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Internal fixation of midshaft clavicle fracture using Synthes superior clavicle plate

    Overview

    Learn the Internal fixation of midshaft clavicle fracture using Synthes superior clavicle plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Internal fixation of midshaft clavicle fracture using Synthes superior clavicle plate surgical procedure.
    Clavicle fractures are common accounting for around 2.6% of all fractures, with middle third fractures accounting for 80%. 2-6% occur in the medial third, while the remaining 12-16% occur in the lateral end of the clavicle. These fractures most commonly occur in a young and active population.
    The management of such injuries can be controversial as historically, displaced mid-shaft clavicle fractures have been managed conservatively with low reported non-union rates. However, more literature has reported much higher rates, up to 20% on occasion. It is widely accepted that this can be reduced significantly with surgical intervention.
    Whilst there is some risk with any surgical intervention, the published results also demonstrate that plate and screw fixation can be performed safely to give a good outcome with improved patient satisfaction and a reduction in the non-union rate compared to conservatively managed fractures.
    For displaced lateral end clavicle fractures, there is a higher rate of non-union and therefore, the threshold for surgical fixation is lower. Options for surgical fixation include specific lateral end anatomic clavicle plates utilising a variety of locking screw options for the smaller lateral fragment. Some plates allow reconstruction of the ruptured coracoclavicular ligaments with a non-absorbable material to augment and support the repair. If standard internal fixation is not possible due to comminution, these fractures can also be managed with a hook plate. The lateral end of this plate hooks under the acromion and butresses the lateral clavicle from displacing superiorly. The disadvantage with this type of fixation is that it needs to be removed once the fracture has healed to avoid impinging on the rotator cuff and causing a cuff tear. Whilst in situ, it may also physically limit the arc of movement in the shoulder.
    There are many implant companies with clavicle specific plates. My preference is for the Synthes LCP clavicular (Locking Compression Plates). These are anatomically contoured and sided plates with either a superior or supero-anterior plates option for mid-shaft clavicle fractures. Superior clavicle plates tend to require less contouring. Theoretically, the medial screws are also directed further away from the neuro-vascular bundle. The plates and screws on the Synthes set are made of stainless steel with the “combi-hole” design allowing the option of either locking or non-locking screws within the same hole. The Synthes clavicle set also provides useful instruments to facilitate the surgical exposure and fracture reduction.

    Indications

    INDICATIONS
    Clavicle fractures are common injuries, and the method of management are a source of debate, research and ongoing discussion within the shoulder & trauma surgery community. The indications for internal fixation of a clavicle fracture are relative and largely depend upon patient factors and the degree of displacement and shortening. The majority of such fractures will unite with conservative measures. Several recent high profile publications have looked at the outcomes from randomised trials of fixation of these. Recent literature suggests that overall outcomes of conservative vs. surgically managed clavicle fractures are not significantly different as long as the fracture heals.
    Therefore, informed consent discussing the pros and cons of conservative and operative management are essential in guiding the patient in making a decision. The risks of surgery including infection, wound problems, risk of neurovascular injury and hardware problems have to be weight up against the benefit of improved union rates. Conversely, the risks of conservative management have to be discussed, including higher rates of non-union. One absolute indication though for surgery would be open fractures of the clavicle. Tenting or threat to the skin, neurovascular injuries and floating shoulder injuries (clavicle and scapula fractures) are a relative indication as is significant shortening of the shoulder girdle due to overlap of the fracture fragments.
    In our unit, clavicle fractures are reviewed in clinic by a senior trauma or shoulder surgeon, where the treatment options are discussed before a decision on management plan is made.
    SYMPTOMS & EXAMINATION
    It is important to ascertain that this was a normal shoulder prior to the injury . The fracture usually results from a fall onto or direct blow to the shoulder girdle. This often happens as a result of sport or leisure activities particularly mountain bikes or contact collision team ball sports such as rugby. Patients present with pain and associated swelling around the region of the clavicle. Initially they will be reluctant to move the shoulder however it is important to ascertain whether there is still glenohumeral movement. Care must be taken to avoid assuming that the obvious fracture in the clavicle is the only injury in the shoulder. Previous shoulder trauma or indeed intervention should be ascertained. At the initial presentation clinical assessment of the rest of the shoulder girdle can be very difficult due to the acute pain. Important features to assess and document are the neurovascular status of the upper limb.
    IMAGING
    2 view plain X-rays are mandatory. Standard views include an AP view and a view with 20-30 degrees cephalic tilt.
    Cross sectional imaging may be indicated if there is concern about a fracture towards the medial end and the sternoclavicular joint as this is notoriously difficult to image with plain X-rays. CT scans or indeed MRI scans can be useful looking for occult injuries around the shoulder and should be assessed on a case-by-case basis. Should there be any concerns as to the vascular status of the upper limb then close liaison with local vascular surgery colleagues is important and consideration should be given to angiography or contrast imaging.
    ALTERNATIVE OPERATIVE TREATMENT
    The technique described here is a superior contoured plate but alternatives would be anterior plating or an intramedullary device.
    NON-OPERATIVE MANAGEMENT
    It would be quite acceptable to propose non-operative treatment in such a patient with immobilisation in a sling or figure of 8 bandage or brace allowing underarm hygiene and encouraging elbow wrist and hand movements. Pendular shoulder exercises should be started early and then as pain settles active assisted shoulder movements can be commence. Most patient with such an injury will require sling immobilisation for the best part of the first four weeks and may struggle to be free from the sling until six weeks. Continued conservative management with graduated physiotherapy rehabilitation to concentrate on regaining range of shoulder motion prior to strengthening is well established.
    CONTRAINDICATIONS
    Patients’ co-morbidities and medical state should be assessed as to whether they are fit enough for surgery under general anaesthetic. Patients should be compliant with a post-operative regime as described. The state of the skin should be carefully assessed in the initial period to ensure that there is no soft tissue and skin abrasions over the site of surgical incision as this would be a relative contraindication to immediate surgery. Often surgery will be postponed or delayed due to the presence of fresh skin contusions or abrasions.

