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A c u t e M i d s h a f t
C l a v i c u l a r F r a c t u r e
A b s t r a c t
Clavicular fractures represent 2.6% to 5% of all fractures, and
m iddle third fractures account for 69% to 82% of fractures of th e
clavicle. The junction of the out er and m iddle third is the th innest
part of the bone and is the only area not protected by or reinforced
w ith muscle and l igamento us at t achments. These anato m ic
features make it prone to fracture, particularly w ith a fall on th e
point of the shoulder, w hich results in an axial load to t he clavicle.
Optimal treatment of nondisplaced or minimally displaced
midshaft fracture is w ith a sling or figure-of-8 dressing; the
nonunion rate is very low . How ever, w hen m idshaft cla vicular
fractures are com pletely displaced or comm inuted, and w hen th ey
occur in elderly patients or fema les, the risk of nonunion , cosmetic
deformit y, and poor outcom e may be markedly higher. Thus, some
surgeons propose surgical st abilizat ion of a com plex m idshaft
clavicular fracture w ith either plate-and-screw fixation or
intram edullary devices. Further random ized, prospective t rials are
needed to provide bett er data on w hich t o base treatm ent decisions.
Th e c l a v i c l e i s o n e o f th e mo s tcomm only fractured bones; cla-vicular fractures represent 2.6% to
5% of all fractures.1,2 The incidence
of clavicular fractu re in adults is es-
tim at ed to be 71 in 100,000 for men
and 30 in 100,000 for w omen, w ith
the incidence of m idshaft fractures
decreasing w ith increasing age. Mid-
shaft fractures account for 69% to
82% o f a l l c l a v ic u l a r f ra c tu res.1-5
Midshaft fractures are m ore comm on
in children and youn g adults. The in-
cidence of high-energy clavicular
f ra c tu r es w i th c o mmi n u ti o n , d i s-
placement, an d shortening appears to
be increasing.2
Tr a di t i o n a ll y , f ra c tu r es o f th e
c la v ic le h a v e b ee n t r ea t e d w i t h
c l os ed r ed u cti o n . M o r e th a n 200
meth o d s h a v e b een d es c ri b ed f o r
closed reduction, y et a classic t ext-
book recognizes that reduction is
practically impossible to maintain,
and a certain am ount of deformit y is
to be expected, generally compatible
w ith satisfactory return of function
in the shoulder. 6 T h e s a me tex t-
b o ok s ta tes th a t ev en c o mp letel y
displaced fractures generally do
w ell w ith non-operative ma nage-
ment. . . . 6
How ever, most previous studies
describing the results of clavicular
fracture h ave used surgeon-based or
radiographic outcome m easures th at
equat e union w ith success. Very few
studies on clavicular fracture have
been published using patient-based
outcomes such as the Medical Out-
comes Study 36-Item Short Form
(Quality Metric, Lincoln, RI) or t he
Di s a b i l i t i es o f th e Ar m, S h o u l d er
and H and q uestionnaire (D ASH; In-
stit ute for Work and Healt h, Toron-
ta, C anada, and the American Acad-
Kyle J. Jeray, M D
Dr. Jeray is Program Director,
Orthopaedic Surgery Education,
Greenville Hospital System, Greenville,
SC.
Neither Dr. Jeray nor the department
with which he is affiliated has received
anything of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Jeray, Greenville
Hospital System, University Medical
Center, Orthopaedic Surgery Education,
701 G rove Road, 2nd Floor ERC
Support Tower, Greenville, SC 296 05.
J Am Acad O rthop Surg2007;15:239-
248
Copyright 20 07 by the American
Academy of Orthopaedic Surgeons.
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em y o f O rt h opa edi c Su rgeo ns
[AAOS]). Recent studies have indi-
cated that outcomes are not alw ays
e xc el le nt , pa r t ic u la rl y i n h i gh -energy fractures.7-11 These studies
r a is e th e q u est i o n w h eth er a c u te
midsha ft clavicular fractures should
be internally fixed.
A n a to m y a n d F u n c t io n
The clavicle is t he first bone t o ossify
in t he f if th w eek of fetal l i fe, and it
is the only lon g bone to ossify by in-
tramem branous ossif ication. Initial
grow th up to age 5 years arises fromthe ossification center in the central
portion of the clavicle, w ith contin-
ued grow th occurring at th e epiphy-
seal plates at the m edial and lat eral
ends of the bone. The m edial grow th
plate, typically t he only plate seen ra-
d i o gr a p h i c a l l y , a c c o u n ts f o r u p to
80% of longitudinal growt h. The me-
dial grow th plate is the last physis to
close, generally at age 22 to 25 years.
The clavicle is subcutaneous, w ith
only the supraclavicular nerves cross-
ing th e bone. How ever, several fascial
layers and muscles attach to the bone
itself and help to create the predict-able deformit y seen w ith fractures.
