Orthopaedics
Emergency Medicine
High Evidence
Peer reviewed

Clavicle Fracture

The landmark Canadian Orthopaedic Trauma Society (COTS) Trial in 2007 fundamentally changed practice by demonstrating that plate fixation of completely displaced midshaft clavicle fractures reduces non-union rates...

Updated 6 Jan 2026
Reviewed 17 Jan 2026
45 min read
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MedVellum Editorial Team
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MedVellum Medical Education Platform

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Urgent signals

Safety-critical features pulled from the topic metadata.

  • Skin Tenting -> Impending Open Fracture (Emergency Surgery)
  • Posterior SC Joint Dislocation -> Airway/Vascular Compromise
  • Pneumothorax -> Apex of lung injury
  • Brachial Plexus Injury -> Ulnar nerve symptoms common

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Differentials and adjacent topics worth opening next.

  • Acromioclavicular Joint Dislocation
  • Sternoclavicular Joint Dislocation

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Reviewed by MedVellum Editorial Team · MedVellum Medical Education Platform

Credentials: MBBS, MRCP, Board Certified

Clinical reference article

Clavicle Fracture

1. Clinical Overview

Summary

Clavicle fractures represent the most common fracture of the shoulder girdle, accounting for 2.6-4% of all adult fractures and up to 44% of shoulder girdle injuries. [1,2] The vast majority (69-82%) occur in the middle third (Allman Group I), with the remaining 15-28% affecting the lateral third and 2-5% the medial third. [3] Management paradigms have evolved significantly over the past two decades, transitioning from predominantly non-operative treatment to selective surgical intervention for specific fracture patterns.

The landmark Canadian Orthopaedic Trauma Society (COTS) Trial in 2007 fundamentally changed practice by demonstrating that plate fixation of completely displaced midshaft clavicle fractures reduces non-union rates from 15-24% to 2-7%, accelerates functional recovery, and improves patient-reported outcomes at 1 year. [4,5] However, this benefit comes at the cost of surgical complications including infection (2-5%), hardware irritation requiring removal (20-50%), and hypertrophic scarring. [6]

Contemporary evidence-based indications for surgical fixation include: shortening > 2cm, displacement > 100%, skin tenting (impending open fracture), open fractures, neurovascular injury, floating shoulder (combined clavicle and scapular neck fracture), and symptomatic non-union. [7,8] Lateral third fractures with coracoclavicular ligament disruption (Neer Type II) demonstrate inherent instability and high non-union rates (22-44%), warranting surgical stabilization with hook plates, superior locking plates, or coracoclavicular ligament reconstruction. [9,10]

The choice between operative and non-operative management requires individualized assessment considering fracture morphology, patient functional demands, occupation, sports participation, and tolerance for cosmetic deformity and prolonged recovery.

Key Facts

Epidemiology

  • Incidence: 29-64 per 100,000 population per year in developed nations. [1]
  • Age Distribution: Bimodal peak—young males (peak 13-20 years) from high-energy trauma and sports injuries; elderly females (peak > 70 years) from low-energy falls. [2,3]
  • Gender: Male predominance 2-3:1 overall, but equal distribution in elderly population. [11]
  • Laterality: Dominant side affected in 60-65% of cases in younger populations. [12]

Mechanism

  • Direct Blow: 87% of fractures result from direct impact to the point of shoulder. [13]
  • Fall Onto Outstretched Hand (FOOSH): Contrary to historical teaching, FOOSH accounts for only 6-8% of clavicle fractures. [13]
  • Indirect Compression: Lateral force compressing shoulder medially with arm adducted. [14]

Anatomical Vulnerability

  • The junction of the middle and lateral thirds represents the biomechanical weak point due to transition from tubular to flattened cross-section and change in curvature. [15]
  • Periosteal sleeve is thickest in children and adolescents, contributing to rapid healing and remodeling potential.
  • Superior periosteum remains intact in 70% of fractures, providing biological envelope for callus formation. [16]

Deforming Forces

  • Medial Fragment: Elevated by sternocleidomastoid (SCM) muscle attachment.
  • Lateral Fragment: Displaced inferiorly and medially by:
    • Weight of upper extremity
    • Pectoralis major pulling medially and inferiorly
    • Trapezius unable to counteract due to loss of bony strut
  • Result: Characteristic Z-deformity with fragment overlap and shoulder protraction. [17]

Clinical Pearls

"Check the Chest, Check the Vessels, Check the Nerves": The clavicle forms the superior boundary of the thoracic outlet, overlying the apex of the lung, subclavian vessels, and brachial plexus. Associated injuries occur in 3-5% of fractures but carry significant morbidity. Always perform: (1) Chest auscultation for pneumothorax, (2) Radial pulse palpation and Allen's test, (3) Neurological examination of C5-T1 nerve roots with particular attention to ulnar nerve function (lower trunk most vulnerable). [18]

"Skin Tenting is a Surgical Emergency": When sharp bone fragments tent the skin causing blanching (white appearance), the perfusion to that skin is critically compromised. Without urgent reduction (within 6-12 hours), skin necrosis will convert a closed fracture to an open one, dramatically increasing infection risk. Emergency closed reduction under sedation or immediate surgical fixation is mandatory. [19]

"The 2cm and 100% Rules": These are the contemporary evidence-based thresholds for considering surgical intervention in midshaft fractures. Shortening > 2cm correlates with increased non-union risk (15-24%), persistent shoulder girdle asymmetry, and potential scapular dyskinesis. Displacement > 100% (complete loss of cortical contact) similarly predicts non-union and prolonged functional impairment. [4,20]

"Hook Plates are Temporary": Hook plates for unstable lateral clavicle fractures achieve excellent reduction and stability, but the subacrominal hook causes rotator cuff impingement and chronic pain if retained long-term. Explicitly counsel patients that hardware removal is planned at 3-4 months once fracture union is achieved. Failure to remove increases reoperation rates for symptomatic hardware to 70-90%. [21]

"Floating Shoulder is Rare but Serious": The combination of clavicle fracture and ipsilateral scapular neck fracture creates a "floating" shoulder girdle detached from the axial skeleton. This double disruption of the superior shoulder suspensory complex (SSSC) causes significant instability and warrants surgical stabilization of at least one fracture site, typically the clavicle. [22]

"Figure-of-8 Bandages are Obsolete": Multiple randomized trials have demonstrated no benefit of figure-of-8 bracing over simple sling immobilization in terms of union rates, alignment, or functional outcomes, while causing significantly more discomfort, skin complications, and transient brachial plexus compression. This historical treatment has been abandoned. [23,24]

2. Epidemiology

Incidence and Prevalence

Clavicle fractures demonstrate consistent epidemiological patterns across international trauma registries:

Overall Incidence

  • 29-64 per 100,000 population annually in North American and European databases. [1]
  • Account for 2.6-4% of all adult fractures presenting to emergency departments. [2]
  • Represent 35-44% of all shoulder girdle injuries when including acromioclavicular and glenohumeral injuries. [3]

Age-Specific Incidence

  • Pediatric (0-10 years): 25-30 per 100,000, predominantly middle third greenstick fractures.
  • Adolescent (11-20 years): Peak incidence 70-80 per 100,000, sports-related high-energy mechanisms. [25]
  • Young Adults (21-40 years): 40-50 per 100,000, motor vehicle accidents, cycling, contact sports.
  • Middle Age (41-64 years): 20-25 per 100,000, work-related injuries.
  • Elderly (≥65 years): 30-40 per 100,000, ground-level falls, increasing with osteoporosis prevalence. [11]

Demographics

Gender Distribution

  • Overall male-to-female ratio: 2-3:1. [1,2]
  • In population less than 40 years: Male predominance 3-4:1 due to higher sports and occupational trauma exposure.
  • In population > 70 years: Approaching 1:1 as osteoporotic fractures equalize risk. [11]

Anatomical Location

  • Middle Third (Allman I): 69-82% of all fractures. [3]
  • Lateral Third (Allman II): 15-28%, higher proportion in elderly and high-energy trauma.
  • Medial Third (Allman III): 2-5%, often missed on standard radiographs. [26]

Laterality

  • Dominant shoulder affected in 60-65% of young adults (protective reaction with dominant arm). [12]
  • Equal distribution in elderly population (random fall mechanisms).

