, it is usually sufficient to secure the
fracture with three bicortical screws (six cortices) both proxi-
mally and distally. If it is not possible to place a lag screw, then
four screws should be inserted both proximally and distally. If
the main fracture line is of a stable configuration, compression
holes can be used to apply compression. If the fracture is comminuted or of an unstable pattern, then the plate should be
applied in a “neutral” mode. Care must be taken not to violate
the subclavicular space and the vital structures therein. If there
is any concern intraoperatively about violation of the pleural
space, a Valsalva maneuver should be performed to identify any
leakage of air.
In general, surgical intervention is selected for only young
active patients with high-quality bone, and for this reason
screw purchase is usually excellent, especially in the cortical area. Although there has been increasing interest in the
use of locking plate technology in this area, there have been
few reports on this technique in the clavicle. Celestre et al.20
reported that a superiorly placed locking plate was biomechanically superior to a conventional compression plate,
although there is little clinical information regarding locking
plate use at the present time. One small retrospective series78
described their use in recalcitrant clavicular nonunions: All
11 fractures eventually healed. I have not found that locking
plates are routinely necessary for the fixation of clavicle fractures, and I have no experience with them. Following fixation,
it is important to close both soft tissue layers with interrupted,
nonabsorbable sutures. Postoperative radiographs are taken in
the recovery room.
Postoperative Care. The surgery can typically be done
on an outpatient basis. Postoperatively, the arm is placed in
a standard sling for comfort and gentle pendulum exercises
are allowed, and the patient is seen in the fracture clinic at 10
to 14 days postoperatively. The wound is checked and radiographs are taken. The sling is discontinued, and unrestricted
range-of-motion exercises are allowed, but no strengthening,
resisted exercises, or sporting activities are allowed. At 6 weeks
postoperatively, radiographs are taken to ensure bony union.
If they are acceptable, the patient is allowed to begin resisted
and strengthening activities. If delayed union is evident, then
more aggressive activities are avoided. It is generally advised
B
A
Figure 38-28 A: A displaced midshaft fracture of the clavicle in a
16-year-old boy, with abrasion and tenting of the skin, approximately
2.5-cm shortening, and an obvious clinical deformity. B: The intervening
fragments were fixed with a lag screw followed by plate fixation. Prompt
anatomic healing occurred, as might be expected in an adolescent.
that contact (football, hockey) and/or unpredictable (mountain
biking, snowboarding) sports be avoided for 12 weeks postoperatively. However, compliance in this predominately young,
male population is variable and many individuals return to
such activities earlier than recommended.
The clavicle has relatively poor soft tissue coverage, and
hardware prominence following plate fixation is a clinical
concern. Previously, prior to the advent of plates specifically
designed for the clavicle, it was often necessary to contour a
straight compression plate to fit the bone by twisting it on its
long axis so that it faced the bone as the underlying clavicle
curved away from it.100,108 In addition to making screw placement difficult, this led to undue prominence of the ends of the
plate and a high incidence of subsequent plate removal. With
the current availability of stronger, curved, low-profile plates
symptomatic prominence of the plates is much lower and routine plate removal is not typically required.
Outcome—Plate Fixation. Older reports described a
high rate of complications and hardware failure with primary
plate fixation of the clavicle. However, with the development
of improved implants, prophylactic antibiotics, and better soft
tissue handling and techniques plate fixation has become a
reliable and reproducible technique which can reasonably be
considered the gold standard at the present time (see also “Controversies: Method of Fixation,” below). Recent studies on the
primary plate fixation of acute midshaft clavicle fractures have
reported high success rates with union from 94% to 100%.
Infection and surgical complication rates are low, under 10%,
and functional outcome is superior to nonoperative treatment.
A meta-analysis of plate fixation for 460 displaced fractures
revealed a nonunion rate of only 2.2%.14–16 In the most recently
published randomized trial comparing operative versus nonoperative treatment, Virtanen et al.192 reported union of all 28
fractures in the plate fixation group, with a low complication
rate. In the largest similar trial reported to date, the union rate
in the plate fixation group was reported to be over 95%, with
the commonest complication being hardware irritation and the
requirement for plate removal. While plating remains the most
popular method of clavicle fixation, the position of plate placement is controversial, with some authorities recommending
plate placement on the superior surface of the clavicle, while
others recommend the anterior/inferior surface.10,15,27,31,82,208
At the present time, there is no published direct comparison
between the two techniques. What is apparent is that plate
fixation, for a selected subgroup of individuals with completely
displaced fractures of the midshaft clavicle, is a safe, reproducible, and reliable technique with a union rate of 95% and a low
complication rate.
Potential Pitfalls and Preventative Measures—
Operative Treatment
• Patient selection is critical: Operative intervention is
reserved for young, healthy, physically active patients with
good bone quality and completely displaced fractures (typically with visible deformity) who stand to benefit most from
operative fixation with an intrinsically low complication rate
(Fig. 38-29).
Figure 38-29 The typical clinical deformity following a displaced
left midshaft clavicular fracture with a short, droopy, “ptotic” shoulder with anterior translation and rotation of the distal fragment and
limb.
• Noncompliance and substance abuse (be it alcohol, illicit
drugs, or prescription narcotics) are contraindications to
surgical intervention. No clavicular fixation is strong enough
to withstand an unprotected fall down stairs or a physical
altercation in the immediate postoperative period.49,140,141
The rates of hardware failure, nonunion, and reoperation
are significantly higher in such individuals.
• It is critical to develop, protect, and securely close the
two soft tissue layers. The superficial layer is the skin and
subcutaneous tissue and the deep layer is the deltotrapezial myofascial layer. This helps protect against deep infection and ensures plate coverage if there is a superficial
infection.
• Comminuted fragments, especially the often seen vertically displaced anterior-superior fragment, should be gently “teased” back into position, maintaining its soft tissue
attachments. They can be secured with mini- or small-
fragment screws. Reduction is important but not at the cost
of denuding all of the soft tissue attachment (Fig. 38-30).
• While typically it is not necessary to dissect in the subclavicular space to place protective retractors, it is very important
not to “plunge” into this area with drills or taps. If a lung
injury is suspected intraoperatively, the wound is filled with
saline and the anesthetist performs a Valsalva maneuver. The
presence of air escape indicates pleural injury and should
prompt a chest radiograph and consultation for pleural
drainage (catheter or chest tube).
• A plate of size and strength commensurate with the patients’
size and compliance should be used. In general, 3.5-mm
compression plates or precontoured plates are ideal, especially for larger individuals (>150 lb) or those who will rehabilitate aggressively.
• IM fixation is reserved for simple fracture patterns (transverse and short oblique fractures).
A
B
Figure 38-30 A: Anteroposterior radiograph with 20-degree cephalad tilt demonstrating a completely displaced midshaft clavicle fracture with shortening. There are often vertically oriented fracture
fragments that arise from the anterosuperior surface of the clavicle at the site of displaced midshaft
fractures, giving many fractures a “Z” pattern. If possible, they should be gently teased back into place
and fixed with small or minifragment screws, followed by plate fixation. It is important not to denude
the fragment when attempting to fix it. Reduction is performed by reducing the vertical intercalated
fragment to the distal fragment and securing it with a 2.7-mm lag screw. The distal assembly is then
reduced to the proximal fragment with the aid of two towel clip reduction forceps, followed by plate
fixation with a precontoured plate. B: Postoperative radiograph revealing restoration of length and
anatomic reduction.
• Reduce the risk of refracture by avoiding routine plate
removal: If required, wait a minimum of 2 years following
fracture union before performing hardware removal
(Table 38-8).
Plate or Hook Plate Fixation of Displaced
Fractures of the Lateral Clavicle
Preoperative Planning. A careful examination of the skin
over the lateral clavicle and planned operative site is important.
As with midshaft fractures, temporizing until the soft tissue status improves may be prudent. The major technical challenges
Table 38-8
in these injuries are purchase in the distal fragment and resisting the primary displacing forces, which draw the proximal
fragment superiorly and the distal fragment (secured by the
AC and coracoclavicular ligaments to the coracoid and scapula)
inferiorly.4,23,42,77,83,130 In addition, the cancellous bone of the
distal fragment may be inferior in quality to that of the shaft,
and there may be unrecognized comminution. The treating surgeon should template the fracture preoperatively to determine
the number of screws that will have purchase in the distal fragment. There are a number of precontoured “anatomic” plates
available for this purpose. If it is anticipated that there will be
insufficient distal purchase then alternative fixation strategies
Potential Pitfalls and Prevention—Operative Treatment
Pitfall
Prevention
Poor patient selection
Young, active patients with displaced fractures benefit from primary fixation: Poor bone quality,
medical comorbidities, and noncompliance negatively affect outcome. Substance abusers have
a dramatically higher complication and reoperation rate. Nonoperative care is preferred in these
individuals
Deep wound infection with
exposed hardware
A two layer closure, consisting of a deep myofascial layer and a superficial skin/subcutaneous tissue
layer, will help decrease or eliminate this potential complication
Plate breakage
Use a strong plate consistent with the size, demands, and compliance of the patient. Most precontoured
plates approach the biomechanical strength of a compression plate. Avoid 3.5-mm reconstruction type
plates, especially in larger individuals
Hardware irritation
Use a precontoured plate, especially in an individual of smaller stature
Loss of reduction and
shortening
Avoid unlocked or small diameter intramedullary devices in complex or comminuted fracture patterns.