The proximal fragment is pulled su-
periorly and posteriorly by the ster-
nocleidomastoid muscle. The distal
segment sags forw ard and rotates in-
feriorly because of t he w eight of th e
upper extremity and, to a lesser ex-
tent, t he pull of the pectoralis mus-
cle on the hum erus.
Th e c l a v i cl e i s a s tr u t th a t c o n -
n ec t s t h e u ppe r e xt r em i t y t o t h e
trunk and is the only l ink to the ax-ial skeleton . It also provides protec-
t i o n f o r th e a d ja c en t a x i ll a r y a n d
subclavicular neurovascular struc-
tures and the apex of the lungs. Lat-
erally, the clavicle is secured by the
acromioclavicular (AC) and coraco-
clavicular ligam ents w here it articu-
lates w ith the acromion. Medially,
the clavicle articulates w ith t he ster-
num and is strongly secured to the
first rib by the intra-articular ster-
noclavicular (SC)joint cartilage, the
oblique fibers of the costoclavicular
ligaments, and the subclavius mus-
c l e. Th e c l a v ic l e i s S -s h a ped a n d
double-curved, concave ventrally on
its lateral half and convex ventrally
o n i ts m edi al h alf. Th e c ro ss-sectional geometry changes from flat
laterally to tubular centrally to trian-
gular m edially (Figure 1).
The shape of the clavicle an d the
l iga m en t ou s a n d m u sc le a t t a ch -
men ts p l a y a r o l e i n f r a c tu r e p a t-
terns. The junct ion of th e outer and
middle thirds is the thinnest part of
the bone and is t he only area not pro-
tect ed by or reinforced w ith m uscle
and ligam entous atta chment s, there-
by rendering it prone to fract ure, par-
ticularly w ith axial loading.12 This
h el ps t o e xpl a in w h y t h e m i d dl e
t h i r d i s t h e m o s t c o m m o n s i t e o f
fracture, occurring at the junction
w here the bone geometry changes
from flat to t ubular.
The mot ion of the clavicle is ulti-
ma t ely l i n ked to th e s u rr ou n d in g
m otion of th e scapula because of the
anatom ic attachm ent to the scapula
through the AC joint and t o the ster-
num t hrough the SC joint. Motion of
the clavicle occurs w ith elevationand abduction of the arm. D uring el-
evation, w ith respect to the SC joint,
the clavicle undergoes elevation of
11 to 15, retraction of 15 to 29,
and posterior long-axis rotation of
15 to 31, w ith the m agnitude and
p la n es v a r y i n g a mo n g s u bjects .13
Other studies suggest that rotation
ma y be as much as 50 and elevation
as high as 30. 14 More importantly,
clavicle rotation is relatively small
until hum eral elevation exceeds 90;
thus, early rehabilitation t hat av oids
over-the-shoulder activity w ill sig-
nificantly l imit rotational forces at
the site of a clavicular fracture.15
M e c h a n is m o f I n ju r y
M i ds h af t c la v ic ul a r f ra c t u re s
h a v e tr a d i t i o n a l l y b een th o u gh t to
occur from a fall on an outstretched
h a n d . H o w ev er , a b i omec h a n i ca l
analysis of t he forces demonstrated
Figure1
Anatomy and cross-sectional geometry of the clavicle. (Adapted with permissionfrom Craig EV: Fractures of the shoulder: Part II. Fractures of the clavicle, inRockwood CA, Green DP, Bucholz RW [eds]: Rockwood and Greens Fracturesin Adults, ed 3. Philadelphia, PA: JB Lippincott, 1991, vol 1, pp 928-990.)
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that a direct injury from the shoul-
der (rather tha n the hand) that pro-
d uc es a f orc e e q u al t o t h e b od y
w eigh t w o u l d exc eed th e c ri t i c a l
b u c kl i n g l o a d a n d r es u l t i n a mi d -
shaft clavicular fracture.16 Several
studies have demonstrated that a di-rect fall or blow ont o the point of the
shoulder accounts for 85%to 94%of
th e injuries.2,3,5,16,17 When the forces
are transmitted through the arm, as
w ith a fall on an out stretched hand,
the forces are not directly delivered
to t he clavicle; thus, they are unlike-
l y to p r o d u c e a mi d s h a f t f r a c tu r e.
This m echanism account s for 2% to
5%of all midshaft fractures. A direct
blow t o the clavicle, such as from a
hockey st ick or a seat belt shoulder-
strap injury, also may produce a frac-
tu re and ac count s for 10% to 13% of
m i d sh a ft f ra c t u re s i n m o s t s t u d-
ies.16 Although rare, direct force on
the t op of the shoulder ma y drive the
mi d s h a ft c l a v ic l e a ga i n st th e f i rs t
rib, resulting in a fracture.
C l a s s i f i c a t i o n
C l a v i c u l a r f ra c tu res h a v e b een
classified by Allma n 18 into t hree ana-
tom ic regions, wit h the middle third
being group I. The classification sys-tem of the Orthopaedic Trauma As-
sociation separates diaphyseal cla-
v i c u l a r f r a c tu r es i n to th r ee ty p es :
06-A (sim ple), 06-B (w edge) an d 06-C
(complex).19 Each type is further bro-
ken dow n in to th ree groups.
