Midshaft clavicle fractures are often best treated with internal fixation with a plate and screws. Here are a couple of cases.
These are the x-rays of a physician who fell while skiing. Her deformity was significant and her pain considerable due to motion of the fracture.
Active motion begins almost immediately after surgery. Most patients have most to all of their motion at 6 – 8 weeks. Occasionally stiffness delays the return of function. If all goes well, the fracture should be healed b y 6 weeks.
Below are the x-rays of a professional pilot.
Postoperative films below reveal a perfect fracture position.
Occasionally the hardware will bother patients and need to be removed. This patient was bothered by the plate. After confirming complete healing on a CT scan, I removed the plate.
Below are the films of a Lifestar helicopter pilot.
These are just a few of the clavicle fractures treated surgically over the past few months. The only complications that occurred was a neuropraxia of one of the supraclavicular sensory nerves in one patient. (It figures that it was in the physician. This resulted in some hypersensitivity of the skin below the skin incision that is improving.) The other problem encountered was stiffness of the shoulder that completely resolved in another patient.
It is my opinion, that when clinically indicated, the repair of a clavicle fracture with plate fixation yields superior short and long term results when compared to nonoperative treatment. I also believe plate and screw fixation is superior to intramedullary fixation in that it provides immediate stability and an opportunity to resume early use of the shoulder and return of function.
Below is a excerpt from a peer review article from our well respected Journal of the American Academy of Orthopaedic Surgeons regarding the management of clavicle fractures.
From J Am Acad Orthop Surg, Vol 15, No 4, April 2007, 239-248.
Indications
The primary goal in treatment is to restore shoulder function to the preinjury level. By allowing the clavicle to heal with minimal deformity, loss of motion and pain can be minimized. Indications for nonsurgical treatment include a nondisplaced or minimally displaced midshaft clavicular fracture. Indications for surgical treatment include open fractures and fractures associated with skin compromise or with neurologic or vascular injury.
Relative surgical indications include certain multiple-system traumatized patients, a floating shoulder, and a painful malunion or nonunion. More recently, relative indications for surgical treatment have been expanded to include high-energy closed fractures with >15 to 20 mm of shortening, fractures with complete displacement, and fractures with comminution. Although these recently adopted indications have received attention in the current literature, articles dating as far back as the 1960s have described similar surgical indications which is often cited as support for nonsurgical management. Randomized controlled trials, one of which has recently been completed, and another that is currently under way, are necessary to determine whether these relative indications should be considered routine and, if so, in which patients with which fracture types.
Nonsurgical Treatment
Historically, nonsurgical treatment has been the mainstay for clavicular fractures. Most commonly, a sling or figure-of-8 brace is applied in the acute setting. With either device, immobilization is typically for 2 to 6 weeks, based on the patient’s level of comfort. Often, mild discomfort can linger in adults for 3 months. Return to athletics or heavy labor is permitted 4 to 6 weeks after clinical and radiographic union has occurred. Light work with restricted overhead activity can begin once the patient’s comfort allows, usually in 2 to 4 weeks after fracture healing.
In a prospective, randomized study, 26% of patients treated with a figure-of-8 bandage were dissatisfied compared with 7% of those treated with a sling. The patients treated with a sling reported less discomfort. There was no difference in overall healing and alignment of the fractures, indicating that a figure-of-8 bandage does little to obtain or maintain reduction.
Surgical Techniques
Plates
Open reduction and internal fixation using plates and screws can be done with the patient in either the supine or the beach-chair position, with the head and neck tilted away from the surgical site. A bump is placed behind the scapula to aid in the reduction. The arm is prepped in the field to allow for traction and manipulation to assist in the reduction. Traditionally, a skin incision is made over the clavicle following Langer’s lines, as the skin permits. A newly described alternative is to incise the inferior skin after pulling it over the fracture site. As the skin is released, it will fall 1 to 2 cm below the clavicle and prevent the wound from being in contact with the plate on the clavicle. The aim is to improve cosmesis and prevent wound complications. The dissection is taken down to bone with care to identify the cutaneous supraclavicular nerves. When necessary, they can be sacrificed. It is important to inform the patient before surgery of the possibility of a patch of numbness in the skin inferior to the clavicle.