    Setup

    The patient is placed in a semi-sitting position at around 45 degrees inclination on a shoulder table. The head is secured in the head clamp of the shoulder table. The head can be laterally rotated and tilted a few degrees to the contralateral side to optimise access to the medial aspect of the clavicle. A small pad is placed behind the medial border of the scapula to aid retraction of the scapula in relation to the thorax. It also aids in stabilising the scapula during surgery and to a lesser extent, aids in maintaining alignment and reduction of the clavicle fracture intra-operatively. The shoulder table cut-outs are removed on the operative side to allow easy access for imaging during the procedure.
    The operative site is prepared in standard sterile fashion and is draped to expose the clavicle from the lateral border of the acromion laterally, to the sternum medially. The lead author does not routinely include the arm in the drapes and is positioned in an adducted position on the the shoulder table.
    Intravenous antibiotics are administered and intermittent calf compression is used for thromboembolic prophylaxis during the procedure unless there is a contraindication.

    Operation – 1

    Pre-operative AP radiograph showing a comminuted, shortened mid-shaft clavicle fracture

    Pre-operative radiographic view with cephalic tilt confirming the amount of shortening
    As it is not possible to get orthogonal views of the clavicle, a radiograph taken with a cephalic tilt of 20-30 degrees can help visualise the fracture pattern better.
    The AP view with cephalic tilt is taken with the patient in an erect position, with the arm in a neutral position at the patient’s side.
    The image receptor is positioned in the coronal plane with the image centred over the clavicle.

    Post-operative AP radiograph taken at 7 weeks
    This radiograph shows that the fixation position is maintained with the the lag screw in situ.
    There is evidence of callus formation at this early stage.

    Post-operative radiograph with cephalic tilt taken at 4 weeks
    A second view help to assess early healing.

    Patient set up on shoulder table, sat up around 40 degrees.The head is secured in a head ring with a slight tilt of 10 degrees to the contralateral side to allow access to the medial clavicle.

    Drapes applied to isolate clavicle and local anaesthetic infiltration used.The shoulder and upper arm is prepped with chlorhexidine and drapes are applied to expose the whole clavicle in the field of view.
    The arm is excluded from the drapes.
    20mls of local anaesthetic with adrenaline 1:200000 is infiltrated along the approach to minimise bleeding during the operation.

    The sternoclavicular joint (SCJ), acromioclavicular joint (ACJ) and lateral border of acromion are marked.
    If it is difficult to locate the ACJ, it is best to palpate the ‘V’ formed by the spine of the scapula (SS) and the posterior border of the clavicle. The lateral border of the acromion (A) is also marked. The ACJ is located at the apex of the ‘V’ and runs anteriorly, parallel to the lateral border of the acromion.