Risk Factors

Fracture Risk Factors

  • Contact sports participation (rugby, ice hockey, lacrosse, martial arts)
  • Cycling (road and mountain biking account for 25-30% in recreational athletes) [27]
  • Motor vehicle accidents (17-23% of clavicle fractures)
  • Seizure disorders (recurrent fractures from tonic-clonic convulsions)
  • Osteoporosis (elderly population, particularly postmenopausal women)
  • Prior clavicle fracture (contralateral or ipsilateral refracture after hardware removal)

Non-Union Risk Factors

  • Fracture Displacement: > 100% translation increases risk 6-8 fold. [4,20]
  • Shortening: > 2cm associated with 15-24% non-union rate. [4]
  • Comminution: Butterfly fragments or segmental fractures (3-5 fold increase). [28]
  • Female Gender: Independent risk factor (adjusted OR 2.1, 95% CI 1.3-3.4). [29]
  • Advanced Age: > 40 years shows delayed healing and increased non-union. [30]
  • Smoking: Current tobacco use increases non-union risk 2-3 fold. [31]
  • Inadequate Immobilization: Early return to heavy activities before callus formation.

3. Pathophysiology

Anatomy

Gross Anatomy

  • The clavicle is the first bone to ossify (5th fetal week) and the last to complete epiphyseal fusion (medial physis closes at 23-25 years). [32]
  • Only long bone to ossify via intramembranous rather than endochondral ossification.
  • S-shaped configuration: medial two-thirds convex anteriorly (sternal end), lateral one-third concave anteriorly (acromial end).
  • Average adult length: 13-15cm (males), 12-14cm (females).
  • Cross-sectional anatomy: cylindrical medially, transitioning to flattened laterally at the middle-lateral third junction (area of maximal stress concentration). [15]

Muscle Attachments

  • Superior Surface: Trapezius (lateral), sternocleidomastoid (medial), deltoid (anterior lateral).
  • Inferior Surface: Subclavius muscle centrally (protective of neurovascular structures), pectoralis major (medial).
  • No Muscle Attachments: Posterior surface and much of the shaft (facilitates surgical plating).

Ligamentous Stabilizers

  • Sternoclavicular (SC) Joint: Costoclavicular ligament (primary stabilizer), anterior/posterior SC ligaments, intra-articular disc.
  • Acromioclavicular (AC) Joint: AC ligament (provides horizontal stability), capsule.
  • Coracoclavicular (CC) Ligaments: Conoid (medial, cone-shaped) and trapezoid (lateral, quadrilateral) ligaments provide vertical stability and are critical for lateral clavicle fracture stability. [33]

Neurovascular Relations

  • Subclavian Vessels: Course posterior to medial clavicle, at risk in medial fractures and SC dislocations.
  • Brachial Plexus: Trunks emerge between anterior and middle scalene muscles, passing posterior to clavicle. Lower trunk (C8-T1) is most vulnerable, explaining ulnar-sided paresthesias in some fractures. [34]
  • Supraclavicular Nerves (C3-C4): Cross superior clavicle obliquely, invariably divided during surgical approach, causing permanent anterior chest wall numbness in 10-20% of patients. [35]

Biomechanics

Mechanical Function

  • Primary strut connecting upper extremity to axial skeleton.
  • Transmits forces from arm and shoulder to sternum and trunk.
  • Protects underlying neurovascular structures and lung apex.
  • Attachment site for 6 major muscles, serving as origin or insertion.

Failure Mechanism

  • The middle-lateral third junction is the stress riser due to:
    • Transition from thick cylindrical (medial) to thin flattened (lateral) geometry. [15]
    • Reversal of curvature (convex to concave).
    • Lack of muscular protection posteriorly.
    • Concentration of bending moments during shoulder compression.
  • Fractures occur when axial compressive force exceeds bone's modulus of elasticity (typically 2000-3000 Newtons in young adults).

Displacement Pattern

  • Medial Fragment: Elevated by unopposed sternocleidomastoid pull.
  • Lateral Fragment: Displaced inferiorly (weight of arm + pectoralis major) and medially (loss of strut function + pectoral adduction).
  • Superior periosteum often remains intact, creating "hinge" that maintains some reduction and provides scaffold for callus. [16]

Classifications

Allman Classification (1967) [Anatomical]

Most widely used clinical classification based on fracture location:

  • Group I (Middle Third): 69-82% of fractures.

    • Location: Between SC and CC ligament attachments.
    • Characteristics: Variable displacement, shortening, comminution.
    • Prognosis: Generally favorable with conservative treatment if minimal displacement.
    • Non-union risk: 0.3-0.8% if undisplaced; 15-24% if displaced > 2cm or > 100%. [4]

  • Group II (Lateral Third): 15-28% of fractures.

    • Location: Distal to CC ligament complex (at or lateral to coracoid process).
    • Characteristics: Stability depends on CC ligament integrity (see Neer classification).
    • Prognosis: Type II (unstable) fractures have 22-44% non-union rate without surgery. [9,10]

  • Group III (Medial Third): 2-5% of fractures.

    • Location: Medial to costoclavicular ligament.
    • Characteristics: Often subtle on plain films, may mimic SC dislocation.
    • Associated injuries: Higher rate of retrosternal complications (pneumothorax, great vessel injury).
    • Imaging: CT chest mandatory to assess for posterior displacement. [26]

Neer Classification for Lateral Clavicle Fractures (1968)

Subdivides Allman Group II based on CC ligament integrity—the key determinant of stability:

  • Type I: Fracture lateral to intact CC ligaments.

    • Mechanism: Usually low-energy direct blow.
    • Stability: Stable—both fragments attached to CC complex.
    • Treatment: Conservative (sling) with excellent prognosis.
    • Non-union rate: less than 5%.

  • Type II: Fracture medial to CC ligaments (or between them with conoid disruption). UNSTABLE.

    • Type IIA: Fracture medial to both conoid and trapezoid (both ligaments attached to lateral fragment).
    • Type IIB: Fracture between conoid and trapezoid (conoid on medial fragment, trapezoid on lateral fragment).
    • Mechanism: High-energy or traction injury.
    • Deformity: Medial fragment displaced superiorly by SCM; lateral fragment displaced inferiorly by arm weight.
    • Treatment: Surgical fixation recommended.
    • Non-union rate: 22-44% with conservative treatment. [9,10]

  • Type III: Intra-articular extension into AC joint.

    • Mechanism: Direct blow to acromion driving it into distal clavicle.
    • Stability: Usually stable (ligaments intact).
    • Treatment: Conservative unless significant joint incongruity.
    • Long-term: May develop post-traumatic AC joint arthritis (10-15% require distal clavicle excision). [36]

Robinson Classification (1998) [Descriptive]

More detailed classification incorporating displacement and comminution:

  • Type 1: Undisplaced or minimally displaced (less than 100%).
  • Type 2: Displaced (> 100% translation).
    • 2A: Simple/wedge pattern.
    • 2B: Comminuted (segmental, butterfly fragment).
  • Type 3: Associated injuries.
    • 3A: Neurovascular injury.
    • 3B: Open fracture.
    • 3C: Floating shoulder (scapular neck + clavicle).

This classification has excellent inter-observer reliability and prognostic value for non-union risk. [3]

Edinburgh Classification (2009) [Medial Clavicle Specific]

For rare medial third fractures:

  • Type 1: Extra-articular, undisplaced.
  • Type 2: Extra-articular, displaced.
    • 2A: Anterior displacement.
    • 2B: Posterior displacement (EMERGENCY—potential airway/vascular compromise).
  • Type 3: Intra-articular (SC joint involvement).
  • Type 4: Epiphyseal separation (adolescents with open medial physis).
  • Type 5: Comminuted.

Type 2B requires immediate CT imaging and potential thoracic surgery consultation. [37]

4. Clinical Presentation

Symptoms

Immediate Post-Injury

  • Pain: Localized to clavicle, exacerbated by shoulder movement, breathing (rib cage elevation), or lying supine.
  • Functional Impairment: Inability to abduct or flex shoulder; patients support affected arm with contralateral hand.
  • Crepitus: Grinding sensation with shoulder movement reported by 40-50% of patients.
  • Deformity Awareness: Visible or palpable "bump" or asymmetry.

Associated Symptoms Suggesting Complications

  • Dyspnea/Pleuritic Pain: Pneumothorax (1-3% of fractures, higher in high-energy mechanisms). [38]
  • Paresthesias: Ulnar-sided hand/forearm numbness suggests lower trunk brachial plexus injury (2-5% incidence). [34]
  • Pallor/Coolness of Hand: Vascular injury (rare, less than 1%, but emergent). [39]
  • Dysphagia/Stridor: Posterior medial fracture displacement compressing esophagus/trachea (medial third fractures only).

Signs

Inspection

  • Shoulder Position: Affected shoulder drooped inferiorly and displaced anteriorly (loss of strut function).
  • Visible Deformity: Prominence/tenting at fracture site in 70-80% of displaced fractures.
  • Skin Integrity: CRITICAL—assess for:
    • Tenting: Blanched white skin over sharp bone end (impending open fracture requiring emergency reduction). [19]
    • Open Fracture: Skin breach (2-3% incidence, dramatically increases infection risk to 10-30%).
    • Ecchymosis: Develops over 24-48 hours, extensive bruising may track down chest wall and arm.
  • Chest Symmetry: Narrowing of shoulder width on affected side with shortening > 2cm.

Palpation

  • Bony Tenderness: Exquisite tenderness over fracture site.
  • Step-Off/Gap: Palpable discontinuity in bone contour.
  • Crepitus: Grating sensation on gentle movement (confirms fracture, avoid excessive manipulation).
  • SC Joint: Palpate medial clavicle—tenderness or asymmetry may indicate medial fracture or SC dislocation (Type III injury).

Range of Motion

  • Active ROM: Severely limited in all planes by pain (patient refuses to move arm).
  • Passive ROM: Gentle passive movement reproduces pain and crepitus.
  • Avoidance: Patient holds arm adducted and internally rotated to minimize clavicle movement.

Neurovascular Examination (MANDATORY)

Vascular Assessment

  • Radial Pulse: Compare bilateral radial pulses (rate, strength, symmetry).
  • Capillary Refill: less than 2 seconds in all digits.
  • Allen's Test: Assess ulnar and radial artery patency (if vascular injury suspected).
  • Subclavian Bruit: Auscultate supraclavicular fossa (arteriovenous fistula or pseudoaneurysm rare delayed complication). [39]

Neurological Assessment

Brachial plexus injury occurs in 2-5% of clavicle fractures, most commonly affecting lower trunk (C8-T1): [34]

  • Upper Trunk (C5-C6):
    • Motor: Deltoid (shoulder abduction), biceps (elbow flexion).
    • Sensory: Lateral arm and forearm.
  • Middle Trunk (C7):
    • Motor: Triceps (elbow extension), wrist extensors.
    • Sensory: Middle finger.
  • Lower Trunk (C8-T1) [MOST VULNERABLE]:
    • Motor: Intrinsic hand muscles (finger abduction/adduction), finger flexors.
    • Sensory: Medial forearm and ulnar hand.
    • Test: Froment's sign (thumb IP flexion compensating for adductor pollicis weakness).

Respiratory Examination

  • Inspection: Asymmetric chest expansion (pneumothorax).
  • Palpation: Subcutaneous emphysema (suggests pneumothorax with chest wall air tracking).
  • Percussion: Hyper-resonance (pneumothorax).
  • Auscultation: Decreased breath sounds apically (pneumothorax in 1-3% of fractures). [38]

Red Flag Signs Requiring Immediate Intervention

  • Skin tenting with blanching
  • Absent or diminished distal pulses
  • Expanding hematoma (suggests active bleeding)
  • Progressive neurological deficit
  • Respiratory distress
  • Posterior displacement of medial fracture (CT to rule out retrosternal injury)

5. Investigations

Imaging

Plain Radiography (First-Line)

Standard Clavicle Series

  • AP View (15-degree cephalic tilt):

    • Technique: Beam angled 15 degrees toward head to project clavicle away from ribs and scapula.
    • Assessment: Fracture location, displacement (superior-inferior, anterior-posterior), comminution.
    • Limitation: Underestimates true shortening due to 2D projection.

  • Zanca View (AP with 10-20 degree cephalic tilt):

    • Technique: Focused on AC joint and lateral clavicle with increased cephalic angulation.
    • Indication: Suspected lateral clavicle or AC joint injury.
    • Advantage: Better visualization of distal clavicle and CC interval.

  • 45-Degree Cephalic Tilt (Apical Lordotic):

    • Technique: Pronounced upward angulation to completely clear ribcage.
    • Indication: Measure true fracture shortening.
    • Method: Measure length of medial and lateral fragments, compare to contralateral side. [40]

Radiographic Measurements

  • Shortening: Difference between affected and contralateral clavicle length. > 2cm indicates increased non-union risk. [4,20]
  • Displacement: Percentage of cortical contact loss. > 100% (complete loss of contact) predicts non-union.
  • Angulation: Usually less relevant than shortening/displacement for decision-making.
  • Comminution: Presence of butterfly fragment or segmental fracture increases instability.

Additional Plain Films Based on Clinical Suspicion

  • Chest X-Ray: Mandatory in high-energy trauma to exclude pneumothorax, hemothorax, or rib fractures. [38]
  • Scapular Y-View: If scapular fracture suspected (floating shoulder).
  • Serendipity View (40-degree cephalic tilt): For medial clavicle fractures to assess SC joint.

Computed Tomography (CT)

Indications

  • Medial Third Fractures: CT chest with IV contrast mandatory to:
    • Differentiate fracture from SC joint dislocation.
    • Assess posterior displacement into mediastinum.
    • Evaluate great vessels (subclavian artery/vein, innominate vessels) for injury. [26,37]
  • Suspected Floating Shoulder: Assess scapular neck fracture displacement.
  • Intra-Articular Fractures: AC or SC joint involvement to determine if articular surface disruption requires surgery.
  • Preoperative Planning: Complex comminuted fractures requiring plate contouring or lag screw placement.

CT Protocol

  • Thin-slice (1-2mm) axial images with coronal and sagittal reconstructions.
  • 3D reconstruction helpful for spatial understanding and patient education.

Magnetic Resonance Imaging (MRI)

Indications (Rare)

  • Brachial plexus injury with progressive neurological deficit (assess for nerve root avulsion vs. stretch).
  • Non-union with unclear infection vs. atrophic bone (MRI differentiates).
  • Assessment of CC ligament integrity in lateral fractures when surgical planning unclear.

Ultrasound

  • Limited role in acute fracture diagnosis.
  • May be used to assess callus formation in healing fractures during follow-up.
  • Can identify associated rotator cuff tears in elderly patients with lateral fractures.

Laboratory Investigations

Usually Not Required in Acute Isolated Fractures

Consider in Specific Scenarios

  • Preoperative Workup (if surgery planned):
    • Complete blood count (CBC)
    • Coagulation profile (PT/INR, aPTT) if anticoagulated
    • Group and screen (blood bank sample)
  • Pathological Fracture Suspected (minimal trauma, lytic lesion on X-ray):
    • Calcium, phosphate, alkaline phosphatase, vitamin D
    • Serum protein electrophoresis (multiple myeloma)
    • Thyroid function, parathyroid hormone (metabolic bone disease)
  • Infection/Non-Union Assessment:
    • Inflammatory markers: CRP, ESR
    • White blood cell count

6. Management Algorithm

                    CLAVICLE FRACTURE SUSPECTED
                              ↓
                   CLINICAL EXAMINATION
                   • Inspection (tenting?)
                   • Palpation (step-off?)
                   • Neurovascular assessment
                   • Respiratory examination
                              ↓
                   PLAIN RADIOGRAPHY
                   • AP clavicle (15° cephalic tilt)
                   • Chest X-ray (if high-energy mechanism)
                              ↓
              ┌────────────────┴────────────────┐
         EMERGENCY?                          NO EMERGENCY
    (Tenting, Open, NV Injury)                  ↓
              ↓                          ANATOMICAL LOCATION?
         IMMEDIATE                    ┌──────┴──────┬──────┐
          SURGERY                  MEDIAL      MIDSHAFT   LATERAL
                                     ↓            ↓          ↓
                                  CT CHEST    DISPLACED?   NEER TYPE?
                                  Retro-      ┌───┴───┐    ┌────┴────┐
                                  sternal?   NO      YES   I/III    II
                                     ↓        ↓        ↓     ↓        ↓
                                  If YES   SLING  SHORTENING? SLING  SURGERY
                                  Surgery         > 2cm OR           (Hook Plate
                                  If NO           > 100%?            or CC
                                  Sling         ┌───┴───┐          Reconstruction)
                                               NO      YES
                                               ↓        ↓
                                             SLING   DISCUSS
                                                     SURGERY
                                                     (Consider:
                                                     Age, Activity,
                                                     Occupation)

7. Management Protocols

Conservative (Non-Operative) Management

Indications

  • Undisplaced or minimally displaced fractures (less than 100% translation, less than 2cm shortening)
  • Middle third fractures with acceptable alignment
  • Lateral third Neer Type I or III fractures (stable)
  • Medial third fractures without posterior displacement
  • Patients unfit for surgery (severe comorbidities)
  • Patient preference after informed consent regarding non-union risk

Immobilization

Simple Broad Arm Sling (Standard of Care)

  • Supports arm weight, reduces pull on lateral fragment
  • Allows elbow mobility to prevent stiffness
  • Duration: 2-4 weeks until pain subsides
  • Evidence: Multiple RCTs show equivalence to figure-of-8 with superior comfort [23,24]

Polysling/Collar-and-Cuff (Alternative)

  • Allows more shoulder mobility
  • May increase comfort in some patients
  • Same outcomes as broad arm sling

Figure-of-8 Bandage (OBSOLETE)

  • Historical device attempting to pull shoulders back and reduce fracture
  • Evidence: No benefit for union or alignment, significantly worse comfort and compliance [23,24]
  • Complications: Axillary skin maceration, brachial plexus compression, patient non-compliance
  • Current recommendation: DO NOT USE

Rehabilitation Protocol

Phase 1: Immobilization (0-2 Weeks)

  • Sling full-time except for hygiene
  • Elbow, wrist, hand ROM exercises hourly
  • Pendulum exercises if pain allows
  • Cryotherapy (ice) for swelling and pain

Phase 2: Early Mobilization (2-6 Weeks)

  • Wean sling as pain permits (typically 3-4 weeks)
  • Active-assisted shoulder ROM (pulley exercises, table slides)
  • Avoid resisted exercises or lifting
  • Clinical assessment at 4-6 weeks
  • X-ray at 6 weeks to confirm callus formation

Phase 3: Strengthening (6-12 Weeks)

  • Progressive resistance exercises once callus visible on X-ray
  • Rotator cuff strengthening
  • Scapular stabilization exercises
  • Return to light duties/non-contact activities

Phase 4: Return to Full Activity (12+ Weeks)

  • Heavy lifting permitted at 12 weeks if fracture united
  • Contact sports at 12-16 weeks with protective padding
  • Full unrestricted activity at 4-6 months

Expected Outcomes with Conservative Treatment

  • Union rate: 95-99% for undisplaced fractures; 76-85% for displaced fractures [4,20]
  • Time to union: 12-16 weeks (clinical), 16-24 weeks (radiographic)
  • Return to work: 6-8 weeks (sedentary), 12-16 weeks (manual labor)
  • Cosmetic: Permanent bony prominence in 70-80% of displaced fractures
  • Functional: 85-90% achieve good-to-excellent shoulder function

Non-Union Risk Stratification

  • Low risk (less than 5%): Undisplaced, simple fracture pattern, non-smoker
  • Moderate risk (10-15%): 1-2cm shortening, simple displacement, older patient
  • High risk (15-24%): > 2cm shortening, > 100% displacement, comminution, female, smoker [4,28,29,31]

Operative Management

Absolute Indications (Emergency or Urgent Surgery)

  • Open fracture (surgical debridement and fixation within 6-8 hours)
  • Skin tenting/impending open fracture (reduction and fixation within 6-12 hours) [19]
  • Neurovascular injury requiring exploration
  • Floating shoulder with displaced scapular neck fracture [22]

Relative Indications (Elective Surgery, Shared Decision-Making)

  • Shortening > 2cm on AP radiograph with cephalic tilt [4,20]
  • Displacement > 100% (complete loss of cortical contact) [4]
  • Comminuted fracture with butterfly fragment [28]
  • Lateral clavicle Neer Type II (unstable) [9,10]
  • Bilateral clavicle fractures (consider fixing one side for functional independence)
  • Polytrauma patient requiring upper extremity function for mobility aids
  • Patient occupation requiring early return to heavy labor
  • Elite or competitive athlete
  • Symptomatic non-union (painful motion, shoulder dysfunction)
  • Patient preference after counseling on risks/benefits

Contraindications

  • Active infection at surgical site
  • Severe osteoporosis precluding stable fixation
  • Medical comorbidities prohibiting safe anesthesia
  • Patient unwilling to accept surgical risks
  • Pediatric fracture with significant remodeling potential remaining

Surgical Techniques

1. Open Reduction and Internal Fixation (ORIF) with Plate

Indications: Midshaft and lateral third fractures requiring stabilization

Approach

  • Incision: Anterior oblique or transverse incision along superior clavicle (follows Langer's lines for better cosmesis)
  • Dissection:
    • Divide subcutaneous tissue and platysma
    • Identify and preserve (or intentionally divide) supraclavicular nerves [counsel patient about numbness]
    • Elevate periosteum subperiosteally anteriorly and posteriorly
    • Protect subclavius muscle and underlying neurovascular structures

Reduction

  • Identify fracture fragments
  • Preserve soft tissue attachments to maintain blood supply
  • Reduce using pointed reduction clamps
  • Restore length and rotation (avoid shortening or malrotation)

Fixation Options

Superior Plating (Most Common)

  • Position: Plate on superior surface (tension side of bone)
  • Advantages:
    • Biomechanically strongest (tension band principle)
    • Easier surgical approach
    • Lower non-union rate (2-7%) [4,5]
  • Disadvantages:
    • Prominent hardware (thin soft tissue coverage superiorly)
    • Higher removal rate for symptomatic hardware (30-50%) [6]
  • Technique: 3.5mm locking or non-locking reconstruction plate, contoured to S-shape, minimum 6 cortices each side

Anteroinferior Plating (Alternative)

  • Position: Plate on anterior or anteroinferior surface
  • Advantages:
    • Less prominent (thicker soft tissue coverage)
    • May reduce hardware irritation and removal rates
    • Safer drilling trajectory (away from pleura)
  • Disadvantages:
    • Technically more challenging (worse visualization)
    • Potential for slightly higher non-union in some series
  • Technique: Pre-contoured anterior clavicle plate preferred

Fixation Principles

  • Minimum 3 screws (6 cortices) in each fragment
  • Use locking screws in osteoporotic bone
  • Lag screw technique for oblique fracture lines (interfragmentary compression)
  • Consider autograft or allograft bone graft for comminuted fractures with bone loss

2. Intramedullary (IM) Fixation

Indications: Simple midshaft fractures, desire to avoid palpable hardware

Techniques

  • Elastic stable intramedullary nail (ESIN)—primarily pediatric
  • Rockwood pin (smooth pin)—largely historical, high failure rate
  • Cannulated screw—selected cases

Advantages

  • Smaller incision (less soft tissue dissection)
  • Lower infection rate
  • Less prominent hardware

Disadvantages

  • Higher reoperation rate (20-30% for migration, non-union)
  • Less rotational stability than plate
  • Not suitable for comminuted fractures
  • Skin irritation from prominent ends

Current Status: Less commonly used than plating due to higher complication rates; may have role in carefully selected simple fractures

3. Lateral Clavicle Fracture Fixation

For Neer Type II (Unstable) Fractures

Hook Plate

  • Technique: Plate with hook that passes under acromion, levering distal clavicle down to intact proximal fragment
  • Advantages: Excellent reduction and stability even with small distal fragments
  • Disadvantages:
    • Mandatory removal at 3-4 months (subacromial impingement causes chronic pain if retained) [21]
    • Rotator cuff erosion if prolonged retention
    • Acromial fracture (1-3%)
  • Outcomes: 90-95% union rate, but reoperation rate approaches 100% for planned removal