Minimizing subperiosteal stripping with gentle handling of the skin and soft tissue helps avoid complications. The plate usually is placed on the tension side of the bone—for the clavicle, the anterosuperior position. The anteroinferior position demands additional soft-tissue stripping and a more difficult contouring of the plate compared with the anterosuperior position.
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Ideally, a 3.5-mm dynamic compression plate or plate of similar strength should be used, with at least six cortices on each side. Semitubular plates are not as rigid and should not be used. Reconstruction plates are more easily contoured and have been used with success; however, they account for several failures to obtain union and would not be the author’s first choice. Precontoured plates of suitable thickness offer the advantage of ease of placement without manipulation of the plate. Locked plates are not necessary for the acute plating of nonosteoporotic clavicular fractures; there is no significant advantage over conventional plating, and the cost is higher.
Once plating is completed, the fascia is repaired over the plate, if possible, and the skin incision is closed. Suture closure is preferable to staples. With a sufficiently stable construct, unrestricted shoulder motion is allowed, with the exception of overhead lifting for 6 weeks. Often, the pain relief associated with stabilizing the fracture is dramatic, and efforts to limit the patient’s activity may be needed. Pain relief is cited as one of the potential benefits of surgical intervention.
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Complications |
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Complications can occur from nonsurgical treatment as well as surgical treatment. Both can produce a cosmetic deformity. Both can result in malunion, nonunion, pain, local tenderness or irritation, and limitation of motion. Other rare complications following surgical or nonsurgical treatment are residual nerve paresthesia; subclavian vessel compression, thrombosis, and pseudoaneurysm; thoracic outlet syndrome; and brachial plexus neuropathy.
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Some complications are unique to surgical intervention, such as infection and hardware problems. Infection rates vary from 0% to 18%, with the lower rates reported in the more recent studies. Painful, irritating hardware requiring plate or pin removal is reported to be as high as 50% to 100%. Following plate removal, the risk for refracture ranges from 0% to 8%. Adhesive capsulitis of the shoulder has been reported with surgical treatment in 0% to 7% of cases.
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Results |
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Whether treated nonsurgically or surgically, most clavicular fractures heal without incident when length and alignment are maintained. Acceptable cosmetic and functional results should be expected. Satisfactory results occur less consistently when the fracture fails to heal or heals with a significant deformity.
Nonunion
Most cases of nonunion are symptomatic, presenting with pain, loss of function, neurologic changes, and/or unsightly clavicular deformity. Although clavicular nonunion has not been clearly defined in the literature, most authors concur that nonunion is present when healing has not occurred by 16 weeks.
Traditional thinking is that clavicular fractures treated nonsurgically almost always heal and that surgical treatment increases the risk of nonunion. Rowe reported a nonunion rate of 3.7% in patients who underwent surgery compared with 0.8% in those treated without surgery. Neer reported nonunion rates of 0.1% with nonsurgical treatment and 4.6% with surgical treatment. Neer suggested that the most important causal factor for nonunion of a midshaft clavicular fracture is improper open surgery. This may be true to some extent; aggressive soft-tissue stripping, inability to reduce the fracture, and inadequate internal fixation all can lead to poor results.
Several recent studies have reported high union rates with surgical intervention using a variety of internal fixation devices, including plating and IM pin or rod fixation. In addition, there is evidence that the nonunion rate after nonsurgical treatment may be higher than previously reported, particularly in certain fracture types and in certain patients. In their review of 581 nonsurgically treated fractures, Robinson et al reported an overall nonunion rate of 4.5% for diaphyseal fractures. Stratification of Robinson’s data revealed that women with displaced diaphyseal fractures had a nonunion rate ranging from 19% to 33%. When comminution was combined with displacement, the nonunion rate in women increased to a range of 33% to 47%. In addition to fracture fragment displacement, female sex, and comminution, other risk factors identified with nonunion include advancing age, lack of cortical apposition, severity of the initial trauma, the extent of fracture fragment displacement, and, arguably, soft-tissue interposition. Early mobilization has not been associated with the development of a nonunion, whether treated surgically or nonsurgically.
