J Shoulder Elbow Surg (2012) 21, 423-429

www.elsevier.com/locate/ymse

Treatment of clavicle fractures: current concepts review

Olivier A. van der Meijden, MD, Trevor R. Gaskill, MD, Peter J. Millett, MD, MSc*

Steadman Philippon Research Institute, Vail, CO, USA

Clavicle fractures are common in adults and children. Most commonly, these fractures occur within the
middle third of the clavicle and exhibit some degree of displacement. Whereas many midshaft clavicle
fractures can be treated nonsurgically, recent evidence suggests that more severe fracture types exhibit
higher rates of symptomatic nonunion or malunion. Although the indications for surgical fixation of mid-
shaft clavicle fractures remain controversial, they appear to be broadening. Most fractures of the medial or
lateral end of the clavicle can be treated nonsurgically if fracture fragments remain stable. Surgical inter-
vention may be required in cases of neurovascular compromise or significant fracture displacement. In chil-
dren and adolescents, these injuries mostly consist of physeal separations, which have a large healing
potential and can therefore be managed conservatively. Current concepts of clavicle fracture management
are discussed including surgical indications, techniques, and results.
Level of evidence: Review Article.
Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Clavicle fractures; treatment; current concepts

Approximately 2% to 5% of all fractures in adults and common, accounting for approximately 25% of all clavicle
10% to 15% in children involve the clavicle.40,44,49 The fractures, and are less likely to be displaced than those
incidence of this type of fracture in the adolescent and adult occurring in the midshaft. Medial-third fractures comprise
population is reportedly 29 to 64 per 100,000 persons the remaining 2% to 3% of these injuries.1,43,47,49,52,56
annually.43,49,52 Fractures of the clavicle also show Traditionally, nonsurgical management has been favored
a bimodal age distribution. Young male patients who are as the initial treatment modality for most clavicle fractures
aged less than 30 years and elderly patients aged over 70 because of the high nonunion rates reported after operative
years appear to be two distinct age groups at higher risk for treatment.42,54 Although nonsurgical management may be
clavicle fractures.56 optimal for many clavicle fractures, good outcomes of
In adults, more than two-thirds of these injuries occur at nonesurgically treated fractures are not universal.25,45,46,53
the diaphysis of the clavicle, and these injuries are more Recent evidence suggests that specific subsets of patients
likely to be displaced as compared with medial- and lateral- may be at high risk for nonunion, shoulder dysfunction, or
third fractures. In children, up to 90% of clavicle fractures residual pain after nonsurgical management.62 In this
are midshaft fractures.31,43 Lateral-third fractures are less subset of patients, acute surgical intervention may mini-
mize suboptimal outcomes. Therefore, specific treatment of
clavicle fractures should not be broadly applied but rather
Institutional review board approval: not applicable (review article). should be individualized based on fracture characteristics
*Reprint requests: Peter J. Millett, MD, MSc, The Steadman Clinic,
Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail,
and patient expectations.
CO, 81657, USA. The purpose of this review is to provide an overview of
E-mail address: [email protected] (P.J. Millett). the current treatment strategies for clavicle fractures based

1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2011.08.053
424 O.A. van der Meijden et al.

on their anatomic location and stability. In addition, a pediatric clavicle fractures. A recent comparison of these
necessary distinction is made between fractures in adults classification systems showed that Craig’s classification
and fractures in skeletally immature patients. was most prognostic when predicting delayed union or
nonunion of lateral-third fractures and Robinson’s clas-
sification had the greatest prognostic value for middle-
Classification of clavicle fractures third fractures.12,47

A number of classification systems have been proposed to

aid in the description of clavicle fracture patterns for Medial-third fractures
clinical and research purposes.1,12,40,43,52 To date, most
modern clavicle fracture classification systems are Nonoperative management
primarily descriptive and not predictive of outcome. The
first widely accepted classification system for clavicle Fractures of the medial third of the clavicle (Edinburgh
fractures was described by Allman1 in 1967. Fractures were type I) are nearly always treated nonoperatively. These
classified based on their anatomic location in descending clavicle fractures are uncommon, are frequently non-
order of fracture incidence. Type I fractures occur within displaced or minimally displaced, and rarely involve the
the middle third of the clavicle, whereas type II and type III sternoclavicular joint.43,52,53 In general, a sling or figure-of-
fractures represent involvement of the lateral and medial 8 brace is provided for comfort, and as pain allows, early
thirds, respectively. range of motion is encouraged. Patient comfort plays a key
Fractures of the lateral third of the clavicle were further role in the total duration of immobilization, but the
subclassified by Neer,40 recognizing the importance of the immobilization period generally varies between 2 and 6
coracoclavicular (CC) ligaments to the stability of the weeks. A structured rehabilitation ensures a satisfactory
medial fracture segment. A type I lateral clavicle fracture outcome for most patients. To protect the healing clavicle,
occurs distal to the CC ligaments, resulting in a minimally it is important to avoid contact sports for a minimum of 4 to
displaced fracture that is typically stable. Type II injuries 5 months.
are characterized by a medial fragment that is discontin-
uous with the CC ligaments. In these cases, the medial Surgical management
fragment often exhibits vertical instability after loss of the
ligamentous stability provided by the CC ligaments. Type Surgical treatment of medial-end clavicle fractures is
III injuries are characterized by an intra-articular fracture of indicated if mediastinal structures are placed at risk
the acromioclavicular joint with intact CC ligaments. because of fracture displacement, in case of soft-tissue
Although these fractures are typically stable injuries, they compromise, or when multiple trauma and/or ‘‘floating
may ultimately result in traumatic arthrosis of the acro- shoulder’’ injuries are present. Closed or open reduction
mioclavicular joint. A more subtle fracture may require should be performed to reduce the displaced fragment in an
special radiographic views for identification and may be emergent fashion.23,33
mistaken for a first-degree acromioclavicular joint injury. When open reduction is necessary, several techniques
A more detailed classification system (Edinburgh clas- have been described for internal fixation of fracture frag-
sification) was proposed by Robinson.52 Similar to earlier ments. These include wire or plate fixation and interosseous
descriptions, the primary classification is anatomically sutures.17,23,33 In general, Kirschner wire fixation has
divided into medial (type I), middle (type II), and lateral proven unsafe because of breakage and migration. By
(type III) thirds. Each of these types is then subdivided contrast, use of interosseous wires or suture and modified
based on the magnitude of fracture fragment displacement. hooked Balser plate fixation appears more successful but
Fracture displacement of less than 100% characterizes requires a second operation for hardware removal.17,23,33
subgroup A, whereas fractures displaced by more than
100% account for subgroup B. Type I (medial) and type III Children/adolescents
(lateral) fractures are further subdivided based on articular
involvement. Subgroup 1 represents no articular involve- Most injuries in children and adolescents involving the
ment, and subgroup 2 is characterized by interarticular medial end of the clavicle consist of physeal separations.
extension. Similarly, type II (middle) fractures are sub- This is because the medial epiphysis of the clavicle does
categorized by the degree of fracture comminution. Simple not ossify until age 20 years and ossification centers rarely
or wedge-type fracture patterns make up subgroup 1, and fuse before age 25 years.22 It is important, however, to
comminuted or segmental fracture patterns represent differentiate physeal separations from true sternoclavicular
subgroup 2. joint dislocations because of the remodeling potential and
Craig12 further modified Neer type II lateral clavicle because the treatment of these 2 diagnoses can differ
fractures by stressing the importance of the conoid greatly. A computed tomography scan can be helpful to
ligament and separately classifying intra-articular and distinguish these entities.22,33
Current concepts review: clavicle fractures 425