    Site the medial aspect of the incision inferior to the clavicle by around 10mm, the lateral aspect is just posterior to the midpoint of the ACJ.An Incise drape is applied to help maintain a sterile field.
    This helps to fix the drapes and prevent the drapes from falling away and desterilising the operative field.

    Incision through skin and fat is made with skin tension maintainedThe fingers are used to spread the skin to maintain tension in the soft tissues.

    The local anaesthetic and adrenaline help minimise bleeding.

    Before incising the deltoid and pectoralis fascia, it is helpful to locate the fracture site (marked by forceps).The deltoid and pectoralis fascia is the fascial layer that overlies the deltoid and pectoralis major muscle. At its superior margin, it attaches onto the clavicle.

    The supraclavicular nerves (A) commonly run across the operative field. These may be cut and allowed to retract if they impede fracture reduction or plate application.
    The supraclavicular nerves arise from the third and fourth cervical nerves and emerge from beneath the posterior border of the sternocleidomastoid and descend in the posterior triangle of the neck.
    They start in the layer beneath platysma and deep cervical fascia but pierce the fascia and platysma around the clavicle to become cutaneous. This is superficial to the deltoid and pectoralis fascia.
    They are normally grouped into an anterior, middle and posterior group. The middle supraclavicular nerves are the nerves that cross the middle third clavicle during the approach.
    Transection of these nerves can result in an area of numbness inferior to the clavicle, although usually improves over time and of minimal clinical significance.

    Incision with diathermy through clavipectoral fascia and periosteum in one layerThe superior aspect of the shaft of the medial fragment is palpated and a longitudinal incision is made through the fascia and periosteum as one layer.

    The local musculature is as annotated on the image:
    A – Pectoralis major
    B – Trapezius
    C – Deltoid

    A Pennybacker elevator is used to lift the periosteum from the clavicle to expose the fracture.It is important to free the periosteum circumferentially to fully expose the fracture edges at the fracture site. It also exposes enough bone to allow the application of a reduction clamp to allow manipulation of the fragments.
    More medially, the periosteum can be elevated superiorly to enough space for plate application.

    Reduction clamp applied to medial fragment to deliver the medial fracture end and then elevate it, giving access to the inferior aspect of the clavicle. By freeing the periosteum circumferentially, the medial fragment can be held with a reduction clamp to aid manipulation and reduction of the fracture fragments.

    Periosteum is elevated of medial fragment inferiorly to expose medio-inferior extent of fracture siteBy lifting the medial fragment, the periosteal elevator can be used to free the inferior aspect of the clavicle medially to determine the medial limits of the fracture.
    When performing this step, it is important to ensure that the periosteal elevator remains in contact with the bone and dissection remains subperiosteal. The brachial plexus and subclavian vein and artery are at risk if there is any deviation from this plane.
    Studies have shown that the subclavian artery lies 15-22mm from the posterior border aspect of the clavicle in the medial third of the clavicle (Lo et al.), whilst the subclavian vein lies even closer at an average of 4.77mm from the clavicle.
    Robinson et al. have shown that the brachial plexus lies closest to the clavicle in the middle third at an average of 15.2mm.

    The deltoid fascia and periosteal layer covering the lateral fragment is incised, exposing the lateral fragment.

    The medial fragment can be displaced to optimise the view when exposing the lateral fragment.The medial fragment can be displaced using a Langenbeck or West retractor. There is little risk as the medial fragment is usually displaced posteriorly and superiorly.
    This is an important step as the lateral fragment commonly lies inferior to the medial fragment.
    This step can only be performed easily if the soft tissue envelope around the bone has been freed adequately.

    A reduction clamp is applied to the lateral fragment.

    The main fragments are distracted to view the fracture site better and assess the level of comminution.In this case, this is a multifragmentary fracture.

    The exposed fracture site reveals a butterfly fragment impacted on the lateral fragment.The butterfly fragment is held in the forceps in this image.

    Once mobilised, it is important to orientate all fragments anatomically to aid adequate restoration of length and rotation of the clavicleIt is important to respect and maintain soft tissue attachments to the butterfly fragments where possible.
    As demonstrated in this image, there is very little soft tissue attachment remaining.
    Despite the lack of soft tissue attachment (and blood supply) to these fragments, the author feels that it is important to retain these fragments if possible to aid in anatomical restoration of length, alignment and rotation.
    If these fragments can also be fixed robustly, it can aid in the stability of the overall construct.
    Do note that these fragments can be significantly displaced and rotated from their original position.

