Approach to the Clavicle (Superior and Anteroinferior)

What it exposes. The approach to the clavicle is a direct subcutaneous exposure of the shaft (and, by extension, its medial and lateral ends) that exploits the fact the bone lies almost entirely beneath the skin, suspended between the sternoclavicular and acromioclavicular joints. The surgeon chooses between a superior and an anteroinferior incision depending on the desired plate position.

Indications - Displaced midshaft clavicle fractures with shortening greater than 2 cm, complete (100 percent) displacement, comminution, or bayonet apposition

• Distal third clavicle fractures (Neer Type II) with displacement driven by the weight of the arm and coracoclavicular ligament disruption
• Open clavicle fractures (surgical emergency)
• Clavicle fractures with neurovascular injury (subclavian vessel or brachial plexus compromise)
• Floating shoulder (clavicle plus glenoid neck fracture) and polytrauma where a stable shoulder girdle aids mobilisation and pulmonary toilet
• Symptomatic nonunion or malunion requiring reconstruction or length-restoring osteotomy
• Distal clavicle excision (Mumford procedure) for symptomatic acromioclavicular arthrosis
• Infection or tumour of the clavicle requiring debridement or excision Contraindications - Minimally displaced or non-displaced fractures best managed nonoperatively
• Medical unfitness for anaesthesia
• Active soft-tissue infection or severe abrasive contusion over the surgical site (delay until skin recovers)
• Low functional demand with an acceptable nonoperative outcome Alternative / adjunct approaches - Anteromedial (Edinburgh) approach to the sternoclavicular joint for medial third pathology
• Minimally invasive / subcutaneous plating for selected simple shaft patterns
• Intramedullary fixation via a small lateral stab incision for selected midshaft patterns (preserves periosteum, weaker rotational control) Position & landmarks. Beach chair (semi-sitting) is preferred for almost all clavicle plating: the patient is sat up so the clavicle is horizontal and the shoulder girdle relaxed, with a small bolster or sandbag between the scapulae to throw the clavicle forward, the arm free-draped so the shoulder can be manipulated to aid reduction, and the head turned slightly away from the operative side and secured. C-arm or portable imaging is available for AP and cephalad-tilt views, and all bony pressure points are padded. For anteroinferior plating, beach chair or supine with a scapular bolster lets the arm fall back to expose the anteroinferior surface.

Key bony landmarks: the sternal notch (medial end at the sternoclavicular joint), the entire clavicular shaft (palpable subcutaneously from sternum to acromion), the acromioclavicular joint (lateral prominence), and the coracoid process (just inferior and medial to the distal clavicle - a key reference for distal third work). Soft-tissue landmarks: the platysma in the superficial fascia, the supraclavicular nerves (the middle branch crosses the mid-clavicle), and the external jugular vein crossing the medial clavicle. Superior versus anteroinferior incision

Incision planning. For a superior incision, a straight longitudinal incision is centred over the fracture, in line with the long axis of the bone, long enough to place a plate of adequate working length. For an anteroinferior incision, a gently curved incision runs 1 to 2 cm below and parallel to the inferior border of the clavicle, deepened up onto the anteroinferior surface of the bone. For distal third fractures, the incision is angled toward the acromioclavicular joint to access the deltotrapezial interval.

Work down through the layers directly onto this subcutaneous bone - splitting platysma in line, protecting the supraclavicular nerves at every step, and staying strictly on bone to keep the deep neurovascular structures safe.

