Acute Midshaft

Clavicular Fracture

Kyle J. Jeray, MD Abstract

Clavicular fractures represent 2.6% to 5% of all fractures, and
middle third fractures account for 69% to 82% of fractures of the
clavicle. The junction of the outer and middle third is the thinnest
part of the bone and is the only area not protected by or reinforced
with muscle and ligamentous attachments. These anatomic
features make it prone to fracture, particularly with a fall on the
point of the shoulder, which results in an axial load to the clavicle.
Optimal treatment of nondisplaced or minimally displaced
midshaft fracture is with a sling or figure-of-8 dressing; the
nonunion rate is very low. However, when midshaft clavicular
fractures are completely displaced or comminuted, and when they
occur in elderly patients or females, the risk of nonunion, cosmetic
deformity, and poor outcome may be markedly higher. Thus, some
surgeons propose surgical stabilization of a complex midshaft
clavicular fracture with either plate-and-screw fixation or
intramedullary devices. Further randomized, prospective trials are
needed to provide better data on which to base treatment decisions.

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 Grove Road, 2nd Floor ERC
Support Tower, Greenville, SC 29605.
J Am Acad Orthop Surg 2007;15:239-
248
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
T he clavicle is one of the most
commonly fractured bones; cla-
vicular fractures represent 2.6% to
5% of all fractures.1,2 The incidence
of clavicular fracture in adults is es-
timated to be 71 in 100,000 for men
and 30 in 100,000 for women, with
the incidence of midshaft fractures
decreasing with increasing age. Mid-
shaft fractures account for 69% to
82% of all clavicular fractures.1-5
Midshaft fractures are more common
in children and young adults. The in-
cidence of high-energy clavicular
fractures with comminution, dis-
placement, and shortening appears to
be increasing.2
Traditionally, fractures of the
clavicle have been treated with
closed reduction. More than 200
methods have been described for
closed reduction, yet a classic text-
book recognizes that “reduction is
practically impossible to maintain,
and a certain amount of deformity is
to be expected, generally compatible
with satisfactory return of function
in the shoulder.”6 The same text-
book states that even completely
displaced fractures “generally do
well with non-operative manage-
ment....”6
However, most previous studies
describing the results of clavicular
fracture have used surgeon-based or
radiographic outcome measures that
equate union with 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
(QualityMetric, Lincoln, RI) or the
Disabilities of the Arm, Shoulder
and Hand questionnaire (DASH; In-
stitute for Work and Health, Toron-
ta, Canada, and the American Acad-