The system developed by Robin-
so n 3 divides midshaft clavicular frac-
tures into type 2A (cortical align-
m ent fract ure)an d ty pe 2B (displaced
fracture). In an effort to provide di-
rection for treatm ent and prognosis,
Robinson further divides these into
subgroup types 2A1 (nondisplaced),
2A2 (angulated), 2B1 (simple or
w edge comm inut ed), and 2B2 (isolat -
ed or comminuted segmental) (Fig-
ure 2). Robinsons classification sys-
tem h a s d emo n s tr a ted s a t i s fa c to ry
levels of interobserver and intraob-
server reliability and reproducibility.
H o w e ve r, a d di t i on a l s t u di es a re
needed t o determine w hether this
classif ication system w ill reliablypr ed ic t t r ea t m e n t a n d f un c t io n a l
outcomes.
C l in i c a l E v a l u a tio n
O f ten w i th c l a v ic u l a r f ra c tu re, a
bruise or abrasion is seen, eith er over
th e point of the shoulder (indicat ing
a direct blow ) or over t he midline
(suggesting a seat belt sh oulder-strap
injury). The shoulder has a droop,
the scapula appears slightly internal-
ly rotated, and the shoulder appears
s h o rten ed r el a t i v e to th e o pp os i te
side. This characteristic deformity is
produced by the pull of m uscles at -
ta c h ed to th e c l a v i c l e . I mmed i a te
sw elling ma y obscure the deformity
of t he bone, w hich w il l be seen on
r a di o gr a ph s i f th e f ra c tu r e i s d i s-
placed. Palpation over the area w ill
reveal tenderness, and gentle manip-
u l a t i o n ma y p ro d uc e c r epi tu s a n d
mo ti o n a t th e f r a c tu re s i te. A n o n -d i sp la c ed o r mi n i ma l l y d i sp la c ed
fracture ma y be suspected w hen pain
and/or skin ch anges are present over
the clavicle.
Bec a u se mi d d le th i r d f ra c tu r es
frequently occur w ith high-energy
t r a um a , a c om p le t e e xa m i n a t i on
should be performed t o a void m iss-
ing associat ed injuries. Skeleta l inju-
ries include fracture-dislocation s of
the SC and AC joints or, in younger
patient s, physeal injuries. C hest w all
trauma may result in high rib frac-
tures, scapular neck and body frac-
tu r es , a n d a p n eu mo th o r a x o r h e-
mothorax. Although acute brachial
plexus injury is rare, the ulnar nerve
is at h ighest risk because of its loca-
tion adjacent to t he middle third of
the clavicle. When a nerve injury is
identif ied, a thorough vascular ex-
a m i na t io n a n d ev a lu a t io n o f t h e
scapulothoracic articulation should
Figure2
Robinsons classification system for midshaft clavicular fractures. (Reproduced withpermission from Robinson CM: Fractures of the clavicle in the adult: Epidemiologyand classification.J Bone Joint Surg B r1998;80:476-484.)
Kyle J. Jeray, MD
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be undertaken to avoid missing an
associated injury. Penetrating trau-
ma is typically the cause of vascular
injury. How ever, vascular injury canoccur from blunt trauma, resulting
in spasm or thrombosis of the sub-
clavian vessels.
R a d i o g r a p h i cE v a l u a t i o n
To determine the fracture pattern
a n d d i sp la c emen t, r a di o gr a ph s i n
tw o p ro ject i o n s a r e n ecess a ry . A
standa rd anteroposterior view should
be accompanied by a 45 cephalic tilt
view (Figure 3). The sh oulder girdle
a n d u ppe r l u ng f ie ld s s h ou l d b e
carefully assessed to avoid m issing
associat ed fract ures or a subtle pneu-
m otho rax. The radiographic evalua-
tion should assess the fracture pat-
t e rn , p res en c e o f c om m i n ut i o n,
displacement , and shortening or dis-
traction of t he fracture.
Several radiographic findings ca n
help guide the surgeons choice of
tr ea tm en t . D i s pl a c emen t w i th o u t
b on y c on t a c t , e spe ci a ll y w i t h a
transversely displaced fragment, is a
r is k f a c to r s tr o n gl y p redi c t i v e o flong-term sequelae.7 Additional ra-
diographic parameters predictive of
increased risk for pain, limit at ion of
m o t i o n, o r n o n un i on i n cl u de a n
overall displacement of the fracture
ends >1.5 cm. This displacement in-
c l u des s h o rten i n g, d i str a c t i on , o r
separation of the ends in the an teri-
or or posterior direction in an y radio-
graphic view.20-22 A second view, at
l ea s t 45 o f f p la n e f r o m th e f i rs t ,
h elp s t o f u rth er d el i n ea te th e d i s-
placement . Oft en, the displacement
is difficult t o assess on a single radio-
graph. For exam ple, as seen in Figure
3, both view s reveal distraction at
the fracture site of at least 1.5 cm.