    Once orientated, the butterfly fragment is held reduced with a pointed reduction clamp, and the rest of the fracture with toothed reduction clamps.

    A 3.5mm drill is drilled through the near cortex of the butterfly fragment.It is applied as perpendicular as practicable to the fracture plane as per the principles of lag screw application. This is to allow compression when a screw is applied without shear.

    The drill hole in the butterfly fragment is shown.

    Operation – 2

    A 2.5mm sleeve is inserted into the drill hole in the butterfly fragment, which is then drilled through to the far cortex.This is to ensure that the drill hole made in the far cortex is aligned and concentric with the near drill hole.

    A 2.5mm drill hole is made in the far cortex.

    A countersink is used in the near drill hole, followed by the depth gauge .This is to allow even distribution of compressive forces of the screw head on the bone when it is applied.
    This minimises the risk of propagation of the fracture if an excessive force is applied.

    A depth gauge is used to measure the length of the screw.
    It is important that, for the lag screw to work, the screw has to be of adequate length so that it engages in the far cortex.
    By measuring the longer distance in oblique fractures ensures this.

    The drill hole in the far cortex of the butterfly fragment is tapped.This step is not necessary if the screw is self tapping.

    A 3.5mm cortical screw is applied across the fracture site to produce inter-fragmentary compression.The position of the reduction clamp is maintained to stabilise the fragment when drilling and applying the screw. Therefore, the preplanning the position of the clamp is important to allow space for the application of the lag screw.
    Note, depending on availability and the size of the butterfly fragment, smaller diameter screws can be used.

    This image shows the lag screw in situ.
    By fixing the butterfly fragment and reducing the number of mobile fragments the fracture can be reduced more easily.

    The clavicle is manipulated into position to allow reduction of the main medial and lateral fracture fragments.In this image, it becomes apparent that there has been a malreduction of the butterfly fragment. This prevents an antomical reduction of the fracture.

    The lag screw is removed and the butterfly fragment is reduced in an anatomical position and held with a 1.6mm Kirschner wire.
    The fragment in this case was rotated by 180 degrees from medial to lateral.
    It can be very difficult in comminuted fractures to adequately reduce these fracture fragments in the correct orientation.

    This image shows a more satisfactory reduction of the fragment.
    It also shows how unstable and difficult the reduction and maintaining the reduction can be.

    A second 1.6mm Kirschner wire is applied to stabilise the butterfly fragment.
    These wires engage into the posterior cortex of the lateral shaft fragment.
    It is important to ensure these wires are not overly proud as the apex of the lung is posteroinferior to the clavicle.

    This slide shows that the fracture edges of the medial and lateral fragments now correspond and allow a better reduction of the fracture.

    If there is insufficient space, a wire may need to be removed to allow the application of the lag screw.

    A 3.5 mm drill is again used to drill the near cortex.

    The drill hole is placed concentrically in the bone.

    A 2.5mm drill sleeve is inserted into the drill hole to maintain concentric drilling.

    A 2.5mm drill is drilled through far cortex.
    Whenever drilling through the far cortex, it is important that the drill does not plunge through the soft tissues.

    The countersink is used again.

    Care need to be excercised using the depth gauge.
    As with the application of any instruments, it is important not to plunge into the soft tissues. When measuring, there is tactile feedback of the hook of the depth gauge passing through 2 cortices and it latching onto the far cortex when pulled back.

    The drill hole is tapped, being careful not to disrupt the reduction achieved.
    To do this, it is important to appreciate the direction of the drill when drilling and measuring with the depth gauge. If the trajectory is off and the tap does not in the far cortex, it can displace the reduction. This can be seen or felt by an increase in resistance. If this is the case, it is important to back the tap out and reassess.
    If you are unable to correct the trajectory, back out the tap and re-pass the depth gauge to help ascertain the direction.

    A 3.5mm cortical screw is applied. As before with tapping, it is important to remember the direction of the screw. If in doubt, reassess with the depth gauge!

    With the butterfly fragment fixed the construct is much more stable.

    A second reduction is performed using reduction clamps.

    Once both ends of the fracture are definitively reduced, the reduction clamps are reorientated across the fracture site to maintain reduction.