Volume 15, Number 4, April 2007 239

Acute Midshaft Clavicular Fracture
Figure 1
Anatomy and cross-sectional geometry of the clavicle. (Adapted with permission
from Craig EV: Fractures of the shoulder: Part II. Fractures of the clavicle, in
Rockwood CA, Green DP, Bucholz RW [eds]: Rockwood and Green’s Fractures
in Adults, ed 3. Philadelphia, PA: JB Lippincott, 1991, vol 1, pp 928-990.)
emy of Orthopaedic Surgeons
[AAOS]). Recent studies have indi-
cated that outcomes are not always
excellent, particularly in high-
energy fractures.7-11 These studies
raise the question whether acute
midshaft clavicular fractures should
be internally fixed.
Anatomy and Function
The clavicle is the first bone to ossify
in the fifth week of fetal life, and it
is the only long bone to ossify by in-
tramembranous ossification. Initial
growth up to age 5 years arises from
the ossification center in the central
portion of the clavicle, with contin-
ued growth occurring at the epiphy-
seal plates at the medial and lateral
ends of the bone. The medial growth
plate, typically the only plate seen ra-
diographically, accounts for up to
80% of longitudinal growth. The me-
dial growth plate is the last physis to
close, generally at age 22 to 25 years.
The clavicle is subcutaneous, with
240
only the supraclavicular nerves cross-
ing the bone. However, several fascial
layers and muscles attach to the bone
itself and help to create the predict-
able deformity seen with fractures.
The proximal fragment is pulled su-
periorly and posteriorly by the ster-
nocleidomastoid muscle. The distal
segment sags forward and rotates in-
feriorly because of the weight of the
upper extremity and, to a lesser ex-
tent, the pull of the pectoralis mus-
cle on the humerus.
The clavicle is a strut that con-
nects the upper extremity to the
trunk and is the only link to the ax-
ial skeleton. It also provides protec-
tion for the adjacent axillary and
subclavicular neurovascular struc-
tures and the apex of the lungs. Lat-
erally, the clavicle is secured by the
acromioclavicular (AC) and coraco-
clavicular ligaments where it articu-
lates with the acromion. Medially,
the clavicle articulates with the ster-
num and is strongly secured to the
first rib by the intra-articular ster-
Journal of the American Academy of Orthopaedic Surgeons
noclavicular (SC) joint cartilage, the
oblique fibers of the costoclavicular
ligaments, and the subclavius mus-
cle. The clavicle is S-shaped and
double-curved, concave ventrally on
its lateral half and convex ventrally
on its medial half. The cross-
sectional geometry changes from flat
laterally to tubular centrally to trian-
gular medially (Figure 1).
The shape of the clavicle and the
ligamentous and muscle attach-
ments play a role in fracture pat-
terns. The junction of the outer and
middle thirds is the thinnest part of
the bone and is the only area not pro-
tected by or reinforced with muscle
and ligamentous attachments, there-
by rendering it prone to fracture, par-
ticularly with axial loading.12 This
helps to explain why the middle
third is the most common site of
fracture, occurring at the junction
where the bone geometry changes
from flat to tubular.
The motion of the clavicle is ulti-
mately linked to the surrounding
motion of the scapula because of the
anatomic attachment to the scapula
through the AC joint and to the ster-
num through the SC joint. Motion of
the clavicle occurs with elevation
and abduction of the arm. During el-
evation, with 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°, with the magnitude and
planes varying among subjects.13
Other studies suggest that rotation
may be as much as 50° and elevation
as high as 30°.14 More importantly,
clavicle rotation is relatively small
until humeral elevation exceeds 90°;
thus, early rehabilitation that avoids
over-the-shoulder activity will sig-
nificantly limit rotational forces at
the site of a clavicular fracture.15
Mechanism of Injury
Midshaft clavicular fractures
have traditionally been thought to
occur from a fall on an outstretched
hand. However, a biomechanical
analysis of the forces demonstrated
 Kyle J. Jeray, MD

that a direct injury from the shoul- Figure 2

der (rather than the hand) that pro-
duces a force equal to the body
weight would exceed the critical
buckling load and result in a mid-
shaft clavicular fracture.16 Several
studies have demonstrated that a di-
rect fall or blow onto the point of the
shoulder accounts for 85% to 94% of
the injuries.2,3,5,16,17 When the forces
are transmitted through the arm, as
with a fall on an outstretched hand,
the forces are not directly delivered
to the clavicle; thus, they are unlike-
ly to produce a midshaft fracture.
This mechanism accounts for 2% to
5% of all midshaft fractures. A direct
blow to the clavicle, such as from a
hockey stick or a seat belt shoulder-
strap injury, also may produce a frac-
ture and accounts for 10% to 13% of
midshaft fractures in most stud-
ies.16 Although rare, direct force on
the top of the shoulder may drive the
midshaft clavicle against the first
rib, resulting in a fracture.
Robinson’s classification system for midshaft clavicular fractures. (Reproduced with
Classification permission from Robinson CM: Fractures of the clavicle in the adult: Epidemiology
Clavicular fractures have been and classification. J Bone Joint Surg Br 1998;80:476-484.)
classified by Allman18 into three ana-
tomic regions, with the middle third
being group I. The classification sys- classification system will reliably motion at the fracture site. A non-
tem of the Orthopaedic Trauma As- predict treatment and functional displaced or minimally displaced
sociation separates diaphyseal cla- outcomes. fracture may be suspected when pain
vicular fractures into three types: and/or skin changes are present over
06-A (simple), 06-B (wedge) and 06-C the clavicle.
Clinical Evaluation
(complex).19 Each type is further bro- Because middle third fractures
ken down into three groups. Often with clavicular fracture, a frequently occur with high-energy
The system developed by Robin- bruise or abrasion is seen, either over trauma, a complete examination
son3 divides midshaft clavicular frac- the point of the shoulder (indicating should be performed to avoid miss-
tures into type 2A (cortical align- a direct blow) or over the midline ing associated injuries. Skeletal inju-
ment fracture) and type 2B (displaced (suggesting a seat belt shoulder-strap ries include fracture-dislocations of
fracture). In an effort to provide di- injury). The shoulder has a droop, the SC and AC joints or, in younger
rection for treatment and prognosis, the scapula appears slightly internal- patients, physeal injuries. Chest wall
Robinson further divides these into ly rotated, and the shoulder appears trauma may result in high rib frac-
subgroup types 2A1 (nondisplaced), shortened relative to the opposite tures, scapular neck and body frac-
2A2 (angulated), 2B1 (simple or side. This characteristic deformity is tures, and a pneumothorax or he-
wedge comminuted), and 2B2 (isolat- produced by the pull of muscles at- mothorax. Although acute brachial
ed or comminuted segmental) (Fig- tached to the clavicle. Immediate plexus injury is rare, the ulnar nerve
ure 2). Robinson’s classification sys- swelling may obscure the deformity is at highest risk because of its loca-
tem has demonstrated satisfactory of the bone, which will be seen on tion adjacent to the middle third of
levels of interobserver and intraob- radiographs if the fracture is dis- the clavicle. When a nerve injury is
server reliability and reproducibility. placed. Palpation over the area will identified, a thorough vascular ex-
However, additional studies are reveal tenderness, and gentle manip- amination and evaluation of the
needed to determine whether this ulation may produce crepitus and scapulothoracic articulation should

Volume 15, Number 4, April 2007 241

Acute Midshaft Clavicular Fracture
Figure 3
Standard radiographic anteroposterior view (A) and 45° cephalic tilt view (B). Both are necessary to determine the extent of
fracture displacement.
be undertaken to avoid missing an
associated injury. Penetrating trau-
ma is typically the cause of vascular
injury. However, vascular injury can
occur from blunt trauma, resulting
in spasm or thrombosis of the sub-
clavian vessels.
Radiographic
Evaluation
To determine the fracture pattern
and displacement, radiographs in
two projections are necessary. A
standard anteroposterior view should
be accompanied by a 45° cephalic tilt
view (Figure 3). The shoulder girdle
and upper lung fields should be
carefully assessed to avoid missing
associated fractures or a subtle pneu-
mothorax. The radiographic evalua-
tion should assess the fracture pat-
tern, presence of comminution,
displacement, and shortening or dis-
traction of the fracture.
Several radiographic findings can
help guide the surgeon’s choice of
242
treatment. Displacement without
bony contact, especially with a
transversely displaced fragment, is a
risk factor strongly predictive of
long-term sequelae.7 Additional ra-
diographic parameters predictive of
increased risk for pain, limitation of
motion, or nonunion include an
overall displacement of the fracture
ends >1.5 cm. This displacement in-
cludes shortening, distraction, or
separation of the ends in the anteri-
or or posterior direction in any radio-
graphic view.20-22 A second view, at
least 45° off plane from the first,
helps to further delineate the dis-
placement. Often, the displacement
is difficult to assess on a single radio-
graph. For example, as seen in Figure
3, both views reveal distraction at
the fracture site of at least 1.5 cm.
Management
Indications
The primary goal in treatment is
to restore shoulder function to the
Journal of the American Academy of Orthopaedic Surgeons
preinjury level. By allowing the clav-
icle to heal with minimal deformity,
loss of motion and pain can be min-
imized. Indications for nonsurgical
treatment include a nondisplaced or
minimally displaced midshaft clav-
icular fracture. Indications for surgi-
cal treatment include open fractures
and fractures associated with skin
compromise or with neurologic or
vascular injury.
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 treatment have been ex-
panded to include high-energy closed
fractures with >15 to 20 mm of
shortening, fractures with complete
displacement, and fractures with
comminution.23-26 Although these re-
cently adopted indications have re-
ceived attention in the current liter-
ature, articles dating as far back as
the 1960s have described similar sur-
gical indications—including Neer’s

article,17 which is often cited as sup-
port for nonsurgical management.
Randomized controlled trials, one of
which has recently been complet-
ed,11 and another that is currently
under way, are necessary to deter-
mine whether these relative indica-
tions should be considered routine
and, if so, in which patients with
which fracture types.
Nonsurgical Treatment
Historically, nonsurgical treat-
ment has been the mainstay for
clavicular fractures. It has varied
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, immobilization is typically for
2 to 6 weeks, based on the patient’s
level of comfort. Often, mild dis-
comfort can linger in adults for
3 months. Return to athletics or
heavy labor is permitted 4 to 6
weeks after clinical and radiograph-
ic union has occurred. Light work
with restricted overhead activity
can begin once the patient’s comfort
allows, usually in 2 to 4 weeks after
fracture healing.
In a prospective, randomized
study,27 26% of patients treated with
a figure-of-8 bandage were dissatis-
fied compared with 7% of those
treated with a sling. The patients
treated with a sling reported less dis-
comfort. There was no difference in
overall healing and alignment of the
fractures, indicating that a figure-
of-8 bandage does little to obtain or
maintain reduction.
Surgical Techniques
Plates
Open reduction and internal fixa-
tion using plates and screws can be
done with the patient in either the
supine or the beach-chair position,
with the head and neck tilted away
from the surgical site. A bump is
placed behind the scapula to aid in
the reduction. The arm is prepped in
the field to allow for traction and
manipulation to assist in the reduc-
Volume 15, Number 4, April 2007
Figure 4
Anteroposterior radiograph demonstrating clavicle plating in the anterosuperior
position, using a 3.5-mm limited-contact dynamic compression plate.
tion. Traditionally, a skin incision is
made over the clavicle following
Langer’s lines, as the skin permits. A
newly described alternative is to in-
cise the inferior skin after pulling it
over the fracture site.28 As the skin is
released, it will fall 1 to 2 cm below
the clavicle and prevent the wound
from being in contact with the plate
on the clavicle. The aim is to im-
prove cosmesis and prevent wound
complications. The dissection is
taken down to bone with care to
identify the cutaneous supraclavic-
ular nerves. When necessary, they
can be sacrificed. It is important to
inform the patient before surgery of
the possibility of a patch of numb-
ness in the skin inferior to the clav-
icle.
Minimizing subperiosteal strip-
ping with gentle handling of the skin
and soft tissue helps avoid complica-
tions. The plate usually is placed on
the tension side of the bone—for the
clavicle, the anterosuperior position
(Figure 4). Biomechanically, this
position provides the best stabili-
ty.29 However, clinically successful
treatment with anteroinferior place-
ment also has been described.30 The
Kyle J. Jeray, MD
anteroinferior position, although
less favorable biomechanically,29 al-
lows for drilling in a direction away
from the subclavian vessels and
lung. It also keeps the plate from be-
ing placed under the incision. This
position theoretically is less likely to
cause irritation, thereby decreasing
the need for plate removal. However,
the anteroinferior position demands
additional soft-tissue stripping and a
more difficult contouring of the
plate compared with the anterosupe-
rior position.
Ideally, a 3.5-mm dynamic com-
pression plate or plate of similar
strength should be used, with at
least six cortices on each side. Semi-
tubular plates are not as rigid and
should not be used.24,31 Reconstruc-
tion plates are more easily contoured
and have been used with success;
however, they account for several
failures to obtain union and would
not be the author’s first choice.24,31
Precontoured plates of suitable
thickness offer the advantage of ease
of placement without manipulation
of the plate. Locked plates are not
necessary for the acute plating of
nonosteoporotic clavicular fractures;
243
Acute Midshaft Clavicular Fracture
Figure 5
Anteroposterior radiograph demonstrating the Rockwood Clavicle Pin (DePuy
Orthopaedics). Note that the anteromedial cortex is not violated, preventing the pin
from migrating medially.
there is no significant advantage
over conventional plating, and the
cost is higher.
Once plating is completed, the
fascia is repaired over the plate, if
possible, and the skin incision is
closed. Suture closure is preferable
to staples. With a sufficiently stable
construct, unrestricted shoulder mo-
tion is allowed, with the exception
of overhead lifting for 6 weeks. Of-
ten, the pain relief associated with
stabilizing the fracture is dramatic,
and efforts to limit the patient’s ac-
tivity may be needed. Pain relief is
cited as one of the potential benefits
of surgical intervention.
Intramedullary Fixation
An alternative to plating is in-
tramedullary (IM) fixation. Many
variations of IM implants have been
described over the past 40 years, in-
cluding Hagie pins, modified Hagie
pins, Knowles pins, Herbert screws,
Steinmann pins, elastic nails, can-
cellous screws, and Kirschner
wires.32-36 Modifications in the tech-
nique have led to a resurgence of in-
terest in IM fixation of these frac-
tures. The potential benefits of IM
244
fixation compared with plate fixa-
tion include less soft-tissue stripping
at the fracture site, better cosmesis
with a smaller skin incision, easier
hardware removal, and less weak-
ness of the bone after hardware re-
moval. Biomechanically, however,
the ability to resist torsional forces
with IM fixation is much less than
that with a plate. Migration of the
pins also has been a major concern.
Newer designs, which include lock-
ing nuts on the lateral end of the IM
devices, prevent medial pin migra-
tion. Newer techniques that avoid
penetration of the medial fragment
cortex also prevent medial migration
of the devices.34
Patient positioning is similar to
that for plate fixation. A small inci-
sion is made over the fracture site,
exposing the fracture ends. The me-
dial segment is prepared by drilling
into the medullary canal, but the an-
terior medial cortex is not violated.
The distal segment is drilled retro-
grade through the canal, exiting the
posterior lateral cortex. The pin is
inserted retrograde through the ca-
nal and exits through the posterolat-
eral hole and out the skin. Next, the
Journal of the American Academy of Orthopaedic Surgeons
fracture is reduced, and the pin is ad-
vanced antegrade across the fracture
into the medullary canal of the me-
dial segment. The Rockwood Clavi-
cle Pin (DePuy Orthopaedics, War-
saw, IN) has two nuts that go over
the threaded end of the inserted pin
posterolaterally. Once the pin is
across the fracture, the first nut is in-
serted posterolaterally, compressing
the fracture, followed by the second
nut, which is cold-welded to the
first. Figure 5 shows the Rockwood
Clavicle Pin in place. Some of the IM
techniques vary slightly depending
on the device, and not all of the tech-
niques allow for fracture compres-
sion.
Patients are allowed to begin
shoulder motion immediately post-
operatively. When rotational stabil-
ity is a concern, forward elevation
should be restricted to 90° and ab-
duction to 90° for the first 4 weeks.
The Rockwood pin should be re-
moved at 8 to 14 weeks. In some sit-
uations, this can be done under local
anesthesia in the office; however,
most Rockwood pins need to be re-
moved in the operating room. Some
of the other IM devices, such as Her-
bert screws, do not need to be re-
moved.
As with plating, a major benefit is
early return to activities. Several
studies have reported athletes’ re-
turning to their sport activities by
2 to 3 weeks.35,37
Complications
Complications can occur from non-
surgical treatment as well as surgical
treatment. Both can produce a cos-
metic deformity (Figure 6). Both can
result in malunion, nonunion, pain,
local tenderness or irritation, and
limitation of motion. Other rare
complications following surgical or
nonsurgical treatment are residual
nerve paresthesia; subclavian ves-
sel compression, thrombosis, and
pseudoaneurysm; thoracic outlet
syndrome; and brachial plexus neu-
ropathy.

Figure 6
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-superior–positioned plate.
Some complications are unique
to surgical intervention, such as in-
fection and hardware problems. In-
fection rates vary from 0% to 18%,
with the lower rates reported in the
more recent studies.24,31,37,38 Painful,
irritating hardware requiring plate or
pin removal is reported to be as high
as 50% to 100%.24,39 Following plate
removal, the risk for refracture rang-
es from 0% to 8%.24,31 Adhesive cap-
sulitis of the shoulder has been re-
ported with surgical treatment in
0% to 7% of cases.24,28
IM devices are associated with
unique complications, including mi-
gration of the pin and hardware irri-
tation, resulting in local skin break-
down that often requires antibiotics
and, ultimately, hardware remov-
al.39 Figure 7 illustrates skin break-
down from an IM pin. Although
most of these complications are rare,
a second surgery for plate or pin re-
moval is sufficiently frequent to be
considered when reviewing treat-
ment choices.
Volume 15, Number 4, April 2007
Results
Whether treated nonsurgically or
surgically, most clavicular fractures
heal without incident when length
and alignment are maintained. Ac-
ceptable cosmetic and functional re-
sults should be expected. Satisfacto-
ry results occur less consistently
when the fracture fails to heal or
heals with a significant deformity.
Nonunion
Most cases of nonunion are symp-
tomatic, presenting with pain, loss
of function, neurologic changes,
and/or unsightly clavicular deformi-
ty. Although clavicular nonunion
has not been clearly defined in the
literature, most authors concur that
nonunion is present when healing
has not occurred by 16 weeks.
Traditional thinking is that cla-
vicular fractures treated nonsurgical-
ly almost always heal and that surgi-
cal treatment increases the risk of
nonunion. Rowe4 reported a non-
Kyle J. Jeray, MD
union rate of 3.7% in patients who
underwent surgery compared with
0.8% in those treated without sur-
gery. Neer17 reported nonunion rates
of 0.1% with nonsurgical treatment
and 4.6% with surgical treatment.
Neer17 suggested that the most im-
portant causal factor for nonunion of
a midshaft clavicular fracture is im-
proper open surgery. This may be
true to some 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 with surgical
intervention using a variety of inter-
nal fixation devices, including plat-
ing and IM pin or rod fixation.39,40 In
addition, there is evidence that the
nonunion rate after nonsurgical treat-
ment may be higher than previously
reported, particularly in certain frac-
ture types and in certain patients. In
their review of 581 nonsurgically
treated fractures, Robinson et al20 re-
ported an overall nonunion rate of
245
Acute Midshaft Clavicular Fracture
Figure 7
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.
4.5% for diaphyseal fractures. Strat-
ification of Robinson’s data revealed
that women with displaced diaphy-
seal fractures had a nonunion rate
ranging from 19% to 33%. When
comminution was combined with
displacement, the nonunion rate in
women increased to a range of 33%
to 47%.41 In addition to fracture frag-
ment displacement, female sex, and
comminution, other risk factors
identified with nonunion include ad-
vancing age, lack of cortical apposi-
tion, severity of the initial trauma,
the extent of fracture fragment dis-
placement,25 and, arguably, soft-
tissue interposition.42 Early mobiliza-
tion has not been associated with the
development of a nonunion, whether
treated surgically or nonsurgically.
A recently published systematic
review of the literature on nonunion
after treatment of midshaft clavicu-
lar fractures revealed a 5.9% non-
union rate in nonsurgically managed
fractures.8 In the completely dis-
placed fractures, the rate increased to
15.1%. In surgically treated 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
These data should be interpreted
with caution, however, because most
246
were from evidence-based level III,
IV, and V studies (ie, observational,
retrospective, case series, and expert
opinion studies) rather than from
level I and II studies (ie, randomized,
prospective studies).
Surgical treatment of nonunion
has a high success rate. Techniques
include plate fixation with bone
graft, IM pin fixation with bone
graft, and external fixation. Union
rates with each method have been
reported to be >92% and as high as
100%.42-45 Plate fixation has the
largest support in the literature and
is currently the most predictable
and recommended treatment for
symptomatic nonunion. Other
methods may be successful in the
hands of an experienced surgeon.
Malunion
Most nonsurgically treated cla-
vicular fractures heal with some de-
formity. The literature does not
clearly define when a deformity is
considered to be a malunion; howev-
er, the evidence strongly suggests
that some clavicular deformities re-
sult in unsatisfactory outcomes. The
deformity is a three-dimensional
problem; the most consistent char-
acteristic is shortening with inferior
displacement of the medial frag-
Journal of the American Academy of Orthopaedic Surgeons
ment. Symptomatic patients help
define the malunion. Symptoms in-
clude weakness and pain in the in-
volved shoulder, loss of shoulder
motion, loss of endurance, neurolog-
ic symptoms consistent with thorac-
ic outlet syndrome and brachial
plexus impingement, and cosmetic
deformity.46
In 1986, Eskola et al21 noted in
89 patients that shortening >12 mm
was associated with increased pain.
Wick et al22 concluded in a retrospec-
tive study that shortening of 2 cm in
midshaft clavicular fractures was as-
sociated with an increased risk of
pain, limitation of motion, or non-
union. McKee et al9 assessed func-
tional outcome following displaced
clavicular fractures and noted signif-
icantly inferior scores for both the
upper extremity–specific (DASH)
outcome scores (P = 0.02) and the
Constant scores (P = 0.01) compared
with the general population. They
concluded that fractures with >2 cm
of shortening tended to be associated
with decreased abduction strength
and greater patient dissatisfaction.
Hill et al25 reported on completely
displaced middle third clavicular
fractures and concluded that final
shortening ≥2 cm was associated
with an unsatisfactory result but not

