Disorders of the Shoulder: Diagnosis and Management
2nd Edition

31
Fractures of the Clavicle
Jonas Andermahr
David C. Ring
Jesse B. Jupiter
Introduction
Fracture of the clavicle is common, and it has long been thought that its inherent reparative capacity will lead to rapid healing despite little more than symptomatic treatment.273 Deformity has been described more often as a cosmetic concern since function is satisfactory despite malunion.189,190 It has been suggested by many that primary operative intervention is meddlesome and will result in unnecessary complications.219,273 However, although the standard of care has long been conservative therapy, operative management of acute clavicle fractures, particularly in polytraumatized patients and in selected cases of young athletes, has proven to be an excellent option.8,136,137,138,139,140,141 Despite the proximity of major vascular, nervous, and cardiopulmonary structures, associated injury is uncommon.
This chapter will present to the reader the changing paradigms related to the management of fracture and related complications of the clavicle. A large percentage of clavicular fractures occur in children and heal readily with remodeling of deformity.231,294 This is not always the case with displaced fractures in adults.
Interest in clavicular nonunion is relatively new25 and has demonstrated that displaced fractures of the middle portion of the clavicle can in fact be troublesome injuries in adults.142,188,307,309 Failure of bony union following clavicular injuries can lead to progressive shoulder deformity, pain, impaired function, and neurovascular compromise. Malunion may also contribute to weakness, pain, and neurovascular compromise.86,87 Data on displaced distal clavicular fractures in adult patients have demonstrated sufficient difficulties with healing to consider primary operative treatment.62,216,217,218 A recent investigation focusing on the results
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of the treatment of displaced midclavicular fractures in adult patients suggests that this subset of fractures may also be prone to nonunion and delayed union.307
Anatomy
The clavicle is unique among diaphyseal bones in many respects, among them its development, shape, structure, and anatomic relationships. It is the first bone to ossify in the embryo, occurring in the fifth gestational week, and the only long bone to ossify from a mesenchymal anlage (intramembranous ossification). While a number of investigations documenting the histologic evaluation of the embryonic clavicle report that ossification proceeds from two separate centers,9,71,76,111,187 others assert that a narrow interconnection between these two centers is present from the outset, but may not be seen in any one particular histologic section and will therefore result in sampling error.92,99,153 Dispute exists as to the cause of congenital pseudoarthrosis of the clavicle, with some suggesting that it is a result of the failure of these two centers to coalesce150,211 and others believing that pressure from the subclavian artery inhibits ossification, leading to pseudoarthrosis.180
Growth in length initially occurs through expansion of the central ossification centers and later by enchondral ossification via epiphyseal growth centers acquired at each end of the bone. The medial (sternal) physis accounts for approximately 80% of the longitudinal growth of the clavicle.235 Ossification of the sternal epiphysis of the clavicle occurs in the midteenage years and is very difficult to visualize on routine radiography.69,235 The acromial epiphysis does not ordinarily form a secondary ossification center.299 Both the sternal and acromial physes can remain open into the third decade of life, particularly the sternal physis, which typically remains open until approximately age 25 years in females and 26 in males.133,234,235,299 As a result, apparent dislocations of the acromioclavicular or sternoclavicular joints are more likely to be physeal separation injuries in adolescents and young adults.59,60,200,303
A number of influences on clavicular length have been investigated. The influence of gender has been clearly shown. In a comparison between African-American males and females and white males, Terry296 demonstrated that male clavicles are longer than female clavicles. Martin and Saller193 emphasized that male clavicles in all races are longer than those of females. Dzigora73 published an average length of 15.6 cm for clavicles of males and 14.3 cm for those of females of Russian ancestry. Investigations looking at body side reveal only the mildest divergence of clavicle length. The left clavicle tends to be longer than the right; this was observed by both Martin and Saller193 and Dzigora.73
The clavicle is named for its S-shaped curvature with one apex anterior medially and another posterior laterally, resembling the musical symbol, clavicula.205 The larger medial curvature widens the space for passage of neurovascular structures from the neck into the upper extremity via the costoclavicular interval. Men display significantly more angulation of the clavicle than do women.118,162 The cause for this anatomic phenomenon appears to be the interaction of muscle and bone, since most authors find a positive correlation between increased musculature and clavicular angles. Body side also has significant influence regarding the medial clavicle angle, as confirmed by both Dzigora73 and Bardeleben.12 The increased musculature on the right side in right-handed people most likely determines these effects. However, another plausible explanation for clavicular curvature considers the fact that the clavