Midshaft (Allman Group I / Edinburgh 2B) and distal (Neer IIA/IIB) clavicle fractures — when to operate, the exposure step by step, and the evidence that anchors the decision.
- Two pivotal midshaft RCTs anchor the operative decision. The Canadian Orthopaedic Trauma Society (COTS) multicentre RCT (2007, PMID 17200303, 132 patients, plate vs sling) reported non-union of 2/67 with ORIF vs 7/65 non-operative, with better Constant and DASH scores. The Robinson Edinburgh RCT (2013, PMID 24005198, 200 patients) reported non-union of 1/200 with ORIF vs 16/200 non-operative — BUT once non-unions were excluded the functional scores were equivalent, so the authors did NOT support routine ORIF for every displaced fracture.
- Absolute indications for ORIF: open fracture, neurovascular compromise, impending skin perforation (tent sign), floating shoulder (ipsilateral scapular neck fracture), and polytrauma or bilateral clavicle fractures.
- Relative indications (shared decision): shortening greater than 2cm, displacement greater than 100% shaft width, comminuted fractures in the dominant arm, and high-demand athletes — the main proven benefit is reduction of non-union, so the operative versus non-operative risk/benefit must be discussed with the patient.
- Distal clavicle Neer IIB fractures: the coracoclavicular ligaments are detached from the distal fragment so the medial (proximal) fragment migrates superiorly — a high non-union rate (about 22–33% historically; 36% in the Hall/McKee RCT) with non-operative treatment, so most displaced type II fractures are offered fixation.
When & Why
Clavicle ORIF restores length, alignment and rotation of a fractured clavicle with plate-and-screw fixation. The central question for a midshaft fracture is not whether you can plate it but when plating is genuinely indicated — the high-level evidence shows surgery reliably prevents non-union and symptomatic malunion but does not, on its own, deliver better function once a fracture unites. The decision is therefore individualised and shared. Absolute indications are non-negotiable. Operate whenever the fracture is open, when there is neurovascular compromise, when bone is tenting the skin (the tent sign — an imminent open fracture), when there is a floating shoulder (an ipsilateral clavicle plus scapular neck fracture), or in polytrauma or bilateral clavicle fractures where the patient cannot weight-bear through either arm.
- Rationale
- Contamination and bone exposure — proceed to debridement and fixation
- Rationale
- Subclavian vessel injury or brachial plexus compromise — emergent exploration
- Rationale
- Bone spike tenting the skin — an imminent open fracture
- Rationale
- Ipsilateral clavicle plus scapular neck fracture — the upper limb is mechanically detached from the thorax
- Rationale
- Polytrauma context — inability to weight-bear through either arm
- Evidence basis
- The strongest single predictor of non-union and a cause of shoulder girdle asymmetry
- Evidence basis
- Associated with worse functional outcomes if non-union occurs
- Evidence basis
- Higher non-union risk; active patient unable to accept prolonged recovery
- Evidence basis
- Early fixation facilitates nursing care and mobilisation and reduces fat embolism risk
- Evidence basis
- Earlier return to sport and specific occupational demands
Distal clavicle fractures — decide on ligament integrity, not displacement alone. The Neer classification hinges on the coracoclavicular (CC) ligaments (full detail in Background & Evidence). A displaced Neer IIB fracture is unstable — the conoid ligament is detached or carried on the proximal fragment, so the proximal fragment is pulled superiorly by the trapezius and has a non-union rate of about 22–33% (36% in the recent Hall/McKee RCT, PMID 34128498). Most displaced type II fractures are therefore offered fixation. Neer I and IIA (CC ligaments intact) are stable and treated non-operatively.
Open, neurovascular compromise, tent sign, floating shoulder, bilateral or polytrauma. These are not optional and should be fixed.
Shortening greater than 2cm, displacement greater than 100%, comminuted dominant arm, high-demand athlete. The proven benefit is fewer non-unions, traded against infection and hardware removal.
Undisplaced or minimally displaced (Edinburgh 2A) and stable distal (Neer I/IIA). A broad arm sling for comfort is the standard of care.
Non-operative management — when to choose it. For undisplaced or minimally displaced midshaft fractures (Edinburgh 2A), non-operative management remains the standard of care. A broad arm sling for comfort is preferred over a figure-of-8 bandage — multiple trials show equivalent outcomes with the sling and significantly better comfort (less axillary skin excoriation and nerve compression). Expected timeline: radiographic union by 12–16 weeks in most adults; return to light activities at 6–8 weeks and sport at 12–16 weeks. Counsel patients that a visible bump (exuberant callus) may develop at the fracture site — it is a normal healing response that typically remodels over 12–24 months but may never completely resolve. For the remaining displaced fractures (Edinburgh 2B), the RCT data supports discussing operative fixation to reduce non-union and malunion — particularly when shortening exceeds 2cm — while acknowledging the Cochrane finding (PMID 30666620) of no clinically important functional gain. Floating shoulder — the concept examiners probe. A floating shoulder is the combination of an ipsilateral clavicle fracture and a scapular neck fracture, effectively disconnecting the upper limb from the thorax through disruption of the superior shoulder suspensory complex (SSSC). The SSSC is a ring — clavicle, AC joint, coracoclavicular ligaments, coracoid process, coracoacromial ligament and the glenoid process — that maintains glenohumeral position. Two-point disruption of this ring (clavicle plus scapular neck) is an absolute indication for clavicle fixation; restoring clavicle length acts as an internal strut and indirectly reduces the scapular neck fracture in most cases, so isolated scapular neck fixation is rarely required. Consent. Specifically warn about: near-universal supraclavicular nerve sensory loss (numbness over the anterior chest and shoulder below the incision — expected and often permanent); symptomatic hardware prominence requiring removal (9–15% of superior plates); infection (1–3%); rare pneumothorax and neurovascular injury; and, for hook-plate distal fixation, the planned second operation to remove the plate at 3–6 months. Setup. Beach-chair position, head on a support or horseshoe headrest, a bump under the ipsilateral scapula, and the arm free-draped to allow traction and manipulation. The image intensifier comes in from the head of the table to give an AP view of the clavicle.
The Operation
The goal is to expose the clavicle through a safe approach, restore length and alignment, and hold the reduction with a contoured plate while protecting the supraclavicular nerves, the deltotrapezial fascia and — critically — the structures lying immediately posterior to the bone. The exposure is laid out in full as the first operative steps below.
Midshaft clavicle ORIF — operative sequence
- Beach chair, 30–45 degrees upright, head on a support or horseshoe headrest, bump under the ipsilateral scapula, arm free-draped.
- Image intensifier from the head of the table for an intraoperative AP view of the clavicle.
- Plan the incision 1–2cm inferior to the palpable clavicle contour, centred over the fracture (8–10cm for a typical midshaft fracture); a longitudinal incision directly over the bone is the alternative for an anteroinferior approach.
- Incise skin and platysma in the line of the planned approach; raise subcutaneous flaps.
- Identify and protect the supraclavicular nerve branches (C3–C4) — they cross from posterior to anterior in the subcutaneous fat at the clavicle level. The intermediate branch (anterior chest) and lateral branch (lateral shoulder and upper arm) are most at risk. This is not always possible, which is exactly why anterior chest numbness is warned about preoperatively.
- Incise the deltotrapezial fascia along the superior surface of the clavicle (deltoid anteriorly, trapezius posteriorly insert here through periosteum and fascia).
- Elevate carefully in a subperiosteal plane to preserve healing biology, working on the superior surface to create the bone–plate interface without straying deep.
- Remember the clavicle is S-shaped: medial two-thirds convex anteriorly, lateral third concave anteriorly — this governs plate contouring.
- Expose the fracture fragments by gentle periosteal elevation and clear haematoma from the fracture ends.
- Restore length with traction first, then angular alignment; hold with a provisional K-wire or reduction clamp.
- For comminuted fractures, lag-screw any large butterfly fragment first and then apply the plate as a neutralisation device — never strip the butterfly fragment of its soft-tissue blood supply.
- Superior plate: pre-contour to the clavicle S-shape and apply to the superior surface; a 3.5mm LC-DCP or pre-contoured clavicle plate with a minimum of three bicortical screws each side of the fracture (6 cortices). A central or compression hole is used for simple fractures.
- Anteroinferior plate: applied on the anteroinferior (tension) surface — biomechanically superior but requires more dissection and greater care protecting the posterior cortex.
- Screw safety: always protect the posterior cortex with a curved Hohmann retractor before drilling, measure drill depth precisely, and avoid unicortical screws in the medial third (insufficient purchase).
- Fluoroscopy in at least two planes: AP clavicle and a 15-degree cephalad tilt (Zanca view equivalent).
- Confirm reduction to within 5mm of anatomic length, all screws contained within bone (no posterior cortex breach on medial screws), no distal screw penetrating the AC joint, and plate contour matching the S-shape with no gapping or toggling.
- If fluoroscopy is unavailable intraoperatively, a portable plain radiograph in the recovery room before the patient wakes is the minimum acceptable check.
- Repair the deltotrapezial fascia over the plate with interrupted absorbable sutures — this reduces hardware prominence and irritation.
- Subcutaneous closure, then skin with a running absorbable or subcuticular suture.
Distal clavicle ORIF — operative sequence
- A direct incision over the distal clavicle and AC joint, 5–6cm.
- Identify the AC joint and expose the lateral clavicle superiorly.
- Identify the coracoclavicular ligaments and assess their integrity to classify the fracture intraoperatively — the key decision point (is the conoid on the proximal or distal fragment?).
- Reduce the fracture with gentle traction and depression of the proximal fragment, which has migrated superiorly.
- Distal locking plate (anatomic) — preferred by many: multiple distal locking screws into the small distal fragment give angularly stable fixation; may be supplemented with CC fixation (Endobutton or suture) if proximal control is inadequate.
- Hook plate — the hook engages the subacromial space under the acromion; excellent initial fixation, useful in very small or comminuted distal fragments, but it commits the patient to a planned removal (see warning below).
- Coracoclavicular fixation supplement — for highly comminuted fractures, add CC cerclage (heavy non-absorbable suture or Endobutton around the coracoid) to control superior migration of the proximal fragment regardless of the plate construct.
- Confirm the classification under direct vision by inspecting the CC ligament attachments.
- With a distal locking plate, angle the distal locking screws to purchase multiple cortices in the small distal fragment.
- If a hook plate is used, ensure the hook is appropriately sized for acromial thickness and seated under the posterior acromion to avoid anterior hook migration.
The subclavian vein passes posterior to the medial clavicle, immediately deep to the posterior cortex (within 5–10mm of bone at the medial third), and is most vulnerable during medial fragment reduction and medial screw placement. The subclavian artery lies posterior and slightly inferior, separated from the vein by the anterior scalene, and the brachial plexus lies posterior and lateral to the artery. The lung apex sits posterior to the medial clavicle, so a blind posterior drill can cause a pneumothorax. Always protect the posterior cortex with a curved Hohmann retractor during drilling and never drill blindly through the posterior cortex at the medial third. If pulsatile bleeding occurs, compress, call for vascular surgery and do not explore blindly.
The supraclavicular nerves (C3–C4) cross the clavicle obliquely in the subcutaneous fat. Division or traction is near-universal with any clavicle incision and produces numbness over the anterior chest and shoulder below the incision — expected, often permanent, and the reason explicit preoperative counselling is mandatory. Do not confuse this with a brachial plexus injury (which adds weakness and a dermatomal pattern).
The clavicle is loaded in bending and the superior surface is the tension side, so an anteroinferior plate functions as a tension-band construct and is biomechanically superior (greater stiffness and load to failure). The trade-off is more dissection and closer proximity to the subclavian structures. Superior plating is technically simpler and more commonly performed, with equivalent published union rates but a higher reoperation rate for symptomatic hardware prominence. Know both for the exam.
A hook plate occupies the subacromial space from day one. Retention causes subacromial impingement, acromial osteolysis or erosion, rotator cuff damage and acromial stress fracture. It must be removed at 3–6 months once united — counsel and consent the patient for this second procedure at the outset. In the Hall/McKee distal-clavicle RCT (PMID 34128498) 44% of the operative group needed a second operation for implant removal.
The clavicle has a double curvature and pre-contoured plates only approximate it; further intraoperative contouring with bending irons is almost always required for the individual anatomy. A poorly contoured plate toggles under load, increasing the risk of screw loosening and non-union — spend the 5–10 minutes contouring before applying.
Aftercare & Complications
Immobilisation. For midshaft ORIF with stable plate fixation, a simple arm sling for comfort for 2–4 weeks is all that is required — no formal splint, with immediate pendulum exercises. For distal ORIF, use a sling for 4–6 weeks (4 weeks with a rigid hook-plate construct) and avoid shoulder external rotation mobilisation until 4 weeks. For every hook-plate patient, remind the patient and all treating clinicians at every encounter that the plate must be removed at 3–6 months. Rehabilitation | Phase | Timing | Focus | Restrictions | |-------|--------|-------|--------------| | 1 | 0–6 weeks | Sling; pendulum exercises from day 1; gravity-assisted ROM; physiotherapy for cervical spine and distal joints | No active abduction against gravity until radiographic callus (typically week 6–8) | | 2 | 6–12 weeks | Active-assisted then full active ROM; strengthen rotator cuff and periscapular stabilisers | No contact sport; no overhead lifting greater than 5kg | | 3 | 12–16 weeks+ | Progressive strengthening and sport-specific loading | Return to light manual work at 8–12 weeks; heavy manual work and contact sport at 12–16 weeks with imaging-confirmed union | Radiographic follow-up. AP and 15-degree cephalad-tilt views at 6 and 12 weeks. Union is bridging callus on at least 3 of 4 cortices on two views; persistent lucency at 12 weeks should prompt investigation for non-union. Driving and work. Patients can typically return to driving an automatic vehicle at 4–6 weeks (when the sling is removed and shoulder control is adequate) and a manual vehicle at 6–8 weeks — advise them to verify with their insurer. Sedentary work resumes at 2–4 weeks; light manual work at 8–10 weeks; heavy manual work and contact sport at 12–16 weeks minimum with confirmed union, guided by occupation-specific functional testing rather than the calendar date alone. Plate removal counselling (midshaft). Not all plates require removal — retention is safe indefinitely once union is confirmed and the hardware is asymptomatic. Reasonable indications for removal are symptomatic prominence with local skin irritation (the most common reason — 9–15% of superior plates), a patient's cosmetic request, infection not resolving with hardware in situ (rare if the fracture is united), or a young patient planning contact sport for many years (to reduce stress-fracture risk at the plate edge). Removal is typically planned at 12–18 months after confirmed union. Inform patients at the initial consent that removal is possible (not guaranteed) and is a separate procedure with its own small risk profile. Monitoring for non-union. Warn patients that failure of union is still possible (less than 1% with ORIF) and to return if pain persists beyond 12 weeks without improvement. Reinforce the modifiable risk factors postoperatively: smoking cessation is critical (provide support), avoid NSAID overuse, ensure adequate protein and calcium intake, and optimise any underlying metabolic conditions.
- Incidence
- About 1% with ORIF (1/200) vs 8% non-operative (16/200) in Robinson 2013; 2/67 vs 7/65 in the 2007 COTS trial
- Prevention
- Adequate fixation (6+ cortices per side), bone graft for comminution, smoking cessation, metabolic optimisation
- Management
- Revision ORIF with autogenous bone graft (commonly iliac crest)
- Incidence
- 9–15% requiring plate removal (superior plating more common)
- Prevention
- Repair deltotrapezial fascia over plate; anteroinferior plate has lower prominence; patient counselling
- Management
- Planned plate removal at 12–18 months once union confirmed
- Incidence
- Near-universal partial cutaneous numbness; significant dysaesthesia 5–10%
- Prevention
- Identify and gently retract branches; warn patients preoperatively
- Management
- Reassurance for partial loss (partial recovery 12–18 months); persistent dysaesthesia — gabapentin, neurology review
- Incidence
- 1–3% overall; deep infection 0.5–1%
- Prevention
- Perioperative cefazolin, meticulous haemostasis, fascial repair over plate, minimise dead space
- Management
- Superficial: oral antibiotics and wound care. Deep: return to theatre, debridement, retain hardware if stable and uniting; remove plate after union if persistent
- Incidence
- Rare (less than 0.5%)
- Prevention
- Protect posterior cortex with a curved Hohmann during all drilling; never drill blindly through the posterior cortex at the medial third
- Management
- Small: observation and monitoring. Symptomatic or large: intercostal drain; avoid positive pressure ventilation until detected
- Incidence
- Virtually universal if not removed; rotator cuff tear 10–20% if left beyond 6 months
- Prevention
- Mandatory pre-planned removal at 3–6 months once united; counsel explicitly at initial consent
- Management
- Remove the hook plate under general anaesthetic; if a cuff tear is identified, proceed to arthroscopic assessment and repair
- Incidence
- Less than 0.5% (subclavian vessels, brachial plexus)
- Prevention
- Protect posterior cortex, avoid excessive retraction medially, avoid blind posterior drilling
- Management
- Compress bleeding, vascular surgery referral; document and monitor a brachial plexus deficit; EMG/NCS at 6 weeks if it persists
Viva & Exam Focus
CLAVICLECLAVICLE — operative indications for a midshaft fracture
NEERNEER — distal clavicle classification and operative decision
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 22-year-old right-hand dominant competitive road cyclist sustains a displaced midshaft right clavicle fracture after a fall. Radiographs show 2.2cm of shortening and greater than 100% displacement. The skin is intact, neurological examination is normal, and he has no other injuries. He competes at national level and is concerned about his racing season. Should you offer surgery, and what is the evidence?”
“A 45-year-old right-hand dominant accountant sustains a Neer type IIB distal right clavicle fracture when she falls from a horse. Radiographs show the proximal clavicle fragment displaced superiorly by 1.5cm. She is otherwise well. What is the significance of the Neer IIB designation, and how would you manage this fracture?”
“Six weeks after right clavicle ORIF with a superior plate for a midshaft fracture, your patient complains of numbness and tingling over the anterior chest wall below the incision, extending to the medial aspect of the upper arm. He is otherwise well, with good wound healing and normal shoulder strength. What is your diagnosis and management?”
Indications (midshaft)
- Absolute: open fracture, neurovascular compromise, tent sign, floating shoulder (ipsilateral scapular neck fx), bilateral clavicle fractures
- Relative (shared decision): shortening greater than 2cm, displacement greater than 100%, comminuted Edinburgh 2B2 in dominant arm, high-demand athlete
- Pivotal RCTs: Robinson 2013 (PMID 24005198) non-union 1/200 ORIF vs 16/200 non-op; 2007 COTS (PMID 17200303) 2/67 vs 7/65; Cochrane 2019 (PMID 30666620) confirms reduced treatment failure but no clinically important functional gain
Neer — distal clavicle
- Type I: lateral to CC ligaments, minimal displacement, non-operative
- Type IIA: medial to the CC ligaments but both intact on the distal fragment — can be non-operative in selected patients
- Type IIB: conoid detached/on the proximal fragment, trapezoid on the distal — UNSTABLE, 22–33% non-union non-op, operative
- Type III intra-articular; Type IV paediatric physeal; Type V inferior comminution
Key anatomy
- Supraclavicular nerves (C3–C4) cross the clavicle in subcutaneous fat — sensory to anterior chest and shoulder; expected loss postoperatively
- Subclavian vessels and brachial plexus lie immediately posterior to the medial clavicle — protect the posterior cortex with a curved Hohmann; never drill blindly
- Deltotrapezial fascia: incise and repair over the plate to reduce hardware prominence
- CC ligaments: conoid (medial, conoid tubercle) — primary superior restraint; trapezoid (lateral, trapezoid ridge) — primary AP restraint — key to Neer IIB instability
Technique pearls
- Superior plate: easier, most common, higher reoperation for hardware prominence (9–15%)
- Anteroinferior plate: tension side, biomechanically superior, technically harder, lower prominence
- Minimum 6 cortices per side (3 bicortical screws each side) for stable fixation
- Lag-screw a butterfly fragment first then use the plate as neutralisation; never strip its blood supply
- Distal clavicle: distal locking plate preferred (no mandatory removal); hook plate effective but mandatory removal at 3–6 months
Complications
- Hardware prominence/plate irritation: 9–15% requiring removal; reduced by anteroinferior plate and fascial repair
- Non-union: about 1% ORIF vs 8% non-op (Robinson 2013, 1/200 vs 16/200); treat with revision ORIF plus autogenous (iliac crest) bone graft
- Supraclavicular nerve sensory loss: expected in virtually all patients — warn preoperatively
- Infection: 1–3%; repair the fascia, drain haematoma, retain hardware while uniting
- Pneumothorax: rare — protect the posterior cortex at the medial third
- Hook plate impingement: inevitable if not removed — bursal thickening, cuff tears, acromial stress fracture
Exam tips
- Know both RCTs by name — Robinson 2013 (PMID 24005198) and 2007 COTS (PMID 17200303); fewer non-unions with plating, but the 2013 trial did not endorse routine ORIF for every displaced fracture
- Distinguish Neer IIA (stable, non-op) from IIB (unstable, operative) by CC ligament anatomy — conoid on the proximal fragment means IIB
- Always mention mandatory hook-plate removal in any distal clavicle question
- Supraclavicular nerve numbness below the incision is EXPECTED, not a complication — preoperative counselling is mandatory
- Non-union risk factors: female sex, age, smoking, displacement greater than 100%, comminution — list these confidently
Background & Evidence
Epidemiology. Clavicle fractures account for 2.6–4% of all fractures (Lenza Cochrane 2019; the Robinson Edinburgh series). They have a bimodal age distribution — young males (sport and road trauma) and elderly females (osteoporotic falls). By location, midshaft (Allman Group I / Edinburgh type 2) is approximately 80%, lateral (Group II / type 3) approximately 15%, and medial (Group III / type 1) approximately 5%. Classifying the fracture. The two complementary systems describe the same bone differently.
- Group / Type
- Group I
- Definition
- Middle third
- Frequency
- About 80%
- Group / Type
- Group II
- Definition
- Distal (lateral) third
- Frequency
- About 15%
- Group / Type
- Group III
- Definition
- Medial (proximal) third
- Frequency
- About 5%
- Group / Type
- Type 1
- Definition
- Medial fifth
- Frequency
- —
- Group / Type
- 2A
- Definition
- Diaphyseal (middle), undisplaced (cortical alignment maintained or greenstick)
- Frequency
- —
- Group / Type
- 2B1
- Definition
- Displaced diaphyseal, simple or single butterfly fragment
- Frequency
- —
- Group / Type
- 2B2
- Definition
- Displaced diaphyseal, comminuted or segmental, no cortical contact
- Frequency
- Highest non-union risk
- Group / Type
- Type 3
- Definition
- Lateral fifth (3A undisplaced, 3B displaced)
- Frequency
- —
- Coracoclavicular ligaments
- Intact, lateral to the CC ligaments
- Stability
- Stable, minimal displacement
- Management
- Non-operative
- Coracoclavicular ligaments
- Medial to both conoid and trapezoid; both intact on the distal fragment
- Stability
- Relatively stable
- Management
- Non-operative in selected patients
- Coracoclavicular ligaments
- Lateral to the conoid — conoid detached or on the proximal fragment; trapezoid on the distal
- Stability
- Unstable — proximal fragment migrates superiorly
- Management
- Operative fixation
- Coracoclavicular ligaments
- Intra-articular AC joint fracture
- Stability
- —
- Management
- Depends on displacement
- Coracoclavicular ligaments
- Paediatric (epiphyseal)
- Stability
- —
- Management
- Per paediatric principles
- Coracoclavicular ligaments
- Inferior comminution
- Stability
- —
- Management
- Often operative
Relevant surgical anatomy. The clavicle is S-shaped in the axial plane (medial two-thirds convex anteriorly, lateral third concave anteriorly); its medial third is roughly tubular and its lateral third flattened in the AP plane, with the transition at the middle third being where comminution typically occurs. At the distal clavicle, the coracoclavicular ligaments anchor the clavicle to the coracoid: the trapezoid (more lateral, from the trapezoid line of the coracoid to the trapezoid ridge on the inferior distal clavicle) is the primary restraint to anteroposterior translation, while the conoid (more medial and conical, from the coracoid knuckle to the conoid tubercle on the clavicle undersurface, about 4cm from the lateral end) is the primary restraint to superior translation. The superior AC capsule is the most important horizontal stabiliser of the AC joint. A hook plate passes directly into the subacromial space, occupying bursal tissue and impinging on the undersurface of the acromion and rotator cuff if retained. Guidelines, registries and global practice. Operative thresholds genuinely differ by region. North American practice (influenced by the 2007 COTS and 2013 Robinson RCTs) has a comparatively higher rate of fixation for displaced fractures. UK BOA/BOAST and much of European practice remains more selective, reserving fixation for absolute indications or markedly displaced and shortened fractures in higher-demand patients — partly reflecting the Cochrane finding (PMID 30666620) that surgery confers no clinically important functional benefit beyond reducing non-union and malunion. No major arthroplasty registry (NJR, AJRR, AOANJRR, SHAR) captures clavicle ORIF volumes, so registry-level implant-survival data are not applicable here; the evidence base is RCT and meta-analysis. For the exam, demonstrate awareness that practice varies across societies and anchor the decision in the RCT and Cochrane evidence rather than any single national guideline. Key evidence (midshaft). Robinson (2013, PMID 24005198) randomised 200 adults aged 16–60 to primary plate ORIF versus a sling (union confirmed on 3D CT): non-union was 1/200 versus 16/200 (relative risk 0.07, p = 0.007), one-year DASH (3.4 vs 6.1) and Constant (92.0 vs 87.8) scores favoured ORIF for the whole cohort, but when non-union patients were excluded there was no significant functional difference — so the benefit is essentially prevention of non-union and malunion, and the authors did not support routine ORIF. The earlier COTS multicentre RCT (2007, PMID 17200303, 132 patients) showed fewer non-unions (2/67 vs 7/65, p = 0.042), no symptomatic malunions versus 9, and faster union, with hardware removal the commonest reason for re-intervention. The Cochrane review (Lenza 2019, PMID 30666620) confirmed that surgery reduces treatment failure but does not deliver a clinically important functional gain. Key evidence (distal). The Hall/McKee multicentre RCT (2021, PMID 34128498) randomised 57 patients with completely displaced Neer type II distal clavicle fractures (27 operative, 30 non-operative): union within one year was 95% operative versus 64% non-operative (p = 0.02), with no between-group difference in DASH or Constant scores, but a second operation for implant removal was needed in 12/27 (44%) — especially with hook plates.
