Relative Indications for Primary Fixation
Fracture-specific | Associated injuries | Patient factors |
|---|---|---|
Displacement > 2 cm | Vascular injury needing repair | Polytrauma needing early upper-extremity weight bearing or use |
Shortening > 2 cm | Progressive neurologic deficit | Motivation for rapid return of function (elite athletes, self-employed professionals) |
Increasing comminution (> 3 fragments) | Ipsilateral upper-extremity injuries or fractures | |
Segmental fractures | Multiple ipsilateral upper rib fractures | |
Open fractures | "Floating shoulder" | |
Impending open fracture with soft-tissue compromise | Bilateral clavicular fractures | |
Obvious clinical deformity | ||
Scapular malposition and winging at initial examination |
Box adapted in Campbell from McKee MD, Rockwood and Green's Fractures in Adults.
Surgical Technique (Collinge et al., Modified)
Positioning
Position the patient supine with a large bump between the scapulae. This lets the injured shoulder girdle fall posteriorly, which helps restore length and improves exposure of the clavicle.
Approach
Make an incision centered over the fracture, running between the sternal notch and the anterior edge of the acromion.
Release the lateral platysma. Identify the supraclavicular nerve and its branches crossing the anterior clavicle, and protect them.
Incise the clavipectoral fascia along its attachment to the anterior clavicle and elevate it carefully inferiorly.
Dissect along the medial and lateral sides of the fracture, and clear periosteum and hematoma from the fracture ends.
Reduction
Reduce the fracture and hold it with bone clamps. A common pattern is an anteroinferior butterfly fragment with a simple posterosuperior transverse fracture line, produced by tension failure.
Where possible, hold the reduction with a minifragment lag screw (2.4 or 2.7 mm).
Anteroinferior Plate Fixation
Contour a 2.7 mm plate to the anteroinferior border of the clavicle. In dual plating, a 2.4 mm plate can be added superiorly. Depending on its length and position, the plate sometimes needs a coronal ("on the flat") bend.
Aim the plate screws posteriorly and superiorly. In oblique fractures, place a lag screw through the plate or directly into bone, at about 90° to the fracture line.
Superior Plate Fixation (Alternative)
Contour the plate to the superior border of the clavicle.
Medially: Make sure instruments cannot plunge, because the neurovascular structures and lung lie directly beneath. Use lag screws wherever possible.
Laterally: Do not leave screws long, to avoid irritating the rotator cuff in the subacromial space.
Postoperative Care
Use a sling for comfort.
Teach pendulum and Codman exercises. The patient is encouraged to use the arm but should avoid heavy lifting, pushing and pulling.
Full activity is allowed once the fracture has healed, usually at 2 months.
Alternative: Intramedullary Fixation
Intramedullary devices have been used for more than 50 years (Rockwood pin, Anser pin, Küntscher nail, Rush nail, titanium elastic nail).
A systematic review found union rates similar to plating, but with device-specific complications. Plates resisted displacement better in biomechanical testing.
Advantages: Small incision, less periosteal stripping, relative stability that allows callus formation, and fewer symptomatic implants.
Disadvantages: Intrathoracic migration, pin breakage, possible damage to underlying structures, and device-specific complications.
Reducing complications with titanium elastic nails (Frigg et al.):
Use an end cap.
Convert to open reduction after two failed closed attempts.
Pass the nail carefully by hand.
Rule out lateral perforation with intraoperative oblique radiographs.
Limit motion to 90° for 6 weeks.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.1.