M a n a g e m e n t
I n d i c a t i o n s
The primary goal in treatm ent is
to restore shoulder function to the
preinjury level. By allow ing the clav-
icle to heal w ith m inimal deformity,
loss of mot ion and pain can be min-
imized. Indications for nonsurgicaltreatm ent include a nondisplaced or
minimally displaced midshaft clav-
icular fracture. Indications for surgi-
cal treatm ent include open fractures
and fractures associated w ith skin
compromise or w ith neurologic or
vascular in jury.
Relative surgical indications in-
clude certain multiple-system trau-
matized patients, a floating shoulder,
and a painful malunion or nonunion.
More recently, relative indications
for surgical treatm ent ha ve been ex-
panded to include high-energy closed
f ra c t u re s w i t h >15 t o 20 m m o f
shortening, fractures w ith complete
d i sp la c emen t, a n d f ra c tu r es w i th
comminution.23-26 Although t hese re-
cently adopted indications ha ve re-
ceived att ention in t he current lit er-
ature, articles dating as far back as
the 1960s have described similar sur-
gical indicationsincluding Neers
Figure3
Standard radiographic anteroposterior view (A)and 45 cephalic t ilt view (B). Both are necessary to determine the extent offracture displacement.
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article,17 w hich is often cited as sup-
p or t f o r n o n s u r gi c a l ma n a gemen t.
Random ized controlled trials, one of
w hich has recently been complet-
ed ,11 a n d a n o th er th a t i s c u r r en tl y
under w ay, are n ecessary to deter-
mine w hether these relative indica-tions should be considered routine
a n d , i f s o , i n w h i c h p a t i en ts w i th
w hich fracture t ypes.
N o n s u r g ic a l Tr e a tm e n t
H i s to ri c a ll y , n o n s ur gi c a l t r ea t-
m e nt h a s b een t h e m a in st a y f or
c l a v ic u l a r f ra c tu r es . I t h a s v a r ied
from plaster shoulder spica casts to
benign neglect. Most commonly, a
sling or figure-of-8 brace is applied
in the acute setting. With either de-
vice, imm obilization is t ypically for
2 to 6 w eeks, based on t he patient s
l ev el o f c o mf o r t . O f ten , mi l d d i s -
c om f o rt c a n l in ge r i n a d ul t s f or
3 m o n t h s. R et u r n t o a t h l et i c s o r
h ea v y l ab or i s p er m it t ed 4 t o 6
w eeks after clinica l an d radiograph-
ic union has occurred. Light w ork
w i th r es tr ic ted o v er h ea d a c t i v ity
can begin once the patient s com fort
allow s, usually in 2 t o 4 w eeks after
fracture healing.
In a pr os pe ct i v e, r an do m i z edstudy,27 26% of patient s treated w ith
a figure-of-8 bandage w ere dissatis-
f i ed c o mp a red w i th 7% o f th o s e
tr ea ted w i th a s l in g. Th e p a t i en ts
treat ed wit h a sling reported less dis-
com fort. There w as n o difference in
overall healing and alignment of the
f ra c tu r es , i n d ic a t i n g th a t a f igu re-
of-8 bandage does little to obtain or
maintain reduction.
S u r g i c a l T e c h n i q u e sP l a t e s
Open reduction an d internal fixa-
tion using plates and screw s can be
done w ith the patient in either the
supine or t he beach-chair position,
w ith the h ead and neck t i l ted aw ay
f ro m th e s u rgic a l s i te . A b u mp i s
placed behind the scapula t o aid in
th e reduct ion. The arm is prepped in
th e f i el d to a l l o w f o r tra c t i o n a n d
ma nipulation to assist in t he reduc-
tion . Traditiona lly, a skin incision is
ma d e o v er th e c l a v ic l e f o ll o w i n g
Langers lines, as th e skin perm its. A
new ly described alt ernat ive is to in -
cise the inferior skin aft er pulling it
over the fracture site. 28 As the skin is
released, it w ill fall 1 to 2 cm below
the clavicle and prevent the w oundfrom being in cont act w ith t he plat e
o n th e c l a v i c l e . T h e a i m i s to i m-
prove cosmesis and prevent w ound
c o mp li c a t i on s . Th e d i ss ec t i o n i s
t a k en d ow n t o b on e w i t h c a re t o
identify the cutaneous supraclavic-
ular nerves. When necessary, they
can be sacrif iced. I t is im portant to
inform the patient before surgery of
the possibility of a patch of numb-
ness in the skin inferior to t he clav-
icle.