with nonunion. After closed treat-
ment, 31% of patients were dissatis-
fied with the final result, 54% were
unhappy with the appearance, and
15% of fractures failed to unite. Us-
ing the same subjective patient ques-
tionnaire as that used by Hill et
al,25 Lazarides and Zafiropoulos10 re-
ported that final clavicular shorten-
ing >18 mm in males and >14 mm in
females was associated with unsatis-
factory results and with increased
patient symptoms.
Ledger et al47 showed the effect of
clavicular shortening >15 mm on
biomechanical parameters of the
shoulder. They found a significant
increase in upward angulation
(mean, 10.7°; P < 0.005) of the SC
joint on the injured side compared
with the uninjured side. The muscle
torque of the injured arm was signif-
icantly weaker than that of the unin-
jured arm in extension (P < 0.05), ad-
duction (P < 0.05), and internal
rotation (P < 0.05).47
These studies indicate that al-
though clavicular deformities are
complex and hard to assess, shorten-
ing of 1.5 to 2 cm, which results in an
increased incidence of clinical symp-
toms, is one parameter that can be
measured. Further investigation is
needed to clearly define the patients
as well as the fracture deformity that
is likely to be symptomatic with a
clavicular malunion. In this way,
acute surgical treatment could be of-
fered to the patients who are most
likely to benefit. In addition, compar-
ative trials are necessary to establish
that patients with clavicular frac-
tures that predictably result in defor-
mity have better outcomes when
treated surgically rather than nonsur-
gically. Several randomized trials cur-
rently are under way, and one has
been completed, assessing the surgi-
cal versus nonsurgical management
of acute displaced midshaft clavicu-
lar fractures. The Canadian Ortho-
paedic Trauma Society has shown in
a multicenter randomized trial of 132
patients that for displaced fractures
of the clavicular shaft, surgical fixa-
Volume 15, Number 4, April 2007
tion with a plate and screws resulted
in an improved functional outcome
and a lower rate of malunion and
nonunion compared with nonsurgi-
cal treatment at 1 year.11
Treatment of a malunion consists
of surgical correction to restore
length, angular deformity, and rota-
tion of the clavicle. Treatment may
or may not involve an intercalary
bone graft. Often, after removing the
callus of the malunion, it is possible
to identify the proximal and distal
fragments in order to anatomically
reconstruct the clavicle.46,48 The ben-
efit of this technique is that there is
no donor-site morbidity for a bone
graft. When difficulty in determining
the length of the malunited clavicle
is anticipated, a preoperative radio-
graphic image of both clavicles is
helpful. Both IM devices and plates
have been used successfully to treat
malunions.46,48-50 Treatment of symp-
tomatic malunions has resulted in
improvement of the function of the
upper extremity, decreased pain, and
increased patient satisfaction.46,50
Summary
The frequency of comminuted and
displaced midshaft clavicular frac-
tures that result from high-energy
injuries is increasing. Nondisplaced
and minimally displaced fractures
should be treated nonsurgically,
preferably with a sling for patient
comfort; the rates of nonunion, pain,
cosmetic deformity, and loss of func-
tion are low. However, for specific
groups of patients, the risk of com-
plications from nonsurgical manage-
ment may be significantly higher.
These patients include those with
completely displaced and commi-
nuted fractures and, possibly, those
who are female or of advanced age.
The current literature suggests that
surgical stabilization, with either
plates and screws or with an IM de-
vice, should be considered as the pre-
ferred treatment option for these
more complex acute midshaft cla-
vicular fractures. Further random-
Kyle J. Jeray, MD
ized, prospective studies are needed
to determine whether the benefits of
surgical fixation outweigh the risks
and, if so, in which types of patients
and for which types of midshaft cla-
vicular fracture.
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