Obtain lag screw fixation if possible, and a minimum of six cortices on either side of the fracture site,
when using plate and screw fixation
Nonunion after operative
fixation
Avoid excessive soft tissue stripping at the fracture site. Small comminuted fragments should be
teased into the best position possible and secured with screws or suture. Soft tissue attachments
are preserved
need to be considered. These can include augmenting fixation
into the coracoid process or achieving purchase to or under
the acromion. In this instance the use of a hook plate (a precontoured plate with a projection or “hook” that is inserted
posteriorly in the subacromial space) can be extremely useful,
especially with very distal fractures.51,56,98
Patient Positioning. Patients are positioned in the “beachchair” or semisitting position, similar to the position used for
midshaft fractures. A small pad or bump is placed behind the
involved shoulder to elevate it into the surgical field. The head
is placed on a round support and rotated out of the way of the
operative field. Recently, frames and supports designed to give
greater exposure of the shoulder (i.e., for shoulder arthroscopy)
have become popular. This type of operative set-up can also
be used, and may facilitate intraoperative radiography. It is not
usually necessary to free-drape the involved arm, although this
can be done if there is any difficulty anticipated with the reduction (i.e., if the fracture is severely displaced or greater than 2 to
3 weeks old).
Surgical Approach. The surgical approach is similar to
that used for superior plating of the clavicle. A skin incision
placed directly superiorly over the distal clavicle, extending
approximately 1 cm past the AC joint is made. The skin and
subcutaneous layer is developed, and the deltotrapezial myofascial layer is incised directly over the distal clavicle and reflected
anteriorly and posteriorly. The AC joint is identified. This can
be done by inserting an 18-gauge needle into the joint from the
superior aspect, and an arthrotomy can be avoided. It is possible to use an anterior/inferior approach for plate fixation of
distal clavicle fractures although in my experience this involves
a significant amount of detachment of the deltoid and it is not
possible to convert easily to coracoclavicular screw augmentation or hook plate fixation.204
Technique. The fracture site is identified and cleaned of
debris and hematoma. The fracture is reduced and it may be
held with either a K-wire or a lag screw. Elevating the distal
fragment to meet the proximal fragment may aid in reduction. If the main fracture line is in the coronal plane, it may be
possible to lag the fracture from anterior to posterior through
a small anterior stab incision separate from the primary incision. Once the fracture is reduced and provisionally stabilized, the optimal type of plate is chosen. Anatomic plates that
fit the distal clavicle are now available, and placing four bicortical, fully threaded, cancellous screws in the distal fragment
should be the goal (Fig. 38-31). Following fixation, the surgeon
must judge whether the number and quality of distal fragment
screws are sufficient to provide stability until union occurs. If
fixation is judged to be inadequate, there are several options
at this point. Since the primary deforming force at the fracture
site is superior displacement of the proximal fragment, it is possible to augment fixation by securing the proximal fragment to
the coracoid with a longer screw inserted through one of the
plate holes (Fig. 38-32). This screw, typically 30 to 40 mm long,
helps secure the proximal fragment to the coroacoid and prevents this superior displacement. Since there is some intrinsic
motion between the clavicle and the coracoid and scapula, with
time this screw either loosens or it may break, but it will give
6 to 8 weeks of stability to secure fracture healing before doing
so. Alternatively, it may be necessary to augment fixation by
using a hook plate with fixation under the acromion to prevent
superior migration of the proximal fragment. This technique is
selected when there is insufficient bony purchase in the distal
fragment with conventional screws.53,56,98 This may be readily
apparent during preoperative planning (Fig. 38-33), or may
only be realized intraoperatively. The advantage of subacromial
fixation is that conventional plating can be rapidly converted
to this technique intraoperatively. The AC joint is identified,
B
A
C
Figure 38-31 Anteroposterior radiograph of a displaced distal clavicle fracture in a 38-year-old physician following a fall off a mountain bike at high speed (A). Although the fracture was closed, there was
significant bruising and swelling over the shoulder. The degree of displacement of this fracture suggests a high likelihood that of delayed union or nonunion would result with nonoperative treatment.
After the soft tissue swelling had subsided 10 days post injury, operative fixation was performed with
a plate specifically designed for the distal clavicle, allowing for the placement of four screws in the
small distal fragment (B). The fracture healed uneventfully and the patient was able to return to work
within a week of the surgery. A final follow-up radiograph (C) following hardware removal for local soft
tissue irritation, a common problem in this area, shows solid union.
A
B
Figure 38-32 A: It is possible to augment fixation in distal clavicle fractures with poor-quality bone
or a very small distal fragment by placing a screw through the plate into the coracoid process, which
helps resist the forces that displace the fracture (superior displacement of the proximal fragment, inferior displacement of the distal fragment). Since there is 10 to 15 degrees of rotational motion between
the clavicle and the coracoid, this fixation will eventually loosen (as it has in this case) or break (B).
However, typically it provides augmented fixation for 6 to 8 weeks postoperatively, which is usually
enough for the fracture to heal.
and the posterior edge of the distal clavicle is dissected free.
An entrance into the subacromial space is then made with a
pair of heavy curved scissors that will create the path of the
“hook” extension of the plate. It is important that this space is
made posteriorly, so that there will be no impingement of the
rotator cuff in the critically tight anterior subacromial space.
Once this path has been created, the hook is placed in it and
the plate reduced to the shaft of the clavicle. Several different
hook depths and lengths are currently available for this plate,
and trial reductions can be performed to determine the optimal plate type. Alternatively, the plate can be “walked down”
onto the clavicular shaft by sequential placement of the screws
from distal to proximal. This can be a very effective technique
of fracture reduction as this maneuver “levers” the distal fragment to the proximal fragment. On occasion, it may be necessary to contour the shaft of the plate to prevent over-reduction
of the fracture; however, if excessive contouring appears to be
required, a more likely explanation is that the fracture is not
reduced and that there is residual superior angulation. It is
possible to securely repair even very distal fractures (that are
essentially AC joint fracture-dislocations) with this technique.
Minimal, if any, purchase is required in the distal fragment.
B
A
Figure 38-33 A: Anteroposterior radiograph of a very distal clavicle
fracture in a 22-year-old female pedestrian struck by a street car. The
fracture was open with significant soft tissue damage, near transection of the superior deltoid and trapezius, and severe instability of the
shoulder girdle. It can be anticipated that conventional plating may be
inadequate given the small size of the distal fragment and the associated shoulder girdle instability. B: The radiograph following irrigation
and debridement, hook plate fixation, and deltoid/trapezial muscle
repair. Early motion was initiated and an excellent result ensued.
Unlike static fixation across the AC joint which is doomed to
loosening or fatigue failure, hook plate fixation allows some
motion between the bones. A cadaver study revealed that this
technique most closely reflected the biomechanics of the native
AC joint, namely secure enough to provide reliable fixation
yet physiologically flexible.98 Following fixation, the wound is
thoroughly irrigated and a two-layer closure similar to that for
midshaft fractures is performed.
Postoperative Care. The arm is placed in a sling and
the patient is allowed early active motion in the form of pendulum exercises. At 10 to 14 days postoperatively the wound
is checked and the stitches are removed. The sling is then
discarded and full range-of-motion exercises are instituted;
sling protection can be extended if the quality of fixation is
questionable. At 6 to 8 weeks, if radiographs are favorable,
resisted and strengthening exercises are instituted. Return to
full contact or unpredictable sports (i.e., mountain biking)
is usually discouraged until 12 weeks postoperatively. While
hardware removal is typically optional for those with conventional plates, it can be anticipated that a high percentage of
individuals with hook plate fixation will require plate removal
to regain terminal shoulder flexion and abduction (see Hardware Removal). This is usually performed at a minimum of
6 months postoperatively.
Potential Pitfalls and Preventative Measures
• The rate of delayed union and nonunion for completely
displaced distal clavicle fractures treated nonoperatively is
approximately 40%.
• Even minimally displaced fractures may take an excessive
period of time to heal, or may develop a fibrous union.
However, without displacement, they are often not symptomatic enough to warrant surgical intervention.
• The technical challenge faced during operative treatment of
distal clavicle fractures is the fixation of the distal fragment;
the surgeon should be prepared to deal with unexpected
comminution or poor screw purchase in the distal fragment
using anatomic plates, coracoclavicular fixation, or hook
plates.
• Hook plate fixation is an effective alternative to conventional
plate fixation when faced with inadequate distal purchase.
To avoid subacromial impingement, the hook should be
placed posteriorly.
• A high percentage of patients treated with hook plate fixation will require plate removal to regain full range of shoulder motion.
• Rigid transacromial fixation has a high rate of loosening and
fatigue failure due to the intrinsic motion at the AC joint and
is therefore not routinely recommended.