Superior Locking Plate with Lateral Extension

  • Technique: Long plate extending onto lateral fragment with multiple locking screws
  • Advantages: Does not require routine removal, no subacromial impingement
  • Disadvantages: Requires adequate distal fragment size for screw purchase
  • Outcomes: 85-90% union rate, lower reoperation rate than hook plate

Coracoclavicular (CC) Ligament Reconstruction

  • Techniques:
    • Suture anchors in coracoid with cerclage around clavicle
    • TightRope or button suspensory device
    • Autograft tendon reconstruction (rarely needed)
  • Indication: Insufficient distal fragment for plate fixation
  • Outcomes: 80-85% union with CC stabilization alone; often combined with plate

4. Medial Clavicle Fracture Management

  • Majority managed conservatively (high union rate)
  • Surgical indications:
    • Posterior displacement with mediastinal compromise [37]
    • Open fracture
    • Significant intra-articular displacement
  • Technique:
    • Small fragment plate or screw fixation
    • Thoracic surgery on standby for posterior fractures (risk of great vessel injury during reduction)

Postoperative Protocol

Immediate (0-2 Weeks)

  • Sling for comfort (not rigid immobilization required with stable fixation)
  • Passive ROM from day 1-2
  • Wound care, suture removal at 10-14 days

Early Mobilization (2-6 Weeks)

  • Sling discontinued at 2 weeks if comfortable
  • Active and active-assisted ROM
  • No resisted exercises or lifting > 5 lbs

Strengthening (6-12 Weeks)

  • Progressive resistance exercises
  • Return to light work at 6-8 weeks
  • Clinical and radiographic assessment at 6 weeks

Return to Full Activity (12+ Weeks)

  • Heavy lifting at 12 weeks (if radiographic union confirmed)
  • Contact sports at 12-16 weeks
  • Unrestricted activity at 4-6 months

Hardware Removal

  • Hook Plates: Mandatory at 3-4 months once union achieved [21]
  • Standard Plates: Symptomatic hardware only (prominence, discomfort, hardware failure)
  • Timing: Minimum 12 months to allow full bone remodeling; earlier removal risks refracture

Surgical Outcomes

  • Union rate: 93-98% with plate fixation [4,5,6]
  • Time to union: 10-14 weeks (faster than conservative)
  • Return to work: 4-6 weeks (sedentary), 8-12 weeks (manual labor)
  • Complication rate: 15-25% (infection, hardware irritation, numbness, reoperation)
  • Patient satisfaction: 80-90% good-to-excellent

8. Complications

Non-Union

Definition: Failure of fracture to heal by 6 months, with persistent pain and motion at fracture site

Incidence

  • Undisplaced fractures: less than 1%
  • Displaced fractures (conservative): 15-24% [4,20]
  • Displaced fractures (operative): 2-7% [4,5]

Risk Factors

  • Shortening > 2cm (strongest predictor)
  • Displacement > 100%
  • Comminution
  • Female gender [29]
  • Age > 40 years [30]
  • Smoking [31]
  • Inadequate immobilization

Clinical Presentation

  • Persistent pain at fracture site (worse with shoulder movement)
  • Palpable motion/clicking at fracture
  • Shoulder fatigue and weakness
  • Cosmetic deformity

Radiographic Findings

  • Persistent fracture line without bridging callus at 6 months
  • Sclerotic bone ends (atrophic non-union) or bone resorption (gap non-union)

Classification

  • Atrophic: Minimal callus, sclerotic ends (biological problem)
  • Hypertrophic: Abundant callus but no bridging (mechanical instability)

Management

  • Conservative for asymptomatic non-unions in elderly/low-demand patients
  • Surgical for symptomatic non-unions:
    • Open reduction and rigid plate fixation
    • Excision of fibrous tissue and sclerotic bone ends
    • Autologous bone graft (iliac crest) for atrophic non-unions [essential for biology]
    • Bone morphogenetic protein (BMP) in selected cases (off-label use)
  • Outcomes: 90-95% healing after surgical treatment of non-union

Malunion

Definition: Fracture healed in non-anatomical position (shortening, angulation, or rotation)

Incidence: 10-20% of conservatively treated displaced fractures

Clinical Consequences

  • Cosmetic: Prominent bump (most common complaint)
  • Shortening > 2cm:
    • Scapular dyskinesis (altered scapulothoracic mechanics)
    • Shoulder fatigue and pain
    • Reduced overhead endurance
    • Possible thoracic outlet syndrome (rare)
  • Excessive Angulation: Usually well-tolerated functionally

Management

  • Most malunions are asymptomatic and require no treatment
  • Corrective osteotomy reserved for:
    • Significant functional impairment from scapular dyskinesis
    • Severe cosmetic deformity unacceptable to patient
    • Documented neurological compromise (brachial plexus)
  • Technique: Osteotomy, lengthening with bone graft, plate fixation

Infection

Incidence

  • Closed fractures treated conservatively: less than 1%
  • Closed fractures ORIF: 2-5% [6]
  • Open fractures: 10-30%

Risk Factors

  • Open fracture
  • Diabetes mellitus
  • Smoking
  • Prolonged operative time
  • Soft tissue stripping

Presentation

  • Acute (0-4 weeks): Erythema, wound drainage, fever, pain
  • Delayed (> 4 weeks): Persistent drainage, non-union, sinus tract

Organisms

  • Staphylococcus aureus (most common)
  • Coagulase-negative staphylococci
  • Gram-negative bacteria (open fractures)

Management

  • Acute superficial: Oral antibiotics, close observation
  • Deep infection:
    • Surgical debridement
    • IV antibiotics (6 weeks)
    • Retain hardware if fracture healing progressing and implants stable
    • Remove hardware if fracture healed or implants loose
  • Chronic osteomyelitis: Staged procedure—hardware removal, debridement, antibiotic spacer, delayed reconstruction

Hardware Complications

Symptomatic Hardware (20-50% of plated fractures) [6]

  • Prominence causing discomfort
  • Backpack strap or seatbelt irritation
  • Cold intolerance over hardware
  • Management: Hardware removal after fracture union (minimum 12 months)

Hardware Failure

  • Plate breakage: 1-5% (usually due to non-union creating cyclic loading)
  • Screw loosening: 2-5%
  • Management: If fracture united, remove hardware; if non-union, revise fixation with grafting

Refracture After Hardware Removal

  • Risk: 2-8% within first 6 months after removal
  • Prevention: Avoid contact sports/heavy loading for 6-12 weeks after removal

Neurovascular Complications

Brachial Plexus Injury (2-5% of fractures) [34]

  • Lower trunk (C8-T1) most commonly affected
  • Mechanism: Traction injury during fracture displacement, or compression by fracture hematoma
  • Presentation: Ulnar-sided hand numbness, intrinsic hand muscle weakness
  • Natural history: 80-90% resolve spontaneously within 3-6 months (neurapraxia)
  • Management:
    • Observation for 3 months (most resolve)
    • EMG/NCS at 3-4 weeks to differentiate neurapraxia (good prognosis) from axonotmesis
    • MRI if progressive deficit (assess for nerve root avulsion)
    • Nerve exploration/repair if no recovery by 3-6 months

Vascular Injury (less than 1%) [39]

  • Subclavian artery or vein laceration or compression
  • Presentation: Absent radial pulse, expanding hematoma, bruit
  • Investigation: CT angiography
  • Management: Emergent vascular surgery consultation, surgical repair

Supraclavicular Nerve Injury (10-20% after surgery) [35]

  • Mechanism: Nerves cross incision and are typically divided
  • Presentation: Numbness over anterior chest wall below clavicle
  • Natural history: Permanent in most cases
  • Prevention: Identify and attempt to preserve nerves intraoperatively (adds time, may not be feasible)
  • Counseling: Inform patients preoperatively this is expected

Thoracic Complications

Pneumothorax (1-3% of fractures) [38]

  • Mechanism: Rib fracture with pleural puncture, or displaced clavicle fragment puncturing lung apex
  • Presentation: Dyspnea, pleuritic pain, decreased breath sounds
  • Investigation: Chest X-ray
  • Management:
    • Small (less than 15%): Observation, supplemental oxygen
    • Moderate-Large: Chest tube thoracostomy
    • Tension pneumothorax: Immediate needle decompression (2nd intercostal space, midclavicular line)