Danger structures and how to protect them

Extensile options. Extend medially toward the sternoclavicular joint for medial third fractures, sternoclavicular dislocation and medial clavicle excision - the sternocleidomastoid (clavicular head) is encountered and retracted superiorly, with increasing risk to the subclavian vessels and pleural apex as dissection moves medially (stay strictly subperiosteal). Extend laterally toward the acromioclavicular joint by developing the deltotrapezial interval between deltoid (anterior/inferior) and trapezius (posterior/superior), exposing the distal clavicle, acromioclavicular joint and coracoid region for distal third (Neer) fractures, acromioclavicular reconstruction and the Mumford procedure. Minimally invasive options include subcutaneous bridge plating through two small stab incisions for selected simple midshaft patterns, and intramedullary fixation through a lateral stab - which preserves periosteum but gives weaker rotational and length control than a plate. Closure principles. The closure is as important as the approach because it determines hardware prominence and scar quality. Irrigate copiously and achieve meticulous haemostasis (a drain is rarely required unless dissection was extensive). Then reapproximate the periosteum and deltotrapezial fascia over the plate to cover the hardware and restore the soft-tissue envelope - for distal third fractures, repair the deltotrapezial interval meticulously. Close platysma as a distinct strong layer with absorbable suture (this is the layer that prevents plate prominence and supports a fine scar), then subcutaneous tissue, then skin with a subcuticular monofilament for a superior incision to optimise cosmesis. Ensure no protected supraclavicular nerve is caught in any suture. Intra-operative complications

Post-operative complications

Management of suspected deep injury - Suspected vascular injury: immediate vascular surgery input, proximal control, repair or shunting as required.

• Suspected pneumothorax: intra-operative chest radiograph, chest drain if confirmed.
• New post-operative neurological deficit: document carefully, neurosurgical or nerve-surgeon referral, targeted imaging. Post-operative care. Document a neurovascular examination of the upper limb against the pre-operative baseline, support the arm in a sling for comfort, and consider a chest radiograph after medial dissection to exclude pneumothorax. Rehabilitation uses a sling for 1 to 2 weeks for comfort with pendulum and gentle active-assisted range of movement from the outset, avoiding heavy lifting and contact sport until radiographic union (typically 3 to 4 months). Follow-up: 2 weeks (wound check and subcuticular suture removal), 6 weeks (radiographs and progress range of movement), 3 months (radiographs, confirm bridging callus, wean restrictions), and 6 to 12 months (final radiographs and functional review).

• Clavicle ORIF - plate fixation of displaced midshaft and distal third clavicle fractures, the principal operation done through this exposure.
• Distal clavicle excision (Mumford) - for symptomatic acromioclavicular arthrosis, via the lateral extension.
• Open fracture debridement and fixation, and nonunion or malunion reconstruction with length-restoring osteotomy.
• Sternoclavicular and medial clavicle pathology via the medial extension, and coracoclavicular stabilisation for distal third (Neer) fractures via the deltotrapezial interval.

Guidelines, Registries & Global Practice Management of clavicle fractures is broadly convergent across examination systems. The modern consensus, built on randomised evidence, is that displaced midshaft clavicle fractures (complete displacement, shortening greater than 2 cm, comminution) carry a materially higher risk of nonunion and symptomatic malunion than was historically taught, which has shifted practice toward operative fixation for clearly indicated fractures. Side-by-side principles (where guidance converges): | Body | Position on clavicle fractures |

|------|-------------------------------| | AO Foundation | Anatomic restoration of length, alignment and rotation; superior or anteroinferior plating with adequate working length; bridge comminution while preserving fragment biology | | BOA / BOAST (open fractures) | Open clavicle fractures are a surgical emergency; urgent debridement and appropriate antibiotics; orthoplastic collaboration for significant soft-tissue injury | | AAOS / OTA | Operative fixation for clearly displaced midshaft fractures with shortening or comminution; recognise the elevated nonunion risk in this subgroup | Population evidence: - Clavicle fractures account for a sizeable proportion of all fractures, with a bimodal distribution: high-energy injury in young men and low-energy fragility falls in older adults.

• Nonunion after nonoperative care is concentrated in fully displaced and comminuted midshaft fractures, where it is far higher than the very low rate seen in non-displaced injuries. Global practice variation: In high-resource settings, precontoured superior and anteroinferior locking plates and cortical-button coracoclavicular constructs are standard. In resource-limited settings, the same biomechanical principles are achieved with contoured small-fragment plates and, for many patterns, well-executed nonoperative care remains acceptable where the fracture is not clearly displaced. Consent (globally applicable): discuss numbness from supraclavicular nerve handling, hardware prominence and possible later removal, infection (subcutaneous bone), nonunion or implant failure, the small but serious risk of injury to the subclavian vessels or pleura, and the typical scar.