Outcomes. There are a number of studies that define the
outcome of nonoperatively treated fractures of the distal clavicle.23,121,132,153,157 The largest and most comprehensive is by
onoperatively
Robinson et al.153 who examined a cohort of 127 n
treated patients with follow-up of 101 these individuals. The
mean Constant score was 93 points, although this excluded
14 patients (14%) with symptoms severe enough to warrant
delayed surgical intervention. Interestingly, although 21 patients
(21%) had a radiographic nonunion, they were minimally
symptomatic and their outcome scores (Constant, SF-36) were
no different than those in patients with uneventful union. They
concluded that nonoperative treatment achieved good results in
middle-aged and elderly patients, with only a small percentage
(14%) requiring delayed surgery. These results were mirrored by
Rokito et al.157 who compared 14 patients treated operatively for
displaced distal third fractures with 16 nonoperatively treated
patients and found no difference in ASES, Constant, or UCLA
shoulder scores despite the fact that 7 (of 16) patients in the nonoperative group developed a radiographic nonunion. In a systematic review of 425 patients (21 studies), Oh et al.132 described a
nonunion rate of 33% in the 60 patients treated nonoperatively,
but noted that little functional deficit occurred. It is clear from
these studies that although the nonunion rate is relatively high
following the nonoperative treatment of displaced distal third
clavicle fractures, functional deficit (especially in middle-aged
and elderly patients) is minimal and conservative care should,
at present, be considered acceptable in most cases. The same
study by Oh et al. described the outcome following various surgical interventions in 365 patients, and recommended that coracoclavicular fixation was preferred due to its low complication
rate (4.8%) compared to hook plate fixation (40.7%) or K-wire
tension banding (20.0%). IM fixation was also associated with
a low complication rate (2.4%) but the number of cases amenable to this type of fixation is limited. In direct comparisons of
surgical techniques, Tan et al.182 reported equivalent union rates
between hook plate fixation and small fragment T plate fixation
(100%), but that more patients in the hook plate group had
residual shoulder pain that required hardware removal (15/23,
74%) for relief. Klein et al.80 compared early versus late distal
clavicle fracture repair with hook plate fixation (22 patients) and
superior locked plate application (16 patients). They found a
high rate of success (union in 36/38 patients), but that fractures
repaired early (<4 weeks) had better outcomes than the delayed
group (ASES score 78 vs. 65), with a lower complication rate
(7% early vs. 36% delayed). Unfortunately, there are few prospective or randomized trials examining distal clavicle fractures.
In the absence of high-quality evidence, we must rely on available information that would suggest that the majority of these
injuries should be treated nonoperatively initially, especially in
middle-aged or elderly individuals.23,80,121,132,153,169 Operative
intervention is reserved for severely displaced fractures, highdemand patients, or for failures of nonoperative care: In these
cases a variety of methods (hook plate repair, coracoclavicular
fixation, tension-band wiring, etc.) can have a high degree of
success.34,42,53,80,132,182,193,204
Medial Clavicle Fractures
There are very few reports on medial fractures of the clavicle,
a rare entity. Low et al.92 reported the successful treatment
of five cases of completely displaced medial clavicle fractures
using internal fixation (plates and/or screws). They stressed
the importance of preoperative imaging as this area is difficult
to visualize with plain radiographs. In a similar series, this
was emphasized by Oe et al.,129 who reported on 10 cases of
medial clavicular fracture. The medial clavicular epiphysis is
the last long bone epiphysis to fuse in the body, and may persist in patients until 25 to 30 years of age. Therefore, medial
clavicular fractures are often epiphyseal fracture-subluxations
or fracture-dislocations. This can be defined by the preoperative CT scan. There is little in the way of evidence-based
medicine to dictate treatment, with the majority of information on this entity contained in small retrospective case series.
Fractures that are significantly displaced may warrant operative repair, especially if there is posterior displacement. The
primary technical difficulty with these injuries is the fixation
in the medial fragment. The surgical approach is similar to
that made to the shaft. It is important to remember that the
subclavian vessels are in close proximity to the bone medially. Following identification, debridement, and reduction of
the fracture, it can be temporarily held reduced with K-wires.
Definitive plate fixation can then be performed in a variety
of ways. If the medial fragment is large enough, then standard plate and screw fixation can be performed; a plate with
an expanded end section (as in a distal clavicle plate from
the contralateral side) may augment multiple screw purchase. There is a significant expansion of the medial clavicle
(Fig. 38-17) and this allows for placement of longer (22 to
24 mm) cancellous screws. If there is insufficient purchase,
than the plate can be extended across the joint onto the sternum. This construct will eventually loosen due to motion
at the SC joint, but will typically stabilize the fracture long
enough (3 months) for union to occur, at which the point
the plate should be removed. Rarely, fixation with a hook
plate intrasternally or retrosternally may be required. This
is a highly specialized technique and cardiovascular support
should be available in the event of inadvertent injury to the
vascular structures found retrosternally. Fixation of the fracture using smooth wires or pins alone is contraindicated, due
to the potential for migration and visceral injury.
Management of the “Floating Shoulder”
The combination of ipsilateral fractures of the clavicle and
scapular neck has traditionally been called the “floating shoulder,” which has been considered to be an unstable injury that
may require operative fixation.45,145,158,188,191,198,200 In fact, this
injury pattern can be considered to be a subgroup of the “double disruption of the superior shoulder suspensory complex
(SSSC),” a concept introduced by Goss.58,136 This describes the
bone and soft tissue circle, or ring, of the glenoid, coracoid
process, coracoclavicular ligaments, clavicle (especially its
distal part), AC joint, and acromion. This complex is extremely
important biomechanically, as it maintains the anatomic relationship between the upper extremity and the axial skeleton.
The clavicle is the only bony connection between the two,
and the scapula is suspended from it by the coracoclavicular
and AC ligaments. Thus, any injury that disrupts this ring at
two or more locations is considered inherently unstable and
one whose cumulative effect may be greater than the sum of
its individual constituents.203 Long-term functional problems
have been reported following significantly displaced injuries
of this nature, including shoulder weakness and stiffness,
impingement syndrome, neurovascular compression, and
pain.30,43,45,65–67,88,145,158,188,191,198,200 Such injuries have been
considered relative indications for operative intervention
(Fig. 38-9). Combined scapular (or glenoid neck) and clavicle
fractures are the commonest type of double disruptions of
the SSSC, and there remains considerable controversy over
optimal treatment.
A study by Leung and Lam88 described good or excellent
results in 14 of 15 patients with this injury pattern following
fixation of both the clavicle and glenoid fractures. However,
Herscovici et al.66 described excellent results in seven of nine
patients who had their floating shoulder treated with reduction and fixation of the clavicular fracture only. These findings
were confirmed in a study by Rikli et al.150 who performed
clavicle fixation is isolation in 11 patients with combined
clavicle and glenoid fractures. They described an average final
Constant score in the operated shoulders of 95% of the unaffected side. These studies support the concept, in selected
cases, of clavicular fracture reduction and fixation alone. It is
postulated that reduction of the clavicle helps to reduce and
stabilize the glenoid fracture, eliminating the requirement for
operative fixation of the glenoid. This is an important point,
since open reduction and internal fixation of the glenoid can
be a difficult and complex procedure with a high complication rate, especially if the surgeon lacks experience in this
anatomic area.
There are also reports that support nonoperative management of this injury. Ramos et al.145 described the results
of nonoperative treatment in 16 patients with ipsilateral
fractures of the clavicle and glenoid. Eleven patients had a
complete recovery to near-normal status, although one had
a significant malunion of the glenoid neck and three had significant shoulder asymmetry. Edwards et al.43 reported good
results (“pleased” or “satisfied”) in 16 of 20 patients with floating shoulder injuries treated nonoperatively. There were four
patients who were “dissatisfied” or “unhappy” with their outcome. While the outcome assessment of these patients was
suboptimal it would appear that nonoperative treatment may
be considered, especially for minimally displaced fractures.
Interestingly, two of the four patients with poor results had
severely displaced clavicular fractures. In a clinical study,
Williams et al.198 evaluated 9 of 11 patients with a floating
shoulder treated nonoperatively and found five excellent, one
good, and three fair results. They found that the worse clinical
results were strongly associated with 3 cm or more of medial
displacement of the glenoid, and recommended nonoperative
care for lesser amounts of glenoid displacement. Similarly,
van Nort et al.188 performed a questionnaire review including
31 of 35 floating shoulder patients treated nonoperatively and
found that only 3 required late operative reconstruction for
clavicular malunion or nonunion. They found that results in
the nonoperative group (a mean Constant score 76) deteriorated with increasing degrees of glenoid displacement. Interestingly, they also found that three of the four patients who
had their clavicle fracture fixed primarily had a poor result
due to scapular malunion. They believed that this failure
of indirect glenoid reduction following clavicular reduction
and fixation was due to associated ligamentous injuries that
caused a dissociation of the two structures.
There is some limited biomechanical evidence to support the
intuitive clinical finding that increasing degrees of fracture displacement in floating shoulder injuries corresponds to poorer
results if left unreduced. Williams et al.200 performed a cadaver
biomechanical study by establishing a scapular neck fracture
and investigating the effect of an ipsilateral clavicle fracture,
a coracoacromial ligament injury, and an AC ligament injury.
They found that substantial instability (lack of resistance to a
medially directed force) only occurred after associated ligamentous disruption. Although there are limitations to this study
(such as the uniaxial direction of the applied deforming force),
it remains one of the only biomechanical studies on this topic.