Hemothorax (less than 1%)

  • Mechanism: Intercostal or internal mammary vessel injury
  • Management: Chest tube drainage, rarely requires thoracotomy

Intraoperative Pleural Injury (less than 1%)

  • Mechanism: Drill plunge during inferior screw placement
  • Prevention: Measure drill depth, use drill stop, anteroinferior plate placement (safer trajectory)
  • Management: Recognize intraoperatively (bubbling, deflated lung), place chest tube if significant pneumothorax

Other Complications

Cosmetic Deformity

  • Hypertrophic callus "bump": 70-80% of displaced fractures treated conservatively
  • Usually well-tolerated; remodels partially over 1-2 years
  • Surgical callus excision reserved for severe cases (risk of refracture)

Shoulder Stiffness

  • Uncommon if appropriate rehabilitation
  • Risk factors: Prolonged immobilization (> 6 weeks), elderly, adhesive capsulitis predisposition
  • Prevention: Early ROM exercises
  • Management: Physical therapy, glenohumeral corticosteroid injection if adhesive capsulitis develops

Complex Regional Pain Syndrome (CRPS) (Rare, less than 1%)

  • Mechanism: Abnormal sympathetic nervous system response
  • Presentation: Severe pain, swelling, skin changes, reduced ROM
  • Management: Multimodal (physical therapy, medications, sympathetic blocks)

9. Prognosis

Natural History

Union Rates by Treatment and Fracture Pattern

  • Undisplaced fractures (conservative): 95-99% union [3]
  • Displaced less than 2cm shortening (conservative): 85-92% union [4]
  • Displaced > 2cm or > 100% displacement (conservative): 76-85% union [4,20]
  • Displaced fractures (plate fixation): 93-98% union [4,5,6]

Time to Union

  • Conservative management: 12-16 weeks clinical union, 16-24 weeks radiographic union
  • Operative management: 10-14 weeks radiographic union
  • Full bone remodeling: 12-24 months

Functional Outcomes

Conservative Treatment

  • Return to activities of daily living: 6-8 weeks
  • Return to manual labor: 12-16 weeks
  • Return to contact sports: 12-16 weeks
  • Good-to-excellent shoulder function: 85-90% at 1 year
  • DASH scores: Return to baseline by 6-12 months in uncomplicated cases

Operative Treatment

  • Return to activities of daily living: 4-6 weeks
  • Return to manual labor: 8-12 weeks (faster than conservative)
  • Return to contact sports: 12-16 weeks
  • Good-to-excellent shoulder function: 90-95% at 1 year
  • DASH scores: Significantly better than conservative at 3, 6, 12 months; equalize by 2 years [4]

Factors Predicting Worse Functional Outcome

  • Non-union or malunion
  • Shortening > 2cm (scapular dyskinesis)
  • Associated scapular fracture
  • Brachial plexus injury
  • Older age (> 60 years)
  • Workers' compensation or litigation status

Long-Term Sequelae

Post-Traumatic Arthritis

  • AC joint: 10-15% after Neer Type III (intra-articular) lateral fractures [36]
  • SC joint: Rare after medial fractures
  • Management: NSAIDs, corticosteroid injection, distal clavicle excision if severe

Chronic Pain

  • Affects 5-10% at 1 year (usually mild, activity-related)
  • Higher in patients with non-union, malunion, or hardware irritation

Shoulder Dysfunction

  • Scapular dyskinesis from shortening > 2 cm: 10-20%
  • Thoracic outlet syndrome: Rare (less than 1%), usually from severe malunion

Aesthetic Outcomes

  • Permanent bony prominence in 70-80% of displaced fractures treated conservatively
  • Surgical scar: 10-15cm, usually acceptable cosmesis following Langer's lines
  • Chest wall numbness after surgery: 10-20% (permanent from supraclavicular nerve division) [35]

Mortality

  • Isolated clavicle fractures carry minimal mortality risk (less than 0.1%)
  • Mortality associated with polytrauma or high-energy mechanisms (not the fracture itself)
  • Medial fractures with posterior displacement and great vessel injury: Significant mortality if unrecognized

10. Evidence & Guidelines

Landmark Trials

Canadian Orthopaedic Trauma Society (COTS) Trial (2007) [4]

  • Design: Multicenter RCT, 111 patients
  • Population: Displaced midshaft clavicle fractures (shortening or displaced)
  • Intervention: Plate fixation vs. sling immobilization
  • Primary Outcome: Constant shoulder score at 1 year
  • Key Findings:
    • Non-union: 2% (operative) vs. 15% (conservative), pless than 0.001
    • Symptomatic malunion: 0% vs. 9%, p=0.02
    • Constant score at 1 year: 98.3 (operative) vs. 93.2 (conservative), p=0.001
    • DASH score significantly better in operative group at 3, 6, 12 months
    • Complications: 37% operative (mostly hardware removal), 23% conservative
  • Conclusion: Operative treatment reduces non-union and improves functional outcomes, but increases surgical complications
  • Impact: Shifted practice toward selective surgical treatment for displaced fractures

COTS Long-Term Follow-Up (2015) [5]

  • Design: 9-10 year follow-up of original COTS trial
  • Key Findings:
    • Functional outcomes (DASH, Constant scores) equivalent between groups at 9-10 years
    • Non-union rate still significantly lower in operative group
    • No difference in post-traumatic arthritis rates
  • Conclusion: Functional advantages of surgery diminish over time; non-union prevention remains primary long-term benefit

UK DRAFFT Trial (2017) [Not included in original but relevant]

  • Compared operative vs. non-operative for displaced midshaft fractures
  • Found no significant functional difference at 1 year
  • Criticized for methodological limitations and high crossover rate

Clinical Practice Guidelines

American Academy of Orthopaedic Surgeons (AAOS)

  • Insufficient evidence to recommend for or against routine operative treatment of displaced midshaft clavicle fractures
  • Weak recommendation for operative treatment in shortening > 2cm based on higher non-union risk
  • Strong recommendation against figure-of-8 bandages

British Orthopaedic Association/British Elbow and Shoulder Society

  • Shared decision-making for displaced midshaft fractures
  • Consider surgery for: shortening > 2cm, complete displacement, floating shoulder
  • Conservative treatment acceptable for most fractures if patient counseled on non-union risk

Australian and New Zealand Orthopaedic Association

  • Operative fixation for Neer Type II lateral clavicle fractures (Grade B recommendation)
  • Selective operative management for midshaft fractures based on displacement and patient factors

Current Evidence Synthesis

Systematic Reviews and Meta-Analyses

The Cochrane Review and multiple meta-analyses demonstrate:

  • Operative treatment reduces non-union (RR 0.14-0.25)
  • Faster return to function (4-8 weeks earlier return to work)
  • Higher complication rate with surgery (primarily hardware-related)
  • No consensus on "optimal" displacement threshold for surgery
  • Patient-specific factors (occupation, activity level, tolerance for deformity) should guide treatment

Areas of Ongoing Controversy

  • Precise thresholds for surgical intervention (2cm shortening not universally accepted)
  • Optimal fixation method (superior vs. anteroinferior plating, plate vs. IM nail)
  • Role of biological augmentation (bone graft, BMP) in high-risk fractures
  • Cost-effectiveness of operative treatment

11. Patient Education

Understanding Your Broken Collarbone

What is the clavicle?

Your clavicle (collarbone) is the horizontal bone connecting your breastbone (sternum) to your shoulder blade (scapula). It acts as a strut that holds your shoulder out to the side and allows your arm to hang freely. It also protects important blood vessels and nerves that travel from your neck into your arm.

How did this fracture happen?

Most clavicle fractures occur from a direct blow to the shoulder—for example, landing on your shoulder during a fall, being tackled in rugby, or hitting your shoulder in a car accident. The fracture usually happens where the bone transitions from thick to thin (about two-thirds of the way out toward your shoulder).

Treatment Options

You have two main treatment options. Your surgeon will help you decide which is best based on how displaced (moved out of place) your fracture is, your activity level, and your preferences.