References
Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures
- Multicentre single-blinded RCT, 200 adults aged 16–60 with acute displaced midshaft fractures; union assessed on 3D CT
- Non-union: 1/200 after plate ORIF vs 16/200 with non-operative care (relative risk 0.07, p = 0.007)
- One-year DASH (3.4 vs 6.1) and Constant (92.0 vs 87.8) scores favoured ORIF for the whole cohort
- When patients who developed non-union were excluded, there was NO significant functional difference at any time point
- ORIF was more expensive and carried implant-related complications not seen with non-operative treatment
Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures (COTS multicentre RCT)
- 132 patients randomised to plate fixation (67) vs sling (65); 111 completed one year
- Non-union: 2/67 (ORIF) vs 7/65 (non-operative), p = 0.042; symptomatic malunion 0 vs 9 (p = 0.001)
- Constant and DASH scores significantly better with ORIF; mean time to union 16.4 vs 28.4 weeks
- Hardware removal was the commonest reason for repeat intervention in the operative group
Surgical versus conservative interventions for treating fractures of the middle third of the clavicle (Cochrane review)
- 14 RCTs, 1469 adults with acute middle-third fractures
- Surgery may NOT improve upper-arm function at one year or more (Constant SMD 0.33, 95% CI -0.02 to 0.67) — not a clinically important difference
- Surgery reduces treatment failure / non-routine secondary surgery (RR 0.32, 95% CI 0.20 to 0.50)
- Symptomatic non-union 11.6% non-operative vs mechanical failure 3.4% operative; hardware removal for discomfort 10.2% in the surgical group; infection 3.2% surgery only
Operative versus nonoperative treatment of acute displaced distal clavicle fractures: a multicenter randomized controlled trial
- 57 patients with completely displaced Neer type II distal clavicle fractures randomised (27 operative, 30 non-operative)
- Union within one year: 95% operative vs 64% non-operative (p = 0.02)
- No between-group difference in DASH or Constant scores at one year
- Second operation for implant removal in 12/27 (44%) operative patients — especially with hook plates
Fractures of the clavicle in the adult: epidemiology and classification (Edinburgh classification)
- Consecutive series of 1000 adult clavicle fractures from the Royal Infirmary of Edinburgh
- A new classification (type 1 medial, type 2 diaphyseal, type 3 lateral; A undisplaced, B displaced) with acceptable inter- and intra-observer reliability
- Displaced diaphyseal (2B) and displaced lateral (3B) fractures carried the highest complications of union
- In 2B fractures, the degree of comminution (in addition to displacement) was an independent risk factor for delayed and non-union
Fractures of the distal third of the clavicle (Neer classification)
- The original description dividing distal clavicle fractures by the integrity of the coracoclavicular ligaments
- Type I — lateral to the CC ligaments, ligaments intact, minimal displacement, stable, non-operative
- Type II — subdivided into IIA (medial to both CC ligaments, both intact) and IIB (conoid detached or on the proximal fragment, unstable, high non-union)
- Type III — intra-articular (AC joint); Type IV — paediatric physeal; Type V — inferior comminution