Minim izing subperiosteal strip-
ping with gentle handling of the skin
and soft tissue helps avoid complica-
tion s. The plate usua lly is placed on
the t ension side of the bonefor the
clavicle, th e ant erosuperior position
(Figure 4). Biomechanically, this
position provides t he best stabili-
t y. 29 How ever, clin ically successful
treatm ent w ith ant eroinferior place-
m ent a lso has been described.30 The
a n tero i n feri o r p os i t i on , a l th o u gh
less favorable biomechanically,29 a l-
low s for drilling in a direction aw ay
f ro m t h e s ub cl a vi a n v es se ls a n d
lung. It also keeps the plate from be-
ing placed under the incision. This
position theoretically is less likely to
cause irritation, thereby decreasingth e need for plate remova l. How ever,
the anteroinferior position demands
additional soft-tissue stripping and a
m o r e d if fi cu l t c on t o u ri n g o f t h e
plate compared w ith t he ant erosupe-
rior position .
Ideally, a 3.5-mm dynam ic com -
p ress i on p la te o r p la te o f s i mi l a r
s tr en gth s h ou l d b e u s ed , w i th a t
least six cortices on each side. Semi-
tu b u l a r pl a tes a r e n o t a s r i gid a n d
should not be used.24,31 Reconstruc-
tion plates are more easily contoured
and have been used w ith success;
how ever, t hey account for several
failures to obtain union a nd w ould
not be the authors f irst choice. 24,31
P r ec on t o u re d pl a t es o f s ui t a bl e
thickn ess offer the advanta ge of ease
of placement w ithout m anipulation
of the plate. Locked plates are not
n ecess a ry f o r th e a c u te p l a t i n g o f
nonosteoporotic clavicular fractures;
Figure4
Anteroposterior radiograph demonstrating clavicle plating in the anterosuperiorposition, using a 3.5-mm limited-contact dynamic compression plate.
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t h e re i s n o s ig ni fi ca n t a d va n t a ge
o v er c o n v en ti o n a l p la t i n g, a n d th e
cost is higher.
O n c e p l a t i n g i s c o mp l eted , th e
fascia is repaired over the plate, i f
p os si bl e, a n d th e s kin i n c is i on i s
closed. Suture closure is preferable
to sta ples. With a sufficient ly sta bleconstruct, un restricted shoulder m o-
tion is allow ed, w ith the exception
of overhead lifting for 6 w eeks. Of-
ten, t he pain relief associated w ith
stabilizing the fracture is dram atic,
and efforts to l im it t he patients ac-
tivity may be needed. Pain relief is
cited as one of the potentia l benefits
of surgical intervention.
I n t ra m e d u l la r y F i x a t io n
A n a l t er n at i v e t o pl a t in g i s i n -tr a medu l l a ry (I M ) f i x a t i on . M a n y
variat ions of IM im plants hav e been
described over the past 40 years, in-
cluding H agie pins, modified H agie
pins, Kn ow les pins, H erbert screw s,
Steinmann pins, elastic nails, can-
c el lo us s crew s , a n d K irs ch n er
wires. 32-36 Modifications in t he tech-
nique h ave led to a resurgence of in-
terest in IM fixation of these frac-
tures. The potential benefits of IM
fixation compared w ith plate f ixa-
tion include less soft-tissue st ripping
at the fracture site, better cosmesis
w ith a smaller skin incision, easier
hardw are removal, and less w eak-
ness of the bone after hardw are re-
moval. Biomechanically, how ever,
the a bility t o resist t orsional forcesw ith IM fixation is much less than
th a t w i th a p la te . M i gra t i o n o f th e
pins also has been a major concern.
N ew er designs, w hich include lock-
ing nuts on t he lateral end of the IM
devices, prevent medial pin m igra-
t i o n . New er tec h n i q u es th a t a v o i d
penetration of t he m edial fragment
cortex also prevent medial migration
of th e devices.34
P a ti en t p os i t i on i n g i s s i mi la r t o
that for plate f ixation. A small inci-sion is made over the fracture site,
exposing t he fractu re ends. The m e-
dial segment is prepared by drilling
into th e medullary canal, but the an-
terior medial cortex is not violated.
The distal segment is drilled retro-
grade through the canal, exiting th e
posterior lateral cortex. The pin is
inserted retrograde t hrough the ca-
nal and exits through th e posterolat-
eral hole and out t he skin. Next, the
fractu re is reduced, and th e pin is ad-
vanced ant egrade across the fracture
into th e medullary canal of the m e-
dial segment . The Rockw ood C lavi-
cle Pin (DePuy Orthopaedics, War-
s a w , I N) h a s tw o n u ts th a t go o v er
th e threaded end of the inserted pinp os tero l a ter a ll y . O n c e th e p in i s
across the fracture, the first nut is in-
serted posterolaterally, com pressing
th e fracture, follow ed by th e second
n u t , w h i c h i s c o ld -w eld ed to th e
first. Figure 5 show s th e Rock w ood
C lavicle Pin in place. Some of the IM
techniques vary slightly depending
on th e device, and not all of the tech-
niques allow for fracture compres-
sion.
P a t i en t s a re a l lo w e d t o b eg in
shoulder mot ion imm ediately post-
operatively. When rotational stabil-
ity is a concern, forw ard elevation
should be restricted to 90 and ab-
duction to 90 for the first 4 w eeks.