A recently published systematic review of the literature on nonunion after treatment of midshaft clavicular fractures revealed a 5.9% nonunion rate in nonsurgically managed fractures. In the completely displaced fractures, the rate increased to 15.1%. In surgically treated displaced fractures, plating of 460 fractures resulted in a nonunion rate of 2.2%, and IM fixation of 152 fractures resulted in a nonunion rate of 2.0%.
Surgical treatment of nonunion has a high success rate. Techniques include plate fixation with bone graft, IM pin fixation with bone graft, and external fixation. Union rates with each method have been reported to be >92% and as high as 100%. Plate fixation has the largest support in the literature and is currently the most predictable and recommended treatment for symptomatic nonunion. Other methods may be successful in the hands of an experienced surgeon.
Malunion
Most nonsurgically treated clavicular fractures heal with some deformity. The literature does not clearly define when a deformity is considered to be a malunion; however, the evidence strongly suggests that some clavicular deformities result in unsatisfactory outcomes. The deformity is a three-dimensional problem; the most consistent characteristic is shortening with inferior displacement of the medial fragment. Symptomatic patients help define the malunion. Symptoms include weakness and pain in the involved shoulder, loss of shoulder motion, loss of endurance, neurologic symptoms consistent with thoracic outlet syndrome and brachial plexus impingement, and cosmetic deformity.
In 1986, Eskola et al noted in 89 patients that shortening >12 mm was associated with increased pain. Wick et al concluded in a retrospective study that shortening of 2 cm in midshaft clavicular fractures was associated with an increased risk of pain, limitation of motion, or nonunion. McKee et al assessed functional outcome following displaced clavicular fractures and noted significantly inferior scores for both the upper extremity–specific (DASH) outcome scores (P = 0.02) and the Constant scores (P = 0.01) compared with the general population. They concluded that fractures with >2 cm of shortening tended to be associated with decreased abduction strength and greater patient dissatisfaction. Hill et al reported on completely displaced middle third clavicular fractures and concluded that final shortening 
2 cm was associated with an unsatisfactory result but not with nonunion. After closed treatment, 31% of patients were dissatisfied with the final result, 54% were unhappy with the appearance, and 15% of fractures failed to unite. Using the same subjective patient questionnaire as that used by Hill et al, Lazarides and Zafiropoulos reported that final clavicular shortening >18 mm in males and >14 mm in females was associated with unsatisfactory results and with increased patient symptoms.
Ledger et al showed the effect of clavicular shortening >15 mm on biomechanical parameters of the shoulder. They found a significant increase in upward angulation (mean, 10.7°; P <> the uninjured side. The muscle torque of the injured arm was significantly weaker than that of the uninjured arm in extension (P <>P <> (P <>
These studies indicate that although clavicular deformities are complex and hard to assess, shortening of 1.5 to 2 cm, which results in an increased incidence of clinical symptoms, is one parameter that can be measured. Further investigation is needed to clearly define the patients as well as the fracture deformity that is likely to be symptomatic with a clavicular malunion. In this way, acute surgical treatment could be offered to the patients who are most likely to benefit. In addition, comparative trials are necessary to establish that patients with clavicular fractures that predictably result in deformity have better outcomes when treated surgically rather than nonsurgically. Several randomized trials currently are under way, and one has been completed, assessing the surgical versus nonsurgical management of acute displaced midshaft clavicular fractures. The Canadian Orthopaedic Trauma Society has shown in a multicenter randomized trial of 132 patients that for displaced fractures of the clavicular shaft, surgical fixation with a plate and screws resulted in an improved functional outcome and a lower rate of malunion and nonunion compared with nonsurgical treatment at 1 year.
Treatment of a malunion consists of surgical correction to restore length, angular deformity, and rotation of the clavicle. Treatment may or may not involve an intercalary bone graft. Often, after removing the callus of the malunion, it is possible to identify the proximal and distal fragments in order to anatomically reconstruct the clavicle. The benefit of this technique is that there is no donor-site morbidity for a bone graft. When difficulty in determining the length of the malunited clavicle is anticipated, a preoperative radiographic image of both clavicles is helpful. Both IM devices and plates have been used successfully to treat malunions. Treatment of symptomatic malunions has resulted in improvement of the function of the upper extremity, decreased pain, and increased patient satisfaction.
JTM, MD