Results members of the Canadian Orthopaedic Trauma Society,

who reported higher nonunion rates and functional deficits
The results of nonsurgical treatment of fractures of the after nonsurgical treatment of midshaft clavicle fractures
medial end of the clavicle are in general satisfactory, when compared with internal fixation.10,36,37
although the low prevalence of these fractures precludes Other authors suggest that specific clavicle fracture
detailed analysis.52 Nonunion rates between 4% and 8% are types are at higher risk for poor patient-reported
reported; however, an increased risk of nonunion accom- outcomes.62 To this end, a retrospective series of 52 non-
panies cases of complete fracture fragment displace- operatively treated patients showed that displaced fractures
ment.52,53 Reports detailing the surgical treatment of with shortening of 2 cm or more are predictive of higher
medial clavicle fractures are also small, providing only nonunion or symptomatic malunion rates.25 Other studies
anecdotal experiences with surgical management.14,17,23,33 have shown that nonunion rates may be as high as 20% in
displaced and comminuted fractures after nonsurgical
Our preferred treatment treatment and that strength and endurance deficits are more
common in these cases.36,52 These reports, in combination
Nonsurgical treatment should be the first treatment of with a more prognostic classification system, have led
choice in the vast majority of patients. However, consid- many authors to recommend acute surgical fixation for
ering the increased risk for fracture nonunion in case of these fracture subtypes.53
complete fracture displacement, open reduction and Therefore, relative indications for acute surgical treat-
internal plate fixation should be considered in these cases. ment may include younger, active patients with clavicle
shortening greater than 1.5 to 2 cm, significant cosmetic
deformity, or multiple-trauma situations. Under these
auspices, surgical fixation may provide more optimal
Middle-third fractures
outcomes and earlier return to sport. Adequate counseling
regarding the risks, benefits, and likely results of treatment
Nonoperative management should occur in these circumstances. Late intervention
should be considered for persistently symptomatic
The goal of clavicle fracture treatment is to achieve bony nonunions or malunions or if acromioclavicular arthritic
union while minimizing dysfunction, morbidity, and changes occur.
cosmetic deformity. Historically, the vast majority of Open reduction and internal fixation of clavicle fractures
clavicle fractures have been treated nonoperatively in the can be performed with either plate or intramedullary pin
acute setting. This is largely because of reported nonunion fixation. Plate fixation can provide immediate rigid fixation,
rates of less than 1% and separate reports by Neer40 and helping to facilitate early mobilization.25,27,39,40 However,
Rowe54 in the 1960s suggesting that operative intervention it is thought that superior clavicle plating may result in
resulted in an increase in nonunion rate by more than 3- a greater risk to underlying neurovascular structures and
fold. In addition, several studies reported high rates of may be more prominent than anterior plating or intra-
patient satisfaction after nonoperative treatment.3,14,43 medullary pin fixation.11,62 A study by Bostman et al6
Nonoperative management remains the treatment of reported that complication and reoperation rates may be
choice for nondisplaced midshaft clavicle fractures (Edin- as high as 43% and 14%, respectively, if hardware removal
burgh type 2A). Meta-analyses of 1,145 nonoperatively is considered. Other reported complications include infec-
treated midshaft fractures, 986 of which were nondisplaced, tion, hardware failure, and hypertrophic scarring.6,8 The
showed a nonunion rate of only 5.9%.62 The nonunion rate recent introduction of anatomically contoured clavicle
for displaced fractures, however, was 15.1% when treated plates may reduce the need for hardware removal.10,26
nonoperatively. Management is identical to that of fractures Antegrade or retrograde intramedullary pin fixation is
of the medial third. typically a more cosmetic technique, requiring a smaller
incision and less stripping of the clavicle compared with
Surgical management plate fixation. Intramedullary pins frequently cannot be
statically locked, thereby providing less rotational and
Definitive indications for acute surgical intervention length stability compared with other fixation tech-
include skin tenting, open fractures, the presence of neu- niques.2,21,54,58 The intramedullary pin also requires routine
rovascular compromise, multiple trauma, or floating removal after clinical and radiographic evidence of healing.
shoulder. Outside of these indications, the management of Reported complications of this specific technique include
displaced fractures of the midshaft (Edinburgh type 2B) implant breakage, skin breakdown, and temporary brachial
remains somewhat controversial. Recent literature is chal- plexus palsy.38,51,57 A recent study reported major
lenging the traditional belief that midshaft clavicle fractures complications requiring revision surgery in 5 of 58
uniformly heal without functional deficit. This paradigm analyzed patients.38 All revisions were performed for
shift is supported by several prospective studies by fracture nonunion.
426 O.A. van der Meijden et al.