Th e R o c kw o o d p in s h o ul d b e r e-
m oved at 8 to 14 w eeks. In some sit-
uation s, this can be done under local
anesthesia in the off ice; h ow ever,
most Rockw ood pins need to be re-
moved in t he operating room. Some
of the other IM devices, such as Her-
bert screw s, do not need to be re-moved.
As wit h plating, a m ajor benefit is
ea rl y r etu r n to a c t i v i t i es . S ev era l
studies have reported athletes re-
tu r n i n g to th ei r s po r t a c t i v i t i es b y
2 to 3 w eeks.35,37
C o m p l ic a t io n s
C omplications can occur from non-
surgical treatm ent as w ell as surgical
treatment. Both can produce a cos-
metic deformity (Figure 6). Both can
result in m alunion, nonunion, pain,
l o c a l ten d er n es s o r i r r i ta t i o n , a n d
l im i t a t i o n o f m o t i o n. O t h e r r a re
complications follow ing surgical or
nonsurgical treatment are residual
nerve paresthesia; subclavian ves-
s el c o mp ress i on , th r o mb o si s , a n d
p seu do a n eu r y sm; th o r a ci c o u tl et
syndrome; and brachial plexus neu-
ropathy.
Figure5
Anteroposterior radiograph demonstrating the Rockwood Clavicle Pin (DePuyOrthopaedics). Note that the anteromedial cortex is not violated, preventing the pinfrom migrating medially.
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S o me c o mp l i c a t i o n s a r e u n i q u e
to surgical intervention, such as in-
fection and hardw are problems. In-
fection rat es vary from 0% to 18%,w ith th e low er rates reported in th e
m ore recent studies.24,31,37,38 Painful,
irritat ing hardw are requiring plate or
pin removal is reported to be as h igh
as 50% to 100%. 24,39 Follow ing plate
removal, t he risk for refracture rang-
es from 0% to 8%.24,31 Adhesive cap-
sulitis of t he shoulder has been re-
p or ted w i th s u rgic a l t r ea tm en t i n
0% to 7% of ca ses.24,28
IM devices a re a ssociated w ith
unique complications, including mi-
gration of th e pin and h ardw are irri-
tation, resulting in local skin break-
down that often requires antibiotics
a n d , u l t i ma tel y, h a r dw a r e r emo v -
a l. 39 Figure 7 illustrates skin break-
d ow n f ro m a n IM pi n . Al t h ou gh
most of these complications are rare,
a second surgery for plate or pin re-
moval is sufficiently frequent t o be
considered w hen review ing treat-
ment choices.
R e s u l t s
Wh eth er tr ea ted n o n s ur gi c a ll y o r
surgically, most clavicular fracturesheal w ithout incident w hen length
and alignment are maintained. Ac-
ceptable cosmetic a nd functiona l re-
sults should be expected. Satisfact o-
r y r es u lts o c cu r l es s c o n si s ten tl y
w h en th e f ra c tu r e f a i l s to h ea l o r
heals w ith a significant deformity.
N o n u n i o n
Most cases of nonunion are symp-
tom atic, presenting w ith pain, loss
o f f u n cti o n , n eu ro l ogic c h a n ges,
and/or unsightly clavicular deformi-
ty . Alth o u gh c l a v ic u l a r n o n u n i o n
has not been clearly defined in the
literature, most authors concur that
nonunion is present w hen healing
has not occurred by 16 w eeks.
Traditional thinking is that cla-
vicular fractures treated nonsurgical-
ly almost alw ays heal and that surgi-
c a l t r ea tm en t i n c rea ses th e r is k o f
nonunion. Row e4 r ep or ted a n o n -
union rate of 3.7% in patients w ho
underw ent surgery compared w ith
0.8% in those t reated w ithout sur-
gery. Neer17 reported nonun ion rat esof 0.1% w ith nonsurgical t reatm ent
and 4.6% w ith surgical treatment.
Neer17 s u gges ted th a t th e m o s t i m-
portan t causal fact or for nonunion of
a m idshaft clavicular fracture is im-
proper open surgery. This ma y be
true to som e extent; aggressive soft-
tissue stripping, inability to reduce
the fracture, and inadequate internal
fixation all can lead to poor results.
Several recent studies have re-
ported high union rates w ith surgical
intervention using a variety of inter-
nal f ixation devices, including plat-
ing and IM pin or rod fixation. 39,40 In
addition, there is evidence that the
nonunion rat e after nonsurgical treat-
ment m ay be higher tha n previously
reported, particularly in certain frac-
ture ty pes and in certain patients. In
their review of 581 nonsurgically
treated fractures, Robinson et al 20 re-
ported an overall nonunion rate of
Figure6
A,Healed clavicular fracture managed nonsurgically. The bump, shortened shoulder width, and subtle droop are evident.B,A healed clavicular fracture treated with plate and screws, showing prominence of the anterior-superiorpositioned plate.