Unfortunately, given the variable and sporadic nature of
this injury, there is a paucity of prospective, randomized, or
comparative trials upon which to base treatment recommendations. What is clear is that earlier recommendations for routine
operative fixation for all floating shoulder injuries were too
liberal, and that poor results occur regularly with badly displaced fractures that are treated nonoperatively. In addition,
the aggressiveness of treatment must be commensurate with
the risk of intervention and the expected functional demands
of the patient. Thus, an operative approach may be indicated
in a young healthy individual who works overhead for a living
whereas the same fracture pattern may be treated nonoperatively in an elderly, low-demand patient with multiple medical
comorbidities. Further research in this area may help iden-
Table 38-9
tify currently unknown factors that may predict outcome and
hence guide treatment.79 Currently, standard operative indications include the following.
1. A clavicle fracture that warrants, in isolation, fixation
2. Glenoid displacement of greater than 2.5 to 3 cm
3. Displaced intra-articular glenoid fracture extension
4.Patient-associated indications (i.e., polytrauma with a
requirement for early upper extremity weight bearing)
5.Severe glenoid angulation, retroversion, or anteversion
>40 degrees (Goss Type II)
6. Documented ipsilateral coracoacromial and/or AC ligament
disruption or its equivalent (coracoid fracture, i.e., AC joint
disruption)
If operative intervention is chosen, then anatomic reduction
and internal fixation of the clavicle is typically performed first,
and the shoulder then reimaged. If there is indirect reduction of
the glenoid such that its alignment is within acceptable parameters, then no further intervention is required apart from close
follow-up. If the glenoid remains in an “unacceptable” position,
then fixation of the glenoid neck, typically performed through a
posterior approach, is indicated (see “Fractures of the Scapula,
Chapter 39”). Also, Oh et al. reported the failure of isolated
clavicle fixation in two cases of floating shoulder. If this method
is chosen in this setting, the clavicle may experience greater
loads than with isolated fractures, and the size and length of
the fixation device selected should be commensurate with these
anticipated loads (Table 38-9).131
Management of Expected Adverse Outcomes and Unexpected Complications
Clavicle Fractures
Common Complications
Prevention
Treatment
Infection
Careful technique, short operative times,
prophylactic antibiotics
Irrigation, debridement, local and intravenous antibiotics,
maintain fixation if stable, remove if loose
Nonunion
Primary fixation reduces nonunion rate in
selected cases
Plate or IM pin fixation, add iliac crest bone graft or
osteoinductive bone substitute if atrophic
Malunion
Primary fixation reduces symptomatic malunion rate in selected cases
Corrective osteotomy and plate fixation
Neurovascular injury
Careful technique to avoid iatrogenic injury
(see text)
Treatment of established injury difficult, and usually
expectant. Prevention is the key (see text)
Hardware failure
Use a plate strong enough for size, activity
level, and compliance of patient. Precontoured plates ideal, 3.5-mm reconstruction
plates should be avoided
If fracture site stable and not displaced, it may heal with
observation. Most cases will require revision ORIF
with stronger plate, ± iliac crest bone graft to promote
healing
Hardware prominence
Use a precontoured plate, especially in
smaller individuals
Hardware removal, minimum 2 years post implantation
Refracture
Avoid plate removal, if necessary, for 2 years
after fixation
If minimally displaced, may heal with nonoperative Rx. If
displaced or unstable, repeat ORIF indicated
Scapular winging
Due to residual clavicular malposition (malunion, nonunion). Primary fixation lessens
incidence
Corrective clavicular surgery with plate or IM pin may be
indicated if symptoms severe
Management of Expected Adverse
Outcomes and Unexpected Complications
in Clavicle Fractures
Infection in Clavicle Fractures
Infection had traditionally been one of the most feared complications following fixation of displaced clavicular fractures,
and earlier series described an unacceptably high rate of deep
infection.2,31,54,115 However, significant improvements have
been made in a number of areas that are well recognized to
decrease infection, including perioperative antibiotics, selective
operative timing with regard to soft tissue conditions, better
soft tissue handling, two-layer soft tissue closure, and fixation which is superior biomechanically.15,82,91,117,140,141,162,166 In a
recent meta-analysis that examined operative series from 1975
to 2005, Zlowodzki et al.209 reported a superficial infection rate
of 4.4%, and a deep infection rate of only 2.2%; these figures
are significantly improved compared to earlier studies. When
infection does occur, if it is superficial, then it is usually possible to temporize with local wound care and systemic antibiotics
until fracture union has occurred. At that point, plate removal,
debridement, and thorough irrigation have a high success rate
in infection eradication.
Deep infection with unstable implanted hardware is a more
complex problem. If it appears that there is progressive bone formation, then temporizing until union occurs followed by hardware removal and debridement may be successful. If there is no
obvious progress toward union, then operative intervention is
indicated. Hardware removal followed by radical debridement of
infected bone and dead or devitalized tissue and subsequent irrigation is performed. At this point there are several options. If the
patient is healthy without comorbidities (as is usually the case)
and the infecting organism is a sensitive one, then immediate
reconstruction with plating, bone grafting, and local antibiotics
may be warranted. Alternatively, especially with polymicrobial infections or resistant organisms (i.e., methicillin-resistant
Staphylococcus aureus), local antibiotic impregnated polymethylmethacrylate cement beads, or an antibiotic impregnated bone
substitute are implanted into any residual dead space following
debridement, and systemic antibiotics are administered until
clinical and hematologic markers indicate the infection has been
eradicated. Delayed reconstruction can then be performed. If
there is a significant soft tissue deficiency, then the assistance of
a plastic surgeon who can perform soft tissue coverage, typically
with a rotational pectoralis major flap, is ideal.184,199
recent studies, the exclusion of children (with their inherently
good natural history), changing mechanisms of injury (mountain biking, all-terrain vehicles, parachuting), and the modern
patients’ intolerance of prolonged immobilization. In addition,
several prospective population-based studies have been helpful
in elucidating factors associated with the development of nonunion (Fig. 38-21). Robinson et al.154 identified increasing age,
female sex, fracture displacement, and comminution as risk factors for nonunion in midshaft fractures. Lateral third fractures
had higher nonunion rates as patient age and fracture displacement increased.153 Nowak et al.125 prospectively followed 208
patients with radiographically verified clavicle fractures and,
9 to 10 years post injury, found that 96 (46%) still had sequelae.
They identified no bony contact between the fracture fragments
as the strongest predictor for sequelae. Nonunion occurred in
15 patients (7%). Zlowodzki et al.209 performed a meta-analysis
of all series of displaced midshaft fractures from 1975 to 2005
and identified 22 published manuscripts. They found that, for
the specific entity of completely displaced midshaft fractures
of the clavicle the nonunion rate with nonoperative treatment
was 15.1%, while the nonunion rate following operative treatment was 2.2%. This represents a relative risk reduction (for
nonunion) of 86% (95 CI 71% to 93%). This meta-analysis,
in addition to recent prospective studies examining primary
operative fixation of clavicle fractures, definitively terminated
the postulation that primary fixation was associated with a
higher, not lower, nonunion rate (Table 38-1). This observation
was based on early operative studies with poor patient selection, inadequate fixation (Figs. 38-26 and 38-27) and inferior
soft tissue management. Undoubtedly there are other factors that
contribute to the incidence of nonunion (i.e., associated fractures,
soft tissue interposition, rotation at the fracture site) that have yet
to be clarified.144,178,195,197 Therefore, at the present time, factors
associated with the development of nonunion include complete
fracture displacement (no contact between the main proximal and
distal fragments), shortening of greater than 2 cm, advanced age,
more severe trauma (both in terms of mechanism of injury and
associated fractures), and refracture. Primary operative fixation
however is not associated with a higher nonunion rate.
Nonunion is defined as the lack of radiographic healing at 6 months post injury (Fig. 38-34). While a significant
percentage of distal nonunions may be asymptomatic, especially in the elderly,122 the majority of midshaft nonunions in
young active individuals will be symptomatic enough to require
treatment.5,13,40,50,89,94,110,127,133,163
Nonunion in Clavicle Fractures
Traditionally, the rate of nonunion of the clavicle has been
described as being less than 1% of all fractures. This was based
on two sentinel studies, one by Neer in 1960 that described
3 nonunions in 2235 patients, and one by Rowe in 1968 in which
only 4 of 566 patients developed nonunion after a fracture of the
clavicle.115,160 More recently, however, the nonunion rate following closed treatment of completely displaced midshaft fractures
of the clavicle has been describe as being exponentially higher,
in the 15% to 20% range.15,68,154,209 The reason for this difference
is unclear but probably includes more complete follow-up in
Figure 38-34 An atrophic nonunion of the clavicle. The degree of
bone loss demonstrated in this case suggests that an intercalary
graft may be required to restore length and obtain union.