Children/adolescents Our preferred treatment

The treatment of choice in children and adolescents with The management of midshaft clavicle fractures should be
midshaft clavicle fractures is less controversial than that in individualized to the patient’s goals and activity level. We
adults. Because of the remodeling capabilities of clavicle generally recommend acute intervention in active patients
fractures in children and adolescents, almost all fractures where displacement of the fracture fragments is greater than
can be treated nonoperatively with a very low incidence of 100%, greater than 1.5 to 2 cm of shortening exists, or
complications.9,48,55 Those patients exhibiting skin perfo- significant comminution is present. For most midshaft frac-
ration or neurovascular compromise may still benefit from tures that do not have excessive comminution or obliquity to
operative intervention.5 In addition, as in adults, the the fracture planes, it is our preference to use intramedullary
degrees of fracture shortening and displacement have pin fixation to minimize fragment stripping, avoid the
recently been reported to predispose to malunion of clavicle supraclavicular nerves, achieve relative stability, and
fractures in adolescents. For these types of fractures, plate improve cosmesis (Fig. 1). In more comminuted fracture
fixation proved a relatively safe and successful treatment to patterns, segmental fractures, or fractures with a large
restore anatomy and shorten time to union.59 amount of obliquity, plate fixation is used. In the case of
Supportive treatment with a sling or figure-of-8 brace is nonunions, the treatment of choice is usually open reduction
used for comfort. Sports participation should be avoided and plate fixation (Fig. 2) with autogenous bone grafting. We
until radiographic evidence of healing is noted, which is use local bone graft in hypertrophic nonunions and iliac crest
typically after a minimum of 6 to 8 weeks. Andersen et al3 bone graft in atrophic nonunions.
evaluated sling and figure-of-8 brace immobilization and
reported no differences in overall alignment or union rates
between the immobilization techniques. In this series,
Lateral-third fractures
however, the sling was better tolerated by patients than the
figure-of-8 brace. Fracture healing is usually accompanied Nonoperative management
by a bump that will undergo remodeling over a number of
months.5,13 Because the majority of fractures of the lateral third of the
clavicle are nondisplaced or minimally displaced and extra-
articular, nonoperative treatment is typically the treatment
of choice.45,52 The rehabilitation and treatment modalities
Results available are similar to those for nonoperative management
of midshaft and medial-end fractures.
Reported outcomes of surgical treatment of midshaft
clavicle fractures have become more favorable over the past Surgical management
2 decades. A meta-analysis of current data on nondisplaced
fractures suggested a relative risk reduction of 72% and The indication for surgical treatment of lateral-third clavicle
57% for nonunion as compared with nonoperative treat- fractures is based on the stability of the fracture segments,
ment by use of intramedullary pin fixation and plate fixa- displacement, and patient age. The integrity of the CC liga-
tion, respectively.62 For displaced fractures, the relative risk ments plays a key role in providing stability to the medial
reduction increased to 87% and 86%, respectively. fracture fragment. Displacement of the medial clavicle is
Patient-reported satisfaction scores may also be superior seen when the CC ligaments are disrupted (Edinburgh type
with early surgical management in some circumstances. A 3B). It is established that this fracture configuration leads to
multicenter trial reported better functional outcomes, lower nonunion rates as high as 28%.40,52 Other authors have
malunion and nonunion rates, and a shorter overall time to reported that the risk of nonunion increases with advancing
union in operatively treated clavicle fractures after plate age and displacement.28,29,53 Again, the presence of soft-
fixation.10 A significant improvement in functional outcome tissue compromise, multiple trauma, and floating shoulder
scores was also reported when operatively and non- are also indications for operative treatment.
operatively treated fractures were compared. The authors Many surgical techniques have been proposed for fixa-
note, however, that functional benefits are less clear when tion of lateral-end fractures. These include Kirschner wire
healed nonoperatively treated fractures and surgically treated fixation,41 CC screws,7 plate or hook-plate fixation,15,24 and
injuries are evaluated. The most recently published trials suture and sling techniques.20,24,32,60 However, reported
comparing intramedullary pin and plate fixation reported complication rates limit their utility. For example, migra-
high union rates and good functional outcome scores in both tion rates of up to 50% and failure of Kirschner wire
groups.16,34 In addition, no significant difference in compli- fixation have led several authors to recommend that it not
cation rates were found between the 2 techniques. be used as a primary fixation technique.18,29,35
Current concepts review: clavicle fractures 427