Option 1: Non-Surgical Treatment (Sling)

  • How it works: A simple arm sling supports the weight of your arm, reducing pull on the fracture. Your body naturally heals the bone over 3-4 months by forming a callus (new bone).
  • Advantages:
    • No surgery, anesthesia, or incision
    • No risk of infection or surgical complications
    • Lower cost
  • Disadvantages:
    • Permanent bony "bump" where the fracture heals (this is normal callus)
    • Your shoulder may be slightly narrower if the bone shortens
    • 1 in 7 chance (15%) the bone won't heal (non-union) and may need surgery later [for displaced fractures]
    • Slower return to work and sports (3-4 months)
  • Recovery timeline:
    • Sling for 2-4 weeks
    • Gentle movement at 2-6 weeks
    • Strengthening at 6-12 weeks
    • Return to contact sports and heavy lifting at 3-4 months

Option 2: Surgical Treatment (Plate and Screws)

  • How it works: Through a 10-15cm incision over your collarbone, a metal plate is attached with screws to hold the bone fragments in perfect alignment while they heal.
  • Advantages:
    • Lower risk of non-union (bone not healing)—only 2-3% [vs. 15% with sling]
    • Faster return to function (6-8 weeks to work, 3 months to sports)
    • Bone heals in correct position (no permanent bump from shortening)
  • Disadvantages:
    • Surgery requires general anesthesia
    • 2-5% risk of infection
    • Permanent numbness in a small patch of skin below the collarbone (from cutting small nerves)—this happens in 10-20% and is usually not bothersome
    • You can feel the plate under the skin—20-50% of patients find this uncomfortable and want it removed later (second operation)
    • Risks: bleeding, blood clots, stiffness, hardware irritation
  • Recovery timeline:
    • Sling for comfort for 2 weeks
    • Gentle movement from week 1-2
    • Strengthening at 6 weeks
    • Return to work at 6-8 weeks
    • Return to contact sports at 3 months

Surgery is essential if you have:

  • Skin tenting: The broken bone is pushing against your skin, turning it white—this will break through the skin within hours and cause infection if not urgently fixed
  • Open fracture: Bone has broken through the skin
  • Nerve or blood vessel injury
  • Floating shoulder: Your shoulder blade is also fractured, making the shoulder unstable

Surgery is strongly considered if you have:

  • Bone shortening more than 2cm (this increases non-union risk significantly)
  • Bone completely separated (100% displacement)
  • The fracture is at the end near your shoulder and unstable (Neer Type II)
  • You are a manual laborer, competitive athlete, or need rapid return to work
  • You have fractures on both sides

What is "Skin Tenting" and Why is it an Emergency?

If your broken bone is pushing sharply against the skin from the inside, creating a white (blanched) area, the blood supply to that skin is cut off. Without urgent reduction (putting the bone back), the skin will die within 6-12 hours, and the bone will poke through (converting a closed fracture to an open fracture with high infection risk). This requires emergency surgery tonight.

Recovery Expectations

Pain Management

  • Expect moderate pain for the first 1-2 weeks (managed with prescribed pain medication)
  • Most pain resolves by 4-6 weeks
  • Occasional discomfort with weather changes or heavy use for 6-12 months is normal

Activity Restrictions (Both Surgical and Non-Surgical)

  • No heavy lifting (> 10 lbs) for 3 months
  • No contact sports for 3-4 months
  • Driving permitted once off narcotic pain medication and can control vehicle safely (typically 2-4 weeks)

What to Expect Long-Term

  • 85-95% of patients achieve excellent shoulder function
  • If treated non-surgically, you'll have a permanent bony prominence (bump)—this is normal healing
  • If treated surgically, you'll have a scar and possible numbness, but straighter bone
  • Return to full unrestricted activities by 4-6 months

Warning Signs to Seek Immediate Care

Contact your surgeon or go to the emergency department if you experience:

  • Increasing redness, warmth, or drainage from surgical incision (infection)
  • Fever > 38.5°C (101.3°F)
  • Sudden severe pain
  • Numbness or tingling in your hand that wasn't there before
  • Loss of movement in your hand or fingers
  • Chest pain or difficulty breathing (rare complication)

12. Examination Focus (Viva Vault)

Core Knowledge Questions

Q1: What are the absolute indications for surgical fixation of a clavicle fracture?

Model Answer: The absolute indications are emergency situations where operative intervention is mandatory:

  1. Open fracture: Bone has penetrated the skin, requiring surgical debridement and fracture stabilization to prevent infection.
  2. Skin tenting (impending open fracture): Sharp bone fragment blanches the skin white by compressing blood supply. Without urgent reduction and fixation (within 6-12 hours), skin necrosis will occur and convert it to an open fracture.
  3. Neurovascular injury: Injury to the subclavian vessels or brachial plexus requiring surgical exploration and vessel repair or nerve decompression.
  4. Floating shoulder: Combined ipsilateral clavicle and scapular neck fractures disrupt the superior shoulder suspensory complex, creating instability that requires surgical stabilization of at least one fracture (typically the clavicle).

Relative indications requiring shared decision-making include shortening > 2cm, displacement > 100%, unstable lateral fractures (Neer Type II), and patient-specific factors like occupation or athletic demands.

Q2: Describe the Neer Classification for lateral clavicle fractures and explain its clinical significance.

Model Answer: The Neer Classification (1968) subdivides lateral third clavicle fractures (Allman Group II) based on the integrity of the coracoclavicular (CC) ligaments, which determines fracture stability and non-union risk:

  • Type I: Fracture lateral to intact CC ligaments (both conoid and trapezoid)

    • Mechanism: Direct blow with both fragments attached to CC complex
    • Stability: Stable—ligaments anchor both fragments
    • Treatment: Conservative (sling)
    • Non-union rate: less than 5%

  • Type II: Fracture medial to CC ligaments or between them—UNSTABLE

    • Type IIA: Fracture medial to both ligaments (both attached to lateral fragment)
    • Type IIB: Fracture between conoid and trapezoid ligaments (conoid on medial fragment, trapezoid on lateral)
    • Mechanism: Traction or high-energy injury disrupting ligamentous support
    • Deformity: Medial fragment displaced superiorly by sternocleidomastoid; lateral fragment displaced inferiorly by arm weight
    • Treatment: Surgical fixation (hook plate, superior locking plate, or CC reconstruction)
    • Non-union rate: 22-44% if treated conservatively

  • Type III: Intra-articular extension into AC joint

    • Stability: Usually stable (ligaments intact)
    • Treatment: Conservative unless significant articular incongruity
    • Complication: 10-15% develop post-traumatic AC arthritis requiring distal clavicle excision

Clinical Significance: Type II fractures have high non-union rates with conservative treatment due to loss of ligamentous support and persistent distraction forces. Identifying Type II fractures is essential to appropriately recommend surgical stabilization.

Q3: What were the key findings of the Canadian Orthopaedic Trauma Society (COTS) Trial, and how did it change clinical practice?

Model Answer: The COTS Trial (2007) was a landmark multicenter randomized controlled trial comparing plate fixation versus sling immobilization for displaced midshaft clavicle fractures.

Key Findings:

  1. Non-union rate: 2% (operative) vs. 15% (conservative), pless than 0.001—surgery reduced non-union by 86%
  2. Functional outcomes: Constant shoulder scores and DASH scores were significantly better in the operative group at 3, 6, and 12 months
  3. Malunion: 0% symptomatic malunion in operative group vs. 9% in conservative group
  4. Complications: 37% in operative group (predominantly hardware irritation requiring removal) vs. 23% in conservative group
  5. Long-term follow-up (9-10 years): Functional differences equalized over time, but non-union rates remained significantly different

Impact on Practice: Prior to COTS, nearly all clavicle fractures were treated non-operatively based on older literature suggesting excellent outcomes. The COTS Trial demonstrated that:

  • Significant displacement creates a high non-union risk (15%) that had been underestimated
  • Surgical fixation dramatically reduces non-union and accelerates functional recovery
  • There is a trade-off: surgery introduces risks (infection, hardware complications) but prevents non-union

This led to a paradigm shift toward selective operative management for displaced fractures with shortening > 2cm or displacement > 100%, particularly in younger, active patients. The decision is now individualized based on fracture morphology, patient activity level, and acceptance of surgical risks versus non-union risk.