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4.5% for diaphyseal fractu res. Strat-
ification of Robinsons data revealed
that w omen w ith displaced diaphy-
s ea l f ra c tu r es h a d a n o n u n i on r a te
ranging from 19% t o 33%. When
c o mmi n u ti o n w a s c o mb i n ed w i th
displacement, th e nonunion rate in
w omen increased to a range of 33%
to 47%.41 In addition to fracture frag-
ment displacement, female sex, and
c om m i n u t i on , o t h er r is k f a ct o rsidentified wit h nonunion include ad-
vancing age, lack of cortical apposi-
t i o n , s everi ty o f th e i n i t i a l t r a u ma ,
the extent of fracture fragment dis-
placement,25 a n d, a rg ua b ly , s of t -
tissue int erposition.42 Early mobiliza-
tion has not been associated with the
development of a nonunion, w hether
treated surgically or nonsurgically.
A recently published system atic
review of the literature on nonunion
after treatm ent of midshaft clavicu-
lar fractures revealed a 5.9% non-
union rate in nonsurgically m anaged
fractures.8 I n t h e c o mpl etel y d i s-
placed fractu res, the rate increased to
15.1%. In surgically treat ed displaced
fractures, plating of 460 fractures re-
sulted in a nonunion rate of 2.2%,
and IM fixation of 152 fractures re-
sulted in a nonunion rate of 2.0%.8
Th ese d a ta s h o ul d b e i n terp reted
w ith caut ion, however, because most
w ere from evidence-based level III,
IV, a nd V stu dies (ie, observation al,
retrospective, ca se series, an d expert
o pi n i on s tu d ies) r a th er th a n f ro m
level I and II studies (ie, random ized,
prospective studies).
S u rgic a l t r ea tm en t o f n o n u n io n
has a high success rate. Techniques
i n cl u de pl a t e f ix a t io n w i t h b on e
g ra f t , IM pi n f ix a t io n w i t h b on e
gra f t , a n d exter n a l f i x a t i on . U n i o nrates w ith each m ethod have been
reported to be >92% and as high as
100%.42-45 P l at e f ix at i on h a s t h e
largest support in the literature and
i s c u rr en tl y th e mo s t p redi c ta bl e
a n d r ec om m e nd ed t r ea t m e n t f or
sy m pt om a t ic n on un io n. O t her
meth o d s ma y b e s u c c es s f u l i n th e
han ds of an experienced surgeon.
M a lu n io n
M o s t n o n s ur gi c a ll y tr ea ted c l a -
vicular fractu res heal w ith some de-
f or m i t y. Th e l it e ra t u re d oe s n o t
clearly define w hen a deformity is
considered to be a m alunion; how ev-
er, the evidence strongly suggests
that some clavicular deformities re-
sult in unsat isfactory outcomes. The
d ef o rmi ty i s a th r ee-d i men si o n a l
problem; the most consistent char-
acteristic is shortening wit h inferior
d is pl a ce m en t o f t h e m e di a l f ra g-
m e n t . S y m pt o m a t i c pa t i en t s h el p
define the malunion. Sym ptoms in-
clude w eakness and pain in the in-
v o l ved s h o ul d er , l o ss o f s h o ul d er
mot ion, loss of endurance, neurolog-
ic symptoms consistent with thorac-
i c o u t le t s y n dr om e a n d b ra c h ia l
plexus impingement, and cosmetic
deformity.46
In 1986, Eskola et al21 n o ted i n
89 patient s tha t short ening >12 m mw as a ssociated w ith increased pain.
Wick et a l22 concluded in a retrospec-
tive study th at shortening of 2 cm in
midshaft clavicular fractures wa s as-
sociated w ith an increased risk of
p a in , l i mi ta t i o n o f mo ti o n , o r n o n -
union. McKee et al9 assessed func-
tional outcome follow ing displaced
clavicular fractures and not ed signif-
icantly inferior scores for both the
upper extremit yspecific (D ASH)
outcome scores (P = 0.02) and t he
C onstant scores (P= 0.01)com pared
w ith the general population. They
concluded that fractures wit h >2 cm
of shortening tended to be associated
w ith decreased abduction strength
and greater patient dissatisfaction.
H i l l et a l 25 reported on completely
d i sp la c ed mi d d le th i r d c l a v ic u l a r
f r a c tu r es a n d c o n c l u d ed th a t f i n a l
shortening 2 c m w a s a s so ci a t ed
w ith an unsatisfactory result but not
Figure7
Healed clavicular fracture treated with intramedullary pinning.A,Note incision size and location over fracture and posterolateral
prominence. B,Early breakdown of the skin resulting from a prominent pin at the posterolateral insertion site.
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w ith nonunion. After closed treat-
m ent, 31% of patients w ere dissatis-
fied w ith th e final result, 54% w ere
unhappy w ith the appearance, a nd
15% of fractures failed to unit e. U s-
ing the sam e subjective patient q ues-
t i o nn a i re a s t h a t u se d b y H i l l e ta l, 25 Lazarides and Z afiropoulos10 re-
ported tha t f inal clavicular shorten-
ing >18 m m in m ales and >14 mm in
females was associated with unsatis-
factory results and w ith increased
patient symptoms.