Figure 2 Nonunion of midshaft clavicle fracture (A) requiring

Figure 1 Preoperative radiograph of right-sided, acute, dis- open reduction and internal plate fixation (B).
placed, midshaft clavicle fracture (A) and corresponding post-
operative radiograph after intramedullary pin fixation (B). because the acromioclavicular and CC ligaments are
biomechanically more robust than the physis. Because of the
Furthermore, the use of CC screw fixation is limited by physeal injury, a large potential for healing and remodeling
the fracture location and extent of comminution. In addi- exists.5 The majority of these injuries can therefore be
tion, screws must be routinely removed because they can treated with a period of immobilization. Indications for
limit shoulder girdle motion. Some failures noted in surgical intervention are infrequent but include considerable
patients treated with CC screw fixation are likely due to the displacement, soft-tissue interposition, open injuries, or risk
combination of rigid (screw) fixation and the motion nor- to soft-tissue structures in older adolescents.30
mally present at this location.
Plate fixation can also be used in circumstances where the Results
distal fragment allows sufficient fixation.28 A hook plate
might be indicated if the distal fragment is inadequate for Nonoperative management of lateral clavicle fractures
screw placement. This is performed in a fashion similar to results in a good outcome in up to 98% of minimally dis-
standard plate fixation with the exception that distal fixation placed or nondisplaced fractures.53 Nonunion rates,
is achieved by placing the ‘‘hooked’’ end of the implant however, are much greater for displaced fractures (Neer
under the acromion to maintain a satisfactory reduction. type II and Edinburgh type 3B) and are reported to be as
Finally, suture and graft sling techniques can be used to high as 33% if treated nonsurgically.40,44,52
reconstruct CC ligaments in a manner similar to anatomic The timing of surgery for lateral-end fractures seems
acromioclavicular joint reconstruction. These techniques more important for patient outcome when compared with
can be used to reinforce other fixation techniques or as the medial-third fractures.28,50 Although the union rate does
primary mode of reconstruction.20,24,32,60 not seem to be influenced by acute or delayed treatment, the
complication rate may be higher when the surgical treat-
Children/adolescents ment is delayed (7% vs 36%).28 Lateral clavicle fractures
that exhibit intra-articular extension may result in an
The physis of the lateral clavicle fuses around the age of 25 increased risk of acromioclavicular joint degeneration. If
years. Therefore, most injuries to the lateral end of the acromioclavicular arthrosis occurs, the patient may require
clavicle result in physeal separation rather than fracture, a late distal clavicle excision.
428 O.A. van der Meijden et al.

Despite the limitations of CC screw fixation, the results of

equivalent of US $500) not related to this manuscript or
fracture healing and restoration of shoulder function are
research from Arthrex. His position was supported by
mostly favorable, although only small cohorts have been
Arthrex.
reported.4,61 Plates have also been used successfully, but
The other author, his immediate family, and any
complications such as peri-implant fracture, nonunion, stiff-
research foundations with which he is affiliated have not
ness, and arthritic progression are of concern in up to 15% of
received any financial payments or other benefits from any
patients.18,19,28 Finally, acceptable functional results and high
commercial entity related to the subject of this article.
union rates have been reported with the use of suture or graft
sling techniques to reconstruct CC ligaments.20,24,32,60