    A Synthes 8 hole superior clavicle plate is selected, this is both a sided implant and available in 6,7 and 8 hole lengths.Once the fracture is reduced, an appropriately sized clavicle plate is selected. With experience, it is usually possible to select the appropriate length plate by eyeballing the fracture configuration.
    The aim is to ensure that there are six cortices held, i.e. 3 screws, either side of the fracture.
    If in doubt, the length of plate needed can be measured. There are also templates that can be used to check length.
    The Synthes superior clavicle plates are anatomic, locking compression plates.
    They are sided come in 6, 7 and 8 hole lengths.

    Operation – 3

    There are laser markings etched on the plate to identify the orientation of the plate on the bone.
    The forceps marks the ‘LAT’ with arrow laser marking that indicates the end of the plate that should lie laterally.
    From experience, the overwhelming majority of plates sit better orientated with the lateral aspect of the plate sitting medially!

    The clamps are carefully loosened as required and the plate is trialled on the bone.It is important to ensure that:
    There is adequate soft tissue exposure to allow seating of the plate.
    Both ends of the plate sit on the bone and that the the curves of the plate match the anatomy of the clavicle to allow adequate screw application.
    The plate is orientated so that there are six cortices of hold either side of the fracture.
    The plate does not span or encroach on the ACJ as this can cause local irritation.
    Note that if the plate still does not align with the contour of the clavicle, the plate can be contoured with bending irons. There is also the option of the superoanterior plate if you are struggling.

    If needed, the skin incision is extended to allow enough exposure to apply the plate.
    The skin incision has been extended laterally to expose the lateral end of clavicle better.

    The plate can now be applied appropriately in relation to the lateral end of clavicle in the first instance.It can be tricky to apply the plate and maintain reduction when the fracture is unstable when no clamps are applied.
    Although there is no substitute for experience in this part of the procedure, the rehearsal of fracture reduction in the previous steps allows the surgeon to appreciated how the fracture can be reduced and can be stabilised once the plate is on.
    Note the branch of the supraclavicular nerve (A) has been preserved in this case.

    The plate can be clamped onto the bone to maintain the position and reduction. A lateral drill hole is made using the 2.5mm drill to the lateral most hole in the plate, and then measured.Once all the conditions for plate application have been met, the position of the plate is set by drilling the lateral hole on the plate.
    As each hole on the plate is a combihole, it has the option to accommodate locking and non-locking screws.
    The section of the hole with threads in is for locking screws application. These require a screw in locking guide to be applied to set the appropriate direction of drill hole for the locking screw to lock into the plate when fully seated.
    Locking screws tend to be reserved for poor quality bone or if there is a concern with adequacy of fixation. The cut out strength of the locking screw/plate construct is higher than for a cortical screw/plate construct.

    The length of the drill hole is measured.
    Note, a mini Hohmanns retractor is used to retract the soft tissues and clear the operative field. It also acts as a guide for the posterior border of the lateral end of clavicle and ensure appropriate seating of the plate.
    It is important the appreciate that the AP width of the lateral end of clavicle increases as it flares towards the ACJ. This can aid in maximising the options for plate positioning.

    The most lateral 3.5mm cortical screw in the plate is applied but not fully tightened to allow mobility of the plate, which is required when planning how to sit the plate for optimal location for the remaining screws through it.

    Before securing the medial end of the plate, it is important to ensure the fracture reduction is maintained and the medial end of the plate sits on the medial end of the clavicle.A pointed reduction clamp may allow greater clearance of the plate to maintain fracture reduction and allowing some mobility of the plate.

    One of the medial holes is drilled using a 2.5mm drill to set the alignment of the plate after which the screw is measured and tapped.Note, this does not have to be the most medial hole. It is usually the second most medial hole as it is easy to access comfortably and can assess whether the plate will sit appropriately along the medial aspect of the clavicle.
    There is usually enough mobility in the soft tissues to retract and expose the medial aspect of the clavicle with a Langenbeck retractor.
    This can help with minimising the length of incision. However, if in any doubt, the incision can be extended as mentioned previously.
    Greater care is required to ensure that the drill does not plunge due to the potential structures at risk at the medial aspect of the clavicle.
    These include the subclavian artery and vein, brachiocephalic trunk and vein, aorta, brachial plexus and thoracic cavity.

    When measuring the screw length, it is important that the screw is long enough to get bicortical hold, but not too long to be proud and irritate the soft tissues.
    It is important to check that the nose of the depth gauge is fully engaged on the plate before taking a reading.
    It is also worth noting whether the plate is sat off the bone, as once the screw is applied and compressed, it can leave the screw proud.