Q4: Why is the figure-of-8 bandage no longer recommended for clavicle fractures?

Model Answer: The figure-of-8 bandage (clavicle brace) was historically used with the rationale that pulling the shoulders backward would reduce the fracture and improve alignment. However, multiple randomized controlled trials have definitively shown:

  1. No benefit for fracture union: Union rates are identical to simple sling immobilization
  2. No benefit for alignment: Radiographic alignment and shortening are no better than sling
  3. Significantly worse patient comfort: Patients report greater pain and dissatisfaction
  4. Higher complication rate:
    • Axillary skin maceration and pressure sores
    • Transient brachial plexus compression causing arm paresthesias
    • Poor compliance (patients remove it due to discomfort)
  5. No functional benefit: Long-term shoulder function is identical to sling

Current evidence-based recommendation: Simple broad arm sling or polysling for comfort during the first 2-4 weeks, allowing early mobilization. Figure-of-8 bracing is considered obsolete and should not be used.

Q5: Describe the deforming forces acting on a displaced midshaft clavicle fracture.

Model Answer: Understanding the deforming forces explains the characteristic "Z-deformity" seen in displaced clavicle fractures:

Medial Fragment:

  • Displaced superiorly by the sternocleidomastoid (SCM) muscle, which attaches to the superior medial clavicle and pulls it upward toward the mastoid process

Lateral Fragment:

  • Displaced inferiorly by:
    • Gravity (weight of the upper extremity)
    • Loss of the bony strut normally supporting the shoulder girdle
  • Displaced medially by:
    • Pectoralis major muscle pulling the shoulder girdle toward the midline
    • Adduction force from arm hanging at side
  • Rotational force: Lateral fragment may rotate as trapezius loses its lever arm

Resultant Deformity:

  • Overlap of fragments creating shortening
  • Z-shaped configuration (medial fragment up and back, lateral fragment down and forward)
  • Shoulder girdle protraction and apparent narrowing of chest width
  • Superior periosteal hinge often remains intact, providing some stability and scaffold for healing

Clinical Implication: These forces explain why simple immobilization does not reduce the fracture. Surgical fixation neutralizes these deforming forces by rigidly fixing the fragments, allowing anatomical healing.

Advanced/Consultant-Level Questions

Q6: What is a "floating shoulder" and how should it be managed?

Model Answer: A floating shoulder is a double disruption of the superior shoulder suspensory complex (SSSC), consisting of:

  1. Clavicle fracture (disrupting the superior strut), AND
  2. Ipsilateral scapular neck fracture (disrupting the lateral scapular column)

This rare injury pattern (less than 1% of shoulder girdle fractures) creates a "floating" shoulder girdle that is completely detached from the axial skeleton, resulting in severe instability.

Classification (Goss):

  • Type I: Minimally displaced clavicle and scapular neck fractures
  • Type II: Significantly displaced fractures creating true instability

Management Principles:

  • Type I: May be managed conservatively if both fractures are minimally displaced
  • Type II: Surgical stabilization recommended—fix at least one fracture (clavicle or scapular neck) to restore stability
    • Clavicle fixation is technically easier and more commonly performed
    • Scapular neck fixation indicated if significant displacement or intra-articular glenoid involvement
    • Dual fixation (both fractures) considered for severe displacement or high-demand patients

Outcomes: Surgical stabilization achieves 85-90% good-to-excellent functional outcomes. Conservative treatment of significantly displaced floating shoulders results in persistent instability and poor function.

Q7: A patient has persistent pain and clicking at their clavicle fracture site 8 months after injury. Radiographs show sclerotic bone ends with a gap. Discuss your management.

Model Answer: This clinical and radiographic picture is consistent with atrophic non-union of the clavicle.

Diagnosis Confirmation:

  • Non-union defined as failure to heal by 6 months with persistent symptoms
  • Atrophic pattern (sclerotic bone ends, gap) indicates biological failure (poor blood supply, inadequate callus formation)

Assessment:

  1. Symptom severity: Quantify pain (VAS scale), functional impairment (DASH score), impact on activities
  2. Physical examination: Palpable motion at fracture site, shoulder strength and ROM, scapular dyskinesis
  3. Imaging: AP and oblique clavicle radiographs to assess gap, bone quality; consider CT to assess bone stock
  4. Patient factors: Age, activity level, occupation, smoking status, medical comorbidities, expectations

Treatment Options:

Conservative (if minimally symptomatic):

  • Reassurance and activity modification
  • Physical therapy for scapular stabilization
  • Appropriate for elderly, low-demand patients willing to accept persistent deformity

Surgical (standard for symptomatic non-union):

  • Open reduction and internal fixation with bone grafting:
    • Technique:
      • Excise fibrous tissue and sclerotic bone ends to create bleeding surfaces
      • Restore anatomical length (measure against contralateral side)
      • Rigid fixation with 3.5mm superior locking plate
      • Autologous iliac crest bone graft (essential for atrophic non-union to provide osteogenic cells and scaffold)
      • Consider recombinant BMP-2 (off-label) if inadequate autograft
    • Postoperative: Sling 2 weeks, progressive ROM, avoid heavy loading for 3 months

Expected Outcomes:

  • 90-95% healing rate after surgical treatment of non-union
  • Significant pain relief and functional improvement in 85-90%
  • Complications: Infection (5%), hardware irritation, donor site morbidity from bone graft

Q8: Discuss the biomechanical considerations of superior versus anteroinferior plating for midshaft clavicle fractures.

Model Answer: The choice between superior and anteroinferior plate positioning involves biomechanical, anatomical, and clinical considerations.

Biomechanics:

Superior Plating:

  • The clavicle experiences bending moments with arm loading—the superior surface is under tension, the inferior surface under compression
  • Tension band principle: Plate on the tension side (superior surface) most effectively neutralizes bending forces
  • Biomechanical studies show superior plates withstand 10-20% higher loads to failure compared to anterior plates
  • Theoretically lower non-union rates (though clinical studies show minimal difference)

Anteroinferior Plating:

  • Plate positioned anteriorly or anteroinferiorly (slightly off the pure compression side)
  • Relies more on compression and shear resistance rather than pure tension banding
  • May have slightly reduced mechanical advantage but clinically adequate stability

Anatomical Considerations:

Superior Plating:

  • Advantages: Easier surgical exposure (simpler dissection), better visualization of fracture
  • Disadvantages:
    • Thin soft tissue coverage superiorly—plate is more palpable and prominent
    • Higher risk of symptomatic hardware requiring removal (30-50%)
    • Supraclavicular nerves cross surgical field (numbness in 10-20%)

Anteroinferior Plating:

  • Advantages:
    • Thicker soft tissue coverage—less prominent hardware
    • May reduce hardware irritation and removal rates (some studies show 20-30% vs. 40-50%)
    • Drilling trajectory directed away from pleura (safer)
  • Disadvantages:
    • More challenging surgical exposure (requires greater soft tissue elevation)
    • Inferior cortex harder to visualize (risk of intra-articular screw penetration at SC or AC joints)

Clinical Outcomes:

  • Meta-analyses show no significant difference in union rates, functional outcomes, or complication rates overall
  • Potential trend toward lower hardware removal with anteroinferior plates, but not consistently demonstrated

Current Practice:

  • Superior plating remains most common (surgeon familiarity, easier technique)
  • Anteroinferior plating increasingly used by surgeons seeking to reduce hardware prominence
  • Pre-contoured anatomical plates now available for both approaches
  • Choice is often surgeon preference based on training and experience

Bottom Line: Both positions achieve excellent union rates (> 95%). Anteroinferior may have marginal advantage for hardware comfort; superior may have marginal biomechanical advantage. No definitive evidence favors one over the other.

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Learning map

Use these linked topics to study the concept in sequence and compare related presentations.

Prerequisites

Start here if you need the foundation before this topic.

  • Shoulder Anatomy
  • Fracture Healing

Differentials

Competing diagnoses and look-alikes to compare.

  • Acromioclavicular Joint Dislocation
  • Sternoclavicular Joint Dislocation

Consequences

Complications and downstream problems to keep in mind.

  • Non-Union
  • Brachial Plexus Injury