Our preferred treatment References

Nonoperative treatment is typically successful in cases where 1. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its
minimal to no displacement of the fracture fragments exists. articulation. J Bone Joint Surg Am 1967;49:774-84.
However, when CC ligament injury is present and fracture 2. Andermahr J, Jubel A, Elsner A, Hohann J, Prokop A, Rehm KE, et al.
displacement exists, surgical fixation is typically recom- Anatomy of the clavicle and the intramedullary nailing of mid-
clavicular fractures. Clin Anat 2007;20:48-56. doi:10.1002/ca.20269
mended. If sufficient bone is available laterally for screw 3. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures.
purchase, our preference is plate fixation. In cases where this Figure-of-eight bandage versus a simple sling. Acta Orthop Scand
is not possible, we prefer to perform CC ligament fixation to 1987;58:71-4.
hold the fracture fragments in place while healing occurs. This 4. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstable
is typically performed with a CC fixation device with cortical fractures of the distal clavicle. A report of five cases. J Bone Joint Surg
Br 1991;73:291-4.
buttons (Tightrope; Arthrex, Naples, FL, USA) or suture 5. Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat
fixation device. Alternatively, a hook plate can be used, but Res 2005;432:41-8. doi:10.1097/01.blo.0000156005.01503.43
this requires removal and may increase the risk of traumatic 6. Bostman O, Manninen M, Pihlajamaki H. Complications of plate
arthrosis of the acromioclavicular joint. fixation in fresh displaced midclavicular fractures. J Trauma 1997;43:
778-83.
7. Bosworth BM. Acromioclavicular separation. New method of repair.
Surg Gynecol Obstet 1941;73:866-71.
Conclusion 8. Bronz G, Heim D, Pusterla C, Heim U. Osteosynthesis of the clavicle
(author’s translation) [in German]. Unfallheilkunde 1981;84:319-25.
Most medial- and lateral-end fractures can be treated 9. Calder JDF, Solan M, Gidwani S, Allen S, Ricketts DM. Management
of paediatric clavicle fracturesdis follow-up necessary? An audit of
nonsurgically if fracture fragments remain stable. 346 cases. Ann R Coll Surg Engl 2002;84:331-3.
Surgical intervention may be required in cases of neuro- 10. Canadian Orthopaedic Trauma Society. Nonoperative treatment
vascular compromise or significant fracture displace- compared with plate fixation of displaced midshaft clavicular frac-
ment. In children and adolescents, these injuries mostly tures. A multicenter, randomized clinical trial. J Bone Joint Surg Am
consist of physeal separations, which have a large healing 2007;89:1-10. doi:10.2106/JBJS.F.00020
11. Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R.
potential and can therefore be managed conservatively. Anterior-inferior plate fixation of middle-third fractures and nonunions
of the clavicle. J Orthop Trauma 2006;20:680-6. doi:10.1097/01.bot.
0000249434.57571.29
12. Craig EV. Fractures of the clavicle. In: Rockwood CA, Green DP,
editors. Fractures in adults. 6th ed., Vol 1. Philadelphia: Lippincott
Disclaimer Williams & Wilkins; 2006. p. 1216-7.
13. England SP, Sundberg S. Management of common pediatric fractures.
This research was supported by the Steadman Philippon Pediatr Clin North Am 1996;43:991-1012.
Research Institute, which is a 501(c)3 nonprofit institu- 14. Eskola A, Vainionpaa S, Myllynen P, Patiala H, Rokkanen P. Outcome
tion supported financially by private donations and of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;
corporate support from the following entities: Smith & 105:337-8.
15. Faraj AA, Ketzer B. The use of a hook-plate in the management of
Nephew Endoscopy, Arthrex, Arthrocare, Siemens, acromioclavicular injuries. Report of ten cases. Acta Orthop Belg
OrthoRehab, and Ossur Americas. This work was not 2001;67:448-51.
supported directly by outside funding or grants. 16. Ferran NA, Hodgson P, Vannet N, Williams R, Evan RO. Locked
Peter J. Millett has received from a commercial entity intramedullary fixation vs plating for displaced and shortened mid-
shaft clavicle fractures: a randomized clinical trial. J Shoulder
something of value (exceeding the equivalent of US
Elbow Surg 2010;19:783-9. doi:10.1016/j.jse.2010.05.002
$500) not related to this manuscript or research from 17. Flinkkila T, Ristiniemi J, Hyvonen P, Hamalainen M. Surgical treat-
Arthrex. He is a consultant and receives payments from ment of unstable fractures of the distal clavicle: a comparative study of
Arthrex and has stock options in Game Ready. Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand
Olivier A. van der Meijden has received from 2002;73:50-3. doi:10.1080/000164702317281404
a commercial entity something of value (exceeding the 18. Flinkkila T, Ristiniemi J, Lakovaara M, Hyvonen P, Leppilahti J.
Hook-plate fixation of unstable lateral clavicle fractures: a report
Current concepts review: clavicle fractures 429