    Both screws at either end of the plate are fully tightened to set the alignment and to stabilise the reduction

    The remaining screw holes are drilled and screws inserted.At this stage, the plate can still be used in compression mode by drilling eccentrically in the plate holes if greater compression at the fracture site is desired.
    To use a plate in compression mode, the drill is engaged eccentrically in the oval drill hole that is furthest away from the fracture site. This is so that when the screw head engages in the plate, it pushes the bone towards the fracture site, thus compressing it.
    A fracture can be serially compressed in this way and can be done on either side, although it is important not to over compress it. Theoretically, it can be serially compressed 2-3 times, although the limitation is down to the size of the oval holes in the plate and how much travel and space remains in the hole.
    If this is desired, when engaging the screw head, it is important to loosen off the previous compression screw to allow mobility of the bone in relation to the plate. Once compressed, the screws can be re-tightened again.

    The image shows adequate reduction and stabilisation of the fracture.

    Fracture fragments that are too small to fix can be sutured into position after screw fixation has finished.These are for fracture fragments to small to take a lag screw but still have some soft tissue attachment.
    In this case, there is an inferior fragment that is not easily visualised from the images taken.
    Note, the lead author finds it safer to pass the blunt end of the needle through the tissues during this step.

    The suture can be secured over the plate.

    The suture can also be secured through the holes of the plate.

    Intra-operative imaging is required before completion of the case to ensure the screws are not long.
    Sterile drapes are applied to the image intensifier to minimise the risk of contamination during imaging. Images are only really required at the end to confirm adequacy of fixation.
    The image intensifier is normally positioned from the contralateral side in a perpendicular plane to the body.
    The removed cut-out from the shoulder table over tha clavicle aids imaging although the table can still obscure the view. If this is the case, it is possible to tilt the beam in the mediolateral plane so that the table is cleared.
    The reason for the imaging is to show adequacy of fixation and that the screws are not too long to put neurovascular structures or the rotator cuff at risk.

    This second adjustment gives a better AP view of the screws and a better appreciation as to whether the screws are long.

    The clavipectoral fascia and periosteal layer are closed in one layer.This is to minimise soft tissue irritation from the plate.
    A number 1 vicryl continuous suture is used for this layer.

    A 2-0 vicryl continuous suture is used to close the fat layer.

    A subcuticular 3-0 monocryl is used for the skin.

    The suture know can be left outside of the skin to minimise soft tissue irritation.

    Half inch steristrips are applied to support the wound closure.

    A waterproof dressing is applied.
    This dressing is left in situ for 2 weeks.

    An absorbant pad and hypafix dressing is applied to absorb any excessive bleeding, although this is uncommon.

    Operation – 4
    Post Operative

    Post-operatively, patients are reviewed by the physiotherapy team before discharge to encourage mobilisation of the elbow, wrist and hand. The arm is supported in a sling for 4-6 weeks. Active assisted shoulder mobilisation is allowed although elevation of arm above shoulder height is restricted for the first four weeks.
    Patients are reviewed in clinic at two weeks to check the wounds and ensure they are compliant with the rehabillitation programme. Check X-rays are taken at 6-8 weeks in clinic.
    Full active range of motion is initiated at four weeks. When clinical and radiographic signs of union are present (around 6-8 weeks), strengthening exercises of the rotator cuff, deltoid, and trapezius are commenced. Patients usually return to sporting activities by three to four months.

    Recommended Reading

    Nicholson JA, Clement N, Goudie EB, Robinson CM. Routine fixation of displaced midshaft clavicle fractures is not cost-effective: a cost analysis from a randomized controlled trial. Bone Joint J. 2019 Aug;101-B(8):995-1001. doi: 10.1302/0301-620X.101B8.BJJ-2018-1253.R2.
    A prospective randomised trial showing no difference in functional outcome scores between non-operative and operative management beyond six weeks. Non-union rates were higher in the conservative group. Once non-union cases were excluded, there was no difference in outcome between the two groups.
    Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10.
    Operative fixation of displaced midshaft clavicle fractures results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up.
    Robinson L, Persico F, Lorenz E, Seligson D. Clavicular caution: an anatomic study of neurovascular structures. Injury. 2014 Dec;45(12):1867-9. doi: 10.1016/j.injury.2014.08.031. Epub 2014 Sep 2.
    A cadaveric study looking at the anatomic relationship of neurovascular structures and their proximity to the clavicle.

    Reference

    • orthoracle.com

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