A variety of methods have been described for the treatment of
an established clavicular nonunion that is symptomatic enough
to warrant operative intervention.11,12,30,32,33,40,50,75,76,94,197,203 Successful nonunion repair usually decreases pain and improves
function. Described methods range from noninvasive techniques such as electrical stimulation and low-intensity ultrasound to minimally invasive techniques (isolated bone grafting,
screw fixation) to formal open reduction and internal fixation
with iliac crest bone grafting. Apart from isolated case reports,
or cases described in larger series of standard treatments, there
is very little objective evidence to support the use of electrical
stimulation or ultrasound in this area.13,30,32 In rare cases where
there is minimal deformity or shortening, a stable hypertrophic
nonunion with good soft tissue coverage and no infection, and
a biologically favorable host (i.e., no smoking or diabetes), such
techniques may occasionally be successful in promoting union.
However, the majority will require mechanical stabilization and
biologic stimulation.
There are two main techniques used to achieve union, plate
fixation, and IM screw or pin fixation. The gold standard treatment against which other methods must be compared is open
reduction and internal fixation with a compression plate and
iliac crest bone graft. Reported success rates with this technique are high if appropriate size and length plates are used.
Manske and Szabo (10/10 healed), Eskola et al. (20/22 healed),
Jupiter and Leffert (16/19 healed), Boyer and Axelrod (7/7
healed), Olsen et al. (16/17 healed), and Bradbury et al. (31/32
healed) all describe excellent results with a low complication
rate.11,12,50,75,94,133 It is important to note that the forces generated by deformity correction and the longer healing time will
mean that the operative construct for a nonunion will require
greater stability for a longer period of time than that for an acute
fracture. Multiple authors stress that short four-hole plates,
weak 1/3 tubular plates, or even 3.5-mm pelvic reconstruction
plates in larger (>200 lb) patients are inadequate for this type
of fixation, and have higher failure rates (Fig. 38-27). A small
fragment compression plate, a precontoured “anatomic” plate
or their equivalent with a minimum of three bicortical screws
in each fragment is recommended (see Authors Preferred Technique, below).11,12,30,32,33,40,50,75,76,94
There are many theoretical advantages to IM pinning with
open bone grafting for the treatment of clavicular nonunions. A
smaller incision with better cosmesis, less soft tissue stripping,
decreased hardware irritation, and easier hardware removal
(often under a local anesthetic) are proposed benefits compared
to plate fixation. There are several reports describing good
results including Boehme et al. (20/21 healed) and Enneking
et al. (13/14 healed).8,48 In the only comparative study of fixation techniques for clavicle nonunion, Wu203 described union
in 9 of 11 patients treated with plate fixation and 16 of 18
of those treated with IM fixation. However, Johnston and
Wilkins reported pin failure in two of four patients treated
in this fashion, and the two failed IM fixations in the series
by Wu both healed with subsequent plate fixation.197,203 In
addition to IM fixation being weaker biomechanically and not
controlling length and rotation as well as a plate, others have
reported difficulty with pin migration and breakage using this
technique.79,93,109,120 A randomized, prospective study comparing plate and IM fixation is required to define their respective
roles in this setting.
Severe bone loss and/or poor bone quality, typically associated with multiple failed operative procedures and infection,
can complicate the reconstruction of recalcitrant clavicular
nonunions. The final treatment option in such circumstances
is clavicular excision, or claviculectomy (either partial or
total).30,32,202 Considering the important strut effect of the clavicle for upper extremity function, and the availability of modern
treatment options, this must be considered a salvage procedure. While reasonable results with retention of a full range
of motion and relief of pain have been described in selected
cases with severe preoperative pathology, a significant decrease
in strength (especially overhead) and a loss of shoulder girdle
stability typically result.
My preferred surgical treatment for a midshaft nonunion
of the clavicle is open reduction and internal fixation with a
precontoured anatomic clavicular plate with the addition of an
iliac crest bone graft or an osteoinductive bone graft substitute.
Patient positioning and draping is similar to that used for the
fixation of acute midshaft fractures, with the exception of having an iliac crest bone graft site prepared (typically the contralateral side) if bone grafting is anticipated (see below). The
surgical approach is similar to that used for a fracture, taking
care to reflect and preserve the myofascial layer for later closure, and the superior surface of the clavicle at the nonunion
site is identified. The ends of the nonunion are identified, and
judicious soft tissue dissection is performed around them to
allow correction of deformity. This usually involves bringing
the distal fragment out to length and translating it superiorly
and posteriorly. The distal fragment is often rotated anteriorly,
and derotating it brings the flat superior surface directly superiorly, facilitating plate placement on the superior surface. The
sclerotic ends of the proximal and distal fragments are identified and a rongeur is used to clear them back to bleeding bone.
It is rarely necessary to resect excessive bone to do this. The
medullary canals are then re-established with a drill to allow
the free egress of osteoprogenitor cells to the nonunion site.
Reduction forceps are then placed on the proximal and distal fragments and a reduction is performed. Remembering that
there is a slight apex superior bow to the native clavicle, excess
superior callus is rongeured away to allow the plate to fit on
the superior surface of the clavicle. Any excess callus removed
in the approach, debridement or deformity correction is saved,
morcellized and inserted into the fracture site at the conclusion of the procedure. If possible, the nonunion is then fixed
with an anterior to posterior small- or minifragment lag screw
(Fig. 38-35). The chance of success of this helpful step can
be increased by recognizing the orientation of the nonunion
line during the approach and debridement. Lag screw fixation
helps hold the reduction while the plate is applied and also
increases the construct stability. If this is not possible than a
2-mm K-wire can be inserted to hold the reduction while a
precontoured clavicle plate is applied to the superior surface.
I typically use an eight-hole plate. This allows for one or even
two empty holes at the nonunion site (often necessary due to
A
B
Figure 38-35 A: An atrophic nonunion 14 months following nonoperative care of a completely displaced
fracture of the clavicle. B: Successful repair with correction of deformity, plate fixation, and addition of
bone morphogenetic protein to the nonunion site. The oblique nature of the nonunion in the coronal plane
facilitated initial fixation with two anterior to posterior lag screws.
bony configuration or lag screw interference) while providing
for three bicortical screws both proximal and distal, which I
consider to be the absolute minimum for fixation. If the nonunion is transverse in nature the first screws on each side are
inserted in a compression mode, and tightened after the provisional K-wire has been removed. Although they are available, I
have not found it routinely necessary to use locking screws or
plates in the clavicle.
If the nonunion is hypertrophic (the minority) then the
morcellized autograft from the local bone is applied to the
nonunion site and a standard closure, as for a fracture case,
is performed. Thorough irrigation and hemostasis is achieved
before closure, and drains are not used.
If the nonunion is atrophic, then either morcellized autograft from the iliac crest or an osteoinductive bone substitute,
such as a bone morphogenic protein, is packed in and around
the nonunion site. Bone substitutes with little osteoinductive
capability, such as calcium phosphates or sulfates, allograft, or
demineralized bone, are to be avoided. A structural or intercalary graft may be required in certain cases where there has
been excessive loss of length or failed previous surgery. Shortening can often be determined preoperatively by comparing the
length of the clavicle radiographically to the measured clinical
length. If there appears to be significant bone loss then an intercalary graft, as per the technique of Jupiter and Ring,76 can be
employed. Postoperative care is similar to that following malunion reconstruction or acute fracture fixation.
Malunion in Clavicle Fractures
Traditionally, it was believed that malunion of the clavicle
(which was ubiquitous with displaced fractures) was of radiographic interest only, and success in the clinical setting was
defined as fracture union. However, more recently, a number
of investigators have described a fairly consistent pattern of
patient symptomatology (with orthopedic, neurologic, “functional,” and cosmetic features) following malunion of displaced
midshaft fractures of the clavicle.7,21,64,74,84,103,136,150 While all of
the factors that contribute to the development of this condition
are unclear; it is typically diagnosed in young, active patients
with significant degrees of shortening at the malunion site
(Fig. 38-36). As could be reasonably anticipated, shortening
of the shoulder girdle (with the typical inferior displacement
and anterior rotation of the distal fragment) results in a variety of biomechanical and anatomic abnormalities that translate
Mean shortening 2.9 cm
A
B
Figure 38-36 Typical clinical features of clavicle malunion (A) with corresponding radiograph (B).
Note the shoulder asymmetry, and the difference in the position of the AC joints (arrows).
Shoulder strength
100
p < 0.05 for all
% of contralateral arm
80
60
40
20
0
Flexion
Abduction
ER
Maximal
Endurance
directly into patient complaints. Orthopedically, shortening of
the muscle-tendon units that traverse the malunion site results
in a sense of weakness and rapid fatigability, with a loss of
endurance strength. It has been previously shown that there are
significant, objective, deficits in maximal strength and endurance (especially of abduction) following the healing of displaced midshaft fractures of the clavicle treated nonoperatively
(Fig. 38-37).99,172 Narrowing and displacement of the thoracic
outlet (the inferior border of which is the clavicle) result in
numbness and paraesthesias, usually in the C8 to T1 nerve root
distribution, exacerbated by provocative overhead activities.