on 63 patients. Acta Orthop 2006;77:644-9. doi:10.1080/ 41. Neer CS II. Fracture of the distal clavicle with detachment of the
17453670610012737 coracoclavicular ligaments in adults. J Trauma 1963;3:99-110.
19. Franck WM, Siassi RM, Hennig FF. Treatment of posterior epiphyseal 42. Neer CS II. Nonunion of the clavicle. J Am Med Assoc 1960;172:
disruption of the medial clavicle with a modified Balser plate. 1006-11.
J Trauma 2003;55:966-8. doi:10.1097/01.TA.0000090756.65556.97 43. Nordqvist A, Petersson C. The incidence of fractures of the clavicle.
20. Goldberg JA, Bruce WJ, Sonnabend DH, Walsh WR. Type 2 fractures Clin Orthop Relat Res 1994;300:127-32.
of the distal clavicle: a new surgical technique. J Shoulder Elbow Surg 44. Nordqvist A, Petersson C, Redlun-Johnell I. The natural course of
1997;6:380-2. lateral clavicle fracture. 15 (11-21) year follow-up of 110 cases. Acta
21. Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical Orthop Scand 1993;64:87-91.
study of plate versus intramedullary devices for midshaft clavicle 45. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures
fixation. J Orthop Surg Res 2008;3:28. doi:10.1186/1749-799X-3-28 in adults: end result study after conservative treatment. J Orthop
22. Grant JCB. Method of anatomy: by regions, descriptive and deductive. Trauma 1998;12:572-6.
7th ed. Baltimore: Williams & Wilkins; 1965. 46. Nowak J, Holgersson M, Larsson S. Can we predict long-term
23. Hanby CK, Pasque CB, Sullivan JA. Medial clavicle physis fracture sequelae after fractures of the clavicle based on initial findings:
with posterior displacement and vascular compromise: the value of a prospective study with nine to ten years follow-up. J Shoulder Elbow
three-dimensional computed tomography and duplex ultrasound. Surg 2004;13:479-86. doi:10.1080/17453670510041475
Orthopedics 2003;26:81-4. 47. O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK. Clavicle
24. Hessmann M, Kirchner R, Baumgaertel F, Gehling H, Gotzen L. fractures: a comparison of five classification systems and their rela-
Treatment of unstable distal clavicular fractures with and without tionship to treatment outcomes. Int Orthop 2011;35:909-14. doi:10.
lesions of the acromioclavicular joint. Injury 1996;27:47-52. 1007/s00264-010-1151-0
25. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced 48. Owings-Web PA. Epiphyseal union of the anterior iliac crest and
middle-third fractures of the clavicle gives poor results. J Bone Joint medial clavicle in a modern multiracial sample of American males and
Surg Br 1997;79:537-41. females. Am J Phys Anthropol 1985;68:457-66.
26. Huang JL, Toogood P, Chen MR, Wilber JH, Cooperman DR. 49. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of
Clavicular anatomy and the applicability of precontoured plates. clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6. doi:10.1067/
J Bone Joint Surg Am 2007;89:2260-5. doi:10.2106/JBJS.G.00111 mse.2002.126613
27. Kabak S, Halici M, Tuncel M, Avsarogullari L, Karaoglu S. Treatment of 50. Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does
mid-clavicular nonunion: comparison of dynamic compression plating delay matter? The restoration of objectively measured shoulder
and low-contact dynamic compression plating techniques. J Shoulder strength and patient-oriented outcome after immediate fixation versus
Elbow Surg 2004;13:396-403. doi:10.1016/j.jse.2004.01.033 delayed reconstruction of displaced mid-shaft fractures of the clavicle.
28. Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, J Shoulder Elbow Surg 2007;16:514-8. doi:10.1016/j.jse.2007.01.001
Mighell MA. Results of surgical treatment for unstable distal clavic- 51. Ring D, Holovacs T. Brachial plexus palsy after intramedullary fixa-