Ledger et a l47 show ed the effect of
c l a v ic u l a r s h o r ten i n g >15 mm o n
b io m e ch a n ic a l pa ra m e t er s o f t h e
shoulder. They found a significant
i nc rea se i n u pw a rd a n gu la t io n
(mean, 10.7; P < 0.005) of the SC
joint on the injured side com pared
w ith the un injured side. The m uscle
torque of the injured arm w as signif-
icantly w eaker tha n that of the unin-
jured arm in extension (P< 0.05), ad -
d uc t i on (P < 0. 05), a n d i n tern a l
rotation (P< 0. 05).47
Th ese s tu d ies i n d i c a te t h a t a l -
th o u gh c l a v ic u l a r d ef o rmi t i es a r e
complex and ha rd to assess, shorten-
ing of 1.5 to 2 cm, w hich results in an
increased incidence of clinical sy m p-
to ms , i s o n e p a r a meter th a t c a n b emeasured. Further investigation is
needed to clearly define the patient s
as w ell as the fracture deformit y t hat
i s l i kel y t o b e s y m p to ma ti c w i th a
c l a v ic u l a r m a l u n i on . I n th i s w a y ,
acute surgical treatm ent could be of-
fered to the patients w ho are most
likely to benefit. In addition, compar-
ative t rials are necessary to establish
th a t p a t i en ts w i th c l a v ic u l a r f r a c-
tures that predictably result in defor-
m i t y h a v e b et t e r o u t co m e s w h en
treated surgically rath er tha n nonsur-
gically. Several randomized trials cur-
r en tl y a r e u n d er w a y , a n d o n e h a s
been completed, assessing the surgi-
cal versus nonsurgical management
of acute displaced midshaft clavicu-
lar fractures. The Canadian Ortho-
paedic Trauma Society has show n in
a m ulticent er random ized trial of 132
patients that for displaced fractures
of the clavicular shaft, surgical fixa-
tion w ith a plate and screw s resulted
in an im proved functional outcom e
a n d a l o w er r a te o f ma l u n i o n a n d
nonunion compared w ith nonsurgi-
cal treatment at 1 year.11
Treatment of a ma lunion consists
o f s ur gi ca l c or re ct i o n t o r es t or elength, angular deformity, a nd rota-
tion of t he clavicle. Treatm ent m ay
o r ma y n o t i n v o l v e a n i n ter c a l a r y
bone graft. Oft en, after rem oving the
callus of the ma lunion, it is possible
to i d en ti f y t h e p ro x ima l a n d d i s ta l
fragments in order to anatomically
reconstruct the clavicle.46,48 The ben -
efit of th is technique is that t here is
no donor-site morbidity for a bone
graft. When difficulty in determ ining
the length of the m alunited clavicle
is anticipated, a preoperative radio-
gr a p h i c i ma ge o f b o th c l a v i c l es i s
helpful. Both IM devices and plates
have been used successfully t o treat
malunions.46,48-50 Treatm ent of sym p-
to ma t i c m a l u n io n s h a s r es u lted i n
improvement of the function of the
upper extrem ity, decreased pain, a nd
increased patient satisfaction.46,50
Su m m a r y
The frequency of comminuted anddisplaced m idshaft clavicular frac-
tures t hat result from high-energy
injuries is in creasing. Non displaced
and minimally displaced fractures
s h o ul d b e tr ea ted n o n s ur gi c a ll y ,
preferably w ith a sling for patient
comfort; th e rates of nonunion, pain,
cosmetic deformity, and loss of func-
tion are low . How ever, for specific
groups of patients, the risk of com-
plications from nonsurgical m anage-
men t ma y b e s i gn i f i c a n tl y h i gh er .
These patients include t hose w ith
c o mp letel y d i sp la c ed a n d c o mmi -
nuted fractures and, possibly, those
w ho are female or of advanced a ge.
The current literature suggests that
s u rgic a l s ta b il i za t i on , w i th eith er
plates an d screw s or w ith an IM de-
vice, should be considered as t he pre-
f er red t r ea tm en t o pti o n f o r th es e
mo r e c o mp l ex a c u te mi d s h a f t c l a -
vicular fractures. Further random-
ized, prospective studies a re needed
to determine w hether the benefits of
surgical fixation outw eigh the risks
and, if so, in w hich t ypes of pat ients
and for w hich t ypes of midshaft cla-
vicular fracture.
R e f e r e n c e s
Evid ence-based M edici ne: Level I/II
prospective studies are references
5, 7, 8, an d 27. The rem ain ing refer-
ences a re level III/IV case-con t rol co -
hort studies or level V, expert opinion.
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Acute Midshaft Clavicular Fracture
2 4 8 Journal of the American Academy of Orthopaedic Surgeons