Due to their deformity, patients complain of the appearance
of their shoulder and difficulty with backpacks, hiking packs,
military gear, and shoulder straps: This has been termed a deficit in “functional cosmesis.” Patients with this condition also
complain of upper back pain and periscapular aching, especially with repetitive activity. There is objective evidence that
the displacement of the distal fragment (to which the scapula is
attached) results in malalignment of the scapulothoracic joint
and a form of scapular winging; this produces periscapular
muscle spasm and fatigue pain.64,146
It would appear that the predominant risk factor for the
development of this condition is shortening at the malunion
site. Gossard59 found that shortening of 2 cm or more was associated with poor functional outcome and a high rate of patient
dissatisfaction. McKee et al.103 described a series of 15 patients
with a symptomatic clavicular malunion who had a mean
amount of shortening of 2.9 cm and Bosch et al.9 described
an “extension osteotomy” in 4 patients with shortening of 0.9
to 2.2 cm. In a retrospective study, Eskola et al.49 reported on
83 patients with displaced fractures and found that shortening of 1.2 cm or more was associated with increased pain at
final follow-up. However, this point remains controversial. In
retrospective reviews, Nordqvist et al.124 (225 midshaft clavicle
IR
Figure 38-37 Objectively measured shoulder strength
following nonoperative treatment of a displaced midshaft fracture of the clavicle (maximal, endurance) compared to the normal contralateral side.99 Patients were
a minimum of 14 months post injury, with a mean of
54 months. ER = ecternal rotation; IR = internal rotation.
(Adapted from: McKee MD, Pedersen EM, Jones C, et al.
Deficits following nonoperative treatment of displaced
midshaft clavicular fractures. J Bone Joint Surg AM. 2006;
88(1):35–40, with permission.)
fractures) and Oroko et al.135 (41 midshaft clavicle fractures)
could not demonstrate a relationship between shortening and a
poor outcome. It is probable that length is just one component
of a complex three-dimensional deformity that, combined with
the intrinsic variability of human response to skeletal injury,
explains why some individuals with a malunion function well
and others determinedly seek operative correction. For patients
with a symptomatic malunion who have failed a course of physiotherapy for muscle strengthening, the options are to accept
the disability or have a corrective osteotomy.
Operative intervention is reserved for patients with signs and
symptoms of malunion that are specific to the condition and sufficiently severe to warrant surgery. A vague and generalized ache
about the shoulder (especially in a patient with medical–legal or
compensation issues) and a radiographic malunion is not necessarily an indication for surgery. Patients selected for surgery are
typically young, active, and healthy with good bone stock. The
primary goal of surgery is to correct the deformity, and preoperative planning is important (Fig. 38-38). Careful measurement
both clinically and radiographically defines the degree of length
to be restored. A posteroanterior thorax or chest radiograph that
includes both clavicles has been shown to be a reliable way of
comparing length to the opposite (normal) clavicle.172 Inferior
displacement and anterior rotation of the distal fragment is corrected by having the plate applied to the superior surface flush
both medially and laterally; some contouring of the plate may be
required in the anterosuperior plane as there is a slight caudal
bow to the clavicle.
Patient positioning and the surgical approach are similar to
those used for acute fracture fixation or nonunion repair.102 The
exception is that in certain cases it is prudent to have an iliac
crest bone graft site prepared (see below). In general, it has not
been routinely necessary to insert an intercalary graft to restore
length. It is usually possible to identify the position of the
A
B
C
D
E
F
Figure 38-38 A: Anteroposterior radiograph of a symptomatic clavicle malunion with 2.5 cm of
shortening. B: The corresponding clinical photograph showing the measurement of clavicular length
from the sternal notch to the acromioclavicular joint. C: An intraoperative photograph of the malunion
site demonstrating the typical displacement of the distal fragment with medial, inferior, and anterior
translation. This also demonstrates the abundant local bone which is usually present at the malunion
site. While it is difficult to appreciate, there is anterior rotation of the distal fragment as well. D: An
intraoperative photograph following osteotomy of the malunion, recreating the original fracture line
and rongeuring of excess callus (which will be used to graft the osteotomy site), and distracting the
fragments to their correct length and position. It is typically not necessary to perform an intercalary
bone graft, as there is rarely absolute bone loss, and the original proximal and distal fragments can
be re-established using a combination of a microsagittal saw and osteotomes. E: An intraoperative
photograph following reduction and plate fixation using an anatomic precontoured plate. F: An anteroposterior radiograph following union. The patient’s preoperative symptoms resolved fully.
proximal and distal fragments in most patients. The malunion
site is cleared, and a mark is made in the bone p
roximally and
distally and the length is measured. This enables the surgeon
to calculate how much length has been gained by remeasuring
the distance between the two marks at the conclusion of the
osteotomy. Next, the osteotomy to recreate the original fracture
and proximal and distal fragments is made with a combination
of a microsagittal saw and osteotomes. Care is taken not to
violate the subclavicular space. Following the osteotomy, the
proximal and distal fragments are grasped with a reduction
forceps and gently distracted to the desired position. It is not
routinely necessary to free-drape the arm for traction. For
difficult cases, a minidistractor can be used to correct length
and maintain position while fixation is applied. Care must be
taken not to overdistract the fragments as neurologic injury
may result.151 Depending on the configuration of the bone
ends, after the osteotomy is performed it is often possible
to fashion an interdigitating or step cut contour to improve
intrinsic stability and increase the bony surface area for healing. The medullary canals are re-established with a drill, and
the osteotomy is temporarily secured with a K-wire. It is then
measured for correction of deformity and length. On occasion, an absolute bone deficit may be encountered, such that
reduction of the fragments does not restore length. Options
at this point include accepting some shortening or using an
intercalary graft. This situation can be anticipated preoperatively when the measured clinical shortening (i.e., 3 cm) is
significantly greater than the degree of shortening seen on the
radiograph of the involved clavicle. Once deformity correction is confirmed, definitive fixation is performed. There are
several precontoured “anatomic” plates designed for clavicular
fixation that are ideal for this purpose.70 If a lag screw can
be placed across the osteotomy then three additional screws
both proximally and distally are usually sufficient. If not, four
screws proximally and distally are recommended. Additional
local bone can be morcellized and added to the osteotomy site.
Wound closure and postoperative care are the same as that for
acute fracture fixation or nonunion repair.
Neurovascular Injury in Clavicle Fractures
Despite the proximity of the brachial plexus and subclavian
vessels, neurovascular injury is surprisingly rare, given the
number of severely displaced clavicular shaft fractures seen in
practice.6,10,18,22,34,38,55,69,147,151,161,187 In general, neurovascular
injuries associated with clavicle fractures can be divided into
three groups: Acute injuries, delayed injuries, and iatrogenic
injuries.
Acute Injuries
A careful vascular and neurologic examination is critical with
any clavicular injury, especially those associated with highenergy trauma. If the signs of vascular injury are present, an
angiogram is indicated. In addition to being diagnostic, with
the refinement of interventional techniques such as embolization and stenting, the procedure can also be therapeutic
(Fig. 38-39). While direct impalement of bony fragments can
occur, most neurovascular injuries occur from excessive traction, which in its most severe form is termed scapulothoracic
dissociation. The unique feature of these injuries is that the
associated clavicular fracture is typically distracted, rather
than shortened. This can be a limb or life-threatening injury.
A study by Ebraheim et al. reported 3 deaths in 15 patients,
and Zelle et al. described 3 deaths and 6 amputations in
22 patients in their series from a major European trauma
center.39,207 If limb salvage is to be performed, shoulder girdle
stabilization (typically plate fixation of the clavicle fracture)
is indicated to create an optimal healing environment for the
soft tissue structures.
There have also been case reports of direct neurologic injury
from clavicular fracture fragments: In this situation operative
decompression of the brachial plexus by reduction and fixation
of the clavicle fracture is indicated.6,10,34,55,69,147,161
Delayed Injuries
Delayed injuries tend to occur due to encroachment upon the
thoracic outlet, either from displacement of the borders (i.e.,
from clavicular displacement due to malunion or nonunion),
or encroachment from inferior clavicular callus formation.
This phenomenon can be especially severe in patients with
a concomitant head injury (Fig. 38-40). In the case reports
describing this entity, debridement of local callus with realignment and fixation of the clavicle injury is indicated.26,47,147 The
timing of this intervention is controversial, but in general it
should be performed as promptly as the patient’s general condition allows. The commonest reason for brachial plexus irritation following clavicular fracture is the chronic thoracic outlet
syndrome (TOS) that results from clavicular malunion (see
above). In this setting, operative treatment should be directed
toward re-establishing the preinjury dimensions of the thoracic outlet through a corrective clavicular osteotomy.7,9,21,103
Simply removing the “bump” around the fracture site, or conventional treatments for TOS such as first rib resection have a
high failure rate. This is due to the fact that the fundamental
anatomical problem is the change in position, orientation, and
contour of the thoracic outlet from the displacement of the
distal clavicular segment, rather than from local impingement
of callus or normal structures (i.e., the first rib). Connolly and
Ganjianpour28 reported the case of a patient with TOS following a clavicular malunion that was treated with first rib resection to no avail, while corrective clavicular osteotomy resulted
in prompt resolution of symptoms. McKee et al.103 reported
resolution of TOS symptoms in 16 patients who underwent
corrective clavicular osteotomy to treat a malunion. Chronic
encroachment upon the thoracic outlet leading to TOS is probably the commonest form of neurovascular “injury” following
displaced clavicular fractures.
Iatrogenic Injury
Despite the proximity of the brachial plexus, catastrophic
injury from intraoperative penetration by drills or taps is very
rare. Shackford and Connolly168 reported a case of subclavian
pseudoaneurysm formation with distal embolization from
A
B
C
D
Figure 38-39 A: Anteroposterior radiograph of a morbidly obese 57-year-old nurse who sustained
a severely displaced midshaft fracture of the clavicle in a fall from a standing height. She also had
a partial brachial plexus injury and a partial laceration of the subclavian artery with pseudoaneurysm
formation (arrow), demonstrated on the preoperative angiogram (B). The patient was treated with
immediate stenting of the resultant pseudoaneurysm, followed by plate fixation of the fracture with a
3.5-mm limited contact dynamic compression plate (C). The indications for fixation included reducing
the severe displacement and creating an optimal environment for neurologic and vascular healing.
Uneventful bony and soft tissue healing ensued (D).
screw penetration after plate fixation of a clavicular nonunion,
and Casselman18 described a similar case. Iatrogenic injury can
occur, but is thought to occur in specific situations where distraction can occur. Ring and Holovacs151 described three cases
of brachial plexus palsy after IM fixation of clavicle fractures.
They postulated that the distraction of the fracture site (a prerequisite for reduction and pin insertion) and the delayed presentation (patients were diagnosed several weeks after their
injury) led to a traction injury of the brachial plexus. Fortunately, all three palsies recovered completely with nonoperative
care. It would appear that distraction of a shortened clavicular
fracture, especially one that presents or is treated some weeks
or months following initial injury, creates a risk for a tractiontype injury to the adjacent brachial plexus. Overdistraction at
the fracture site or any violation of the subclavicular space is to
be avoided during operative repair of clavicular injuries. Fortunately, with the information presently available, these injuries
are usually transient in nature and a full recovery with time can
usually be expected.
Hardware Failure in Clavicle Fractures
This complication occurs when the stress placed upon the
implant exceeds its biomechanical strength, typically due to early
overuse from noncompliance, implant/patient size mismatch, or
delayed union or nonunion. This complication can be prevented
by proper surgical technique (i.e., avoiding extensive soft tissue
stripping, stable fixation) and the use of implants commensurate
with the patient’s size and compliance (i.e., avoiding the use of
3.5-mm pelvic reconstruction plates). These technical details are
described in “Plate Fixation” (above). The incidence of hardware
A
C
B
Figure 38-40 The initial anteroposterior radiograph of a
46-year-old polytrauma patient with a head injury demonstrates a displaced clavicle fracture (A). The anteroposterior radiograph at 6 weeks post injury reveals abundant
callus formation around the fracture (B). The patient had
increasing neuralgic pain in the associated upper extremity with progressive objective muscle weakness in the
hand. The involved hand (C, arrow) had signs of venous
obstruction with swelling, loss of skin wrinkle definition, and violaceous discoloration. A CT scan confirmed
obstruction of the thoracic outlet due to a combination
of severe shortening and displacement of the fracture
site and exuberant callus formation (D). This patient was
treated with operative corrective of the deformity, complete resection of the supraclavicular callus, and judicious
resection of infraclavicular callus followed by plate fixation.
A prompt resolution of symptoms, complete neurologic
recovery, and uncomplicated fracture union ensued (E).
failure should decrease as improved implants (in terms of
strength, materials and contour) become available.
Hardware Prominence in Clavicle Fractures
Local irritation from prominent hardware remains a clinical
concern following the operative treatment of clavicle fractures,
given its relatively scanty soft tissue coverage. The incidence
of hardware removal ranges from less than 5% to essentially
100% in some series (i.e., where pin removal is a planned second stage of the procedure). The use of bulky, straight plates in
thin or small individuals is associated with greater degrees of
local irritation. It is probable that the incidence of plate removal
can be minimized by using a precontoured plate. In addition,
proponents of anterior-inferior plating suggest that this technique results in less prominence and irritation, although this
remains to be proven. With regard to plate fixation in general,
it is clear that routine plate removal is not recommended or
D
E
desirable in the majority of cases following ORIF. Asymptomatic plates can and should be left in situ with a low rate of longterm complications, similar to retained plates in other areas in
the upper extremity such as the forearm or humerus. Plates that
provoke local irritation sufficient to warrant operative intervention should be removed only after 2 years have elapsed since
fracture union to minimize the risk of refracture (as in the forearm). Collision athletes should have their plates removed at the
end of a season to further decrease refracture risk. Anecdotally,
many patients who have symptomatology at 1 year and desire
plate removal find that by 2 years post injury the symptoms
have ameliorated to the point where intervention is not desired.
In general, small diameter or unlocked IM devices are removed
because of the high degree of backing out and prominence as
the fracture consolidates. This can be performed earlier than
plate removal due to the intrinsic differences in healing patterns
between these implants. It is unclear if more modern lockable
IM devices will have a lower removal rate, although that is certainly one of their theoretical advantages.
Refracture in Clavicle Fractures
True refracture after healing of a fracture of a clavicle is surprisingly rare. It has been my experience that many individuals
who have claimed to have sustained multiple fractures of the
clavicle have in fact a nonunion of their initial fracture that has
never healed completely. Recurrent episodes of trauma prompt
medical attention, and new radiographs are misinterpreted as
showing a “refracture.” The few cases that are reported describe
a higher nonunion rate following “refracture”. Regardless of the
exact etiology, patients with this condition should be counseled
about the high rate of unsatisfactory outcome and that they
may benefit from fixation.15,30,32
Given the increasing popularity of operative fixation of displaced clavicle fractures, and the patient population involved,
it is not surprising that fractures at the end of a plate used for
fixation of a prior clavicle fracture are being encountered. This
typically happens from recurrent high-energy trauma. Large
prospective series are not available and recommendations are
based on only a few cases. In general, a fracture in the upper
extremity that occurs at the end of a stable implanted diaphyseal plate has a poor natural history and a high chance of
delayed union or nonunion. It is my experience that these fractures, if displaced, generally require repeat fixation. Attempts
should be made to fix the fracture and span the area of bone
previously repaired (Fig. 38-41). If the fracture is minimally
displaced, a trial of nonoperative care with the arm at rest in a
sling is reasonable.
Scapular Winging in Clavicle Fractures
Scapular winging has a variety of etiologies, and there are a
number of case reports describing this condition following
the nonoperative treatment of displaced midshaft fractures of
the clavicle. Rasyid et al.146 reported two cases of winging of the
scapula, one from a “neglected” fracture of the clavicle with 2-cm
of shortening. A recent paper by Ristevski et al.152 examined
A
18 patients with symptomatic clavicular malunion and evidence of scapular winging clinically (Fig. 38-42) The authors
performed CT scanning of all patients and were the first to be
able to describe and quantify a consistent pattern of scapular
malalignment. The patients had a mean clavicular shortening of
2.1 cm, and the acromion was found to translate with the distal clavicular fragment medially, inferiorly, and anteriorly. The
average acromial translation was 2.4 cm. The posterior aspects
of the scapula were found to translate less (superior angle,
1 cm; inferior angle, 0.6 cm). This gives the typical clinical
appearance of a shortened, protracted shoulder seen in clavicle
malunion or nonunion (Fig. 38-43). The main function of the
clavicle is as a strut to position the scapula in its correct location. Since the scapula is the base upon which the arm and
hand function, a malunion or nonunion of the clavicle alters
the position of the scapula such that the mechanical advantage
of the associated muscles is affected. The negative mechanical effects of this shoulder position are well documented, with
a mean decrease in rotational strength ranging from 13% to
24% in one study.175 While it is difficult to prove a direct link
between scapular malalignment and poor outcome following
nonoperative treatment of displaced fractures of the clavicle,
it is hypothesized that the early fatigability, weakness, spasm,
and pain from the shoulder girdle musculature may be related
to scapular malposition.
While the relationship between scapular malalignment
and outcome may be unclear at present it may help explain
some of the variability in outcome seen with clavicle fractures.
While we use the measurement of clavicular shortening as a
surrogate for overall displacement, it is clear that significant
degrees of scapular malposition (and inherent symptomatology) can result from translation and rotation of the distal
clavicular fragment and scapula with minimal “shortening”
seen on standard radiographs. Prospective studies to analyze
the degree of scapular malalignment in the acute setting of a
clavicle fracture would help determine whether a correlation
exists between this malalignment and outcome, and could aid
in surgical decision making.
B
Figure 38-41 A 40-year-old professional motorcycle racer had plate fixation of a midshaft clavicle
nonunion that developed following a displaced midshaft fracture. The nonunion healed uneventfully,
but 2 years later, following another high-velocity crash, he sustained a fracture at the lateral end of
the plate (A). This fracture also developed into a nonunion, and required repeat fixation with a longer
plate (B). This is a potential risk for individuals with plate fixation of the clavicle who continue to
participate in high-risk activities.
A
B
C
Figure 38-42 Artists rendition of typical deformity and resulting
scapular malposition following clavicular malunion or nonunion. It is
this malposition that results in clinical evidence of scapular winging
and resultant symptomatology. A: Anterior view of inferior scapular
translation. B: Side view demonstrating scapular protraction. C: Superior view showing anterior translation. D: Posterior view demonstrating inferior scapular translation. (Adapted from: Ristevski B, Hall JA,
Pearce D, et al. The radiographic quantification of scapular malalignment after malunion of displaced clavicular shaft fractures. J Shoulder Elbow Surg. 2013;22(2):240–246, with permission.)
D
Figure 38-43 A clinical photograph of scapular winging of the left
shoulder associated with a midshaft clavicle malunion with 3-cm shortening. There is a characteristic protrusion of the inferior angle of the
scapula, produced as the scapula rotates and translates anteriorly with
the distal clavicular fragment.
1468
Midshaft clavicle
fracture
Undisplaced, or
minimal
displacement
Displaced*
High demand
<60 yrs of age
>16 yrs of age
Active,
healthy patient
Comminuted,
segmental, or
complex fracture
Transverse or short
oblique fracture
Precontoured plate
Low demand
>60 yrs of age
<16 yrs of age
Medical co-morbidities
substance abuse
IM Pin
Sling, ROM when
comfortable
Sling, ROM when
comfortable
Precontoured plate
*Displaced: 1.5-cm shortening, obvious clinical deformity, associated rotational deformity, and scapular winging.
Figure 38-44 Clavicle: Author’s Preferred Treatment.
Author’s Preferred Method
for Clavicle Fractures
of Treatment
The above figure describes the author’s preferred method of
treatment of clavicle fractures (Fig. 38-44).
Controversies and Future Directions
in Clavicle Fractures
Patient Selection for Operative Intervention
for Clavicle Fractures
Recent studies have made it clear that there is a subset of
patients, especially those with shortened, displaced fractures
who would benefit from primary operative repair of clavicular injuries.15,68,154 However, these early interventions are not
without risk and consume significant health care resources. In
addition, there are patients who would seem to have prognostic factors for a poor outcome following a clavicular fracture
(i.e., displacement of greater than 2 cm) and yet heal promptly
(albeit in a “displaced” position) with minimal symptomatology and full function of the involved shoulder. While some
of the explanation for this is undoubtedly due to the inherent
variability of patient response to musculoskeletal injury, there
may be other factors that are not clearly define or understood
at present. For example, while most studies use the magnitude
of shortening when defining fracture displacement, this alone is
a relatively simplistic linear measurement of what is typically a
complex three-dimensional deformity. Since most of the major
muscle groups of the shoulder have a scapular origin it may be
that the final position of the scapula relative to the trunk and
upper arm (which is difficult to measure, see Scapular Winging) may be the dominant factor in determining prognosis.64
While the prognostic index published by Robinson et al.154 is a
dramatic advance in providing objective information and facilitating our ability to predict outcome, there are still significant
improvements that can be made so that intervention can be
selected specifically for those patients for whom the risk/benefit
ratio of surgery is favorable. It is also clear that patient noncompliance, especially when associated with substance abuse, is a
clear contraindication for surgery. Bostman et al.,10 in a study
of 103 consecutive adults with acute, displaced midshaft fractures of the clavicle, stated that “Patient noncompliance with
the postoperative regimen could be suspected to have a major
cause of the failures.”
Method of Fixation for Clavicle Fractures
There has been increasing interest in direct comparative studies examining the outcome of various IM nails versus plates
for displaced fractures of the midshaft clavicle. This includes
two prospective randomized trials, two retrospective comparative studies, and one meta-analysis.25,37,52,81,86 In a prospective
study, Ferran et al.52 randomized 32 patients to Rockwood pin
fixation (17 patients) or small fragment compression plate fixation (15 patients) and found 100% union in both groups with
no difference in Constant scores at final follow-up (pin group
mean score 92, plate group mean score 89, p = 0.365). They
concluded that both techniques were effective, although there
was a high rate of hardware removal (100% of pins and 53%
of plates), and their study could be criticized for its small numbers. Lee et al. performed a similar study (Knowles pins vs. plate
fixation) in 62 patients over the age of 50 years, and although
there was no difference in functional outcome (Constant score
85 in the pin group vs. 84 in the plate group), there were fewer
complications, decreased OR time and hospital stays, and less
symptomatic hardware in the pin group. Kleweno et al.81 performed a retrospective review of 40 patients treated operatively
for completely displaced, simple pattern (transverse or wedge
type) midshaft fractures of the clavicle and were able to follow up 18 treated with Rockwood pins and 14 treated with
plates. They reported five complications in the pin group and
five adverse events in the plate group with no documented differences in functional outcome, and concluded that pinning
was a suitable option for simple pattern fractures. Chen et al.25
reported on a 141 patients treated with flexible titanium elastic
nails (TENs, 57 patients) or small fragment pelvic reconstruction plates (plate, 84 patients). They reported no significant difference between the two groups with regard to complications,
although the TEN group had shorter operative times and less
blood loss than the plate group, with better DASH scores (mean
8 point difference) early at 6 months. There was no difference at
2 years, with excellent DASH and Constant scores (mean 96 in
both groups) in both groups. They concluded that TEN fixation was an excellent option but it should be stressed that they
restricted its use to simple fracture patterns in a group of patients
typically much smaller than the North American population. At
the present time, TEN nailing has not been widely reported in
the North American literature, and caution must be used in its
application. Duan et al.37 conducted a meta-analysis of these
studies and concluded that the evidence failed to show a difference in treatment effects between plating and IM pin fixation,
although there were more hardware complications with plating.
They also stress that more high-quality, multicenter comparative
studies are required for firm conclusions to be made.
Timing of Surgical Intervention for
Clavicle Fractures
Conventional thinking has been that nonoperative treatment
is appropriate for most if not all fractures of the clavicle, even
severely displaced injuries, with the assumption that the reconstructive repair of those that developed nonunion or symptomatic malunion would produce results similar to that of primary
operative repair of the original fracture. Since these injuries are
nonarticular, and the reported “success” rate of reconstruction
is high, this approach seems to have inherent merit. However,
there is recent evidence that while operative reconstruction of
malunion or nonunion is a reliable procedure, with increas-
ing refinement of outcome measures and objective muscle
strength testing it is apparent that there are residual deficits
compared to what primary operative repair can provide. Potter
et al.143 examined a cohort of 15 patients who had undergone
late reconstruction with plate fixation for clavicular nonunion
or malunion (“delayed group”) at a mean of 63 months post
injury and compared them to a similar cohort of 15 patients
who had primary plate fixation of a clavicle fracture a mean of
0.5 months after injury (“acute group”). The groups were similar in age, sex, original fracture characteristics, and mechanism
of injury. They found that there were subtle but significant
differences between the two groups with regard to shoulder
scores (Constant score 89 in the delayed group, and 95 in
the acute group, p = 0.02), and the delayed group demonstrated inferior endurance strength in the involved shoulder.
They concluded that while late reconstruction is a reliable and
reproducible procedure, there were subtle decreases in outcome compared to acute fixation, and they recommended that
this information be used in decision making when counseling patients with displaced midshaft fractures of the clavicle.
Rosenberg et al.158 reported similar results in a group of 13
patients who had late reconstruction for clavicular malunion
and nonunion. While osseous healing occurred in all cases
there was a mean 20-point deficit in Constant score (61 vs.
81, p = 0.01) in the affected shoulders. The authors felt that
“lasting functional impairment” was possible even with objective success. With time, substantial adaptive changes (muscle
atrophy, soft tissue contracture, bone loss) occur in the shoulder girdle of individuals with clavicular malunion or nonunion
that will compromise the outcome of late reconstructive surgery to some degree when compared to the results of primary
fixation. This is useful, objective information to use when
evaluating the risk/benefit ratio of early operative intervention.
Clavicle Fracture Summary
There are now available a number of high-quality, prospective,
and randomized studies that define the role of primary operative
intervention for fractures of the clavicle. While the majority of
clavicle fractures will heal with nonoperative care (a simple sling
is probably best) and a prompt return of near normal shoulder
function can be expected, there is a subset of fractures that benefit from operative intervention. Poor prognostic signs that have
been defined include increasing fracture displacement (especially
shortening), fracture comminution, and an increasing number of
fracture fragments, especially in older patients. A meta-analysis
of randomized clinical trials comparing operative versus nonoperative treatment for displaced midshaft fractures of the clavicle
has revealed some consistent findings: Plate fixation is a reliable
technique with a low nonunion rate, nonoperative treatment
results in a nonunion rate of 20% to 25%, malunion remains a
problem in nonoperatively treated patients, and primary fixation
results in modest (10 points on a 100-point scale) improvement,
in general, in the operative group. Anterior-inferior plate placement may have some advantages over superior plate positioning
with respect to soft tissue irritation. IM fixation has many theoretical advantages and a high rate of success in skilled hands,
although results in the literature remain inconsistent. Although
the difference is small, primary plate fixation provides significantly improved results in terms of strength and shoulder scores
compared to delayed reconstruction. Malunion of the clavicle is
a definite clinical entity that benefits from corrective osteotomy,
which can usually be performed without a bone graft. Scapular winging from scapular malposition is a consistent, definable,
and common finding following the failure of primary nonoperative care and the development of a nonunion or a symptomatic
malunion, and it can lead to significant patient symptomatology.
Future studies that are randomized, prospective, and comparative are needed to refine the indications for primary operative
repair, investigate the role that scapular malposition plays, and
determine the ideal method of fixation.
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