ular fractures. J Shoulder Elbow Surg 2010;19:1049-55. doi:10.1016/j. tion of a clavicular fracture. A report of three cases. J Bone Joint Surg
jse.2009.11.056 Am 2005;87:1834-7. doi:10.2106/JBJS.D.02919
29. Kona J, Bosse MJ, Steaheli JW, Rosseau RL. Type II distal clavicle 52. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and
fractures: a retrospective review of surgical treatment. J Orthop Trauma classification. J Bone Joint Surg Br 1998;80:476-84.
1990;4:115-20. 53. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE.
30. Kubiak R, Slongo T. Operative treatment of clavicle fractures in Estimating the risk of nonunion following non-operative treatment of
children: a review of 21 years. J Pediatr Orthop 2002;22:736-9. a clavicle fracture. J Bone Joint Surg Am 2004;86:1359-65.
31. Landin LA. Fracture patterns in children: analysis of 8682 fractures 54. Rowe CR. An atlas of anatomy and treatment of midclavicular frac-
with special reference to incidence, etiology, and secular changes in tures. Clin Orthop Relat Res 1968;58:29-42.
Swedish urban populations. Acta Orthop Scand 1983;54(Suppl):1-109. 55. Sanders JO, Rockwood CA, Curtis RJ. Fractures and dislocations of
32. Levy O. Simple, minimally invasive surgical technique for treatment the humeral shaft and shoulder. In: Rockwood CA, Wilkins KE,
of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg 2003; Beatty JH, editors. Fractures in children. 4th ed. Philadelphia: Lip-
12:24-8. doi:10.1067/mse.2003.128564 pincott-Raven; 1996. p. 905-1019.
33. Lewonowski K, Bassett GS. Complete posterior sternoclavicular 56. Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular
epiphyseal separation. A case report and review of the literature. Clin fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br
Orthop Relat Res 1992;281:84-8. 1988;70:461-4.
34. Liu HH, Chang CH, Chia WT, Chen CH, Tarng YW, Wong CY. 57. Strauss EJ, Egol KA, France MA, Koval KJ, Zuckerman JD.
Comparison of plates versus intramedullary nails for fixation of dis- Complications of intramedullary Hagie pin fixation for acute midshaft
placed midshaft clavicular fractures. J Trauma 2010;69:E82-7. doi:10. clavicle fractures. J Shoulder Elbow Surg 2007;16:280-4. doi:10.1016/
1097/TA.0b013e3181e03d81 j.jse.2006.08.012
35. Lyons FA, Rockwood CA Jr. Migration of pins used in operations on 58. Thumroj E, Kosuwon W, Kamanarong K. Anatomic safe zone of pin
the shoulder. J Bone Joint Surg Am 1990;72:1262-7. insertion point for distal clavicle fixation. J Med Assoc Thai 2005;88:
36. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, 1551-6.
Schemitsch EH, et al. Deficits following nonoperative treatment of 59. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative
displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006; treatment versus nonoperative treatment of midshaft clavicle fractures
88:35-40. doi:10.2106/JBJS.D.02795 in adolescents. J Pediatr Orthop 2010;30:307-12. doi:10.1097/BPO.
37. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the 0b013e3181db3227
clavicle. J Bone Joint Surg Am 2003;85:790-7. 60. Webber MC, Haines JF. The treatment of lateral clavicle fractures.
38. Millett PJ, Hurt JM, Horan MP, Hawkins RJ. Complications of clav- Injury 2000;31:175-9.
icle fractures treated with intramedullary fixation. J Shoulder Elbow 61. Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth
Surg 2011;20:86-91. doi:10.1016/j.jse.2010.07.009 method for unstable fractures of the distal clavicle. Int Orthop 1998;
39. Mullaji AB, Jupiter JB. Low-contact dynamic compression plating of 22:366-8.
the clavicle. Injury 1994;25:41-5. 62. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of
40. Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop acute midshaft clavicle fractures: systematic review of 2144 fractures.
Relat Res 1968;58:43-50. J Orthop Trauma 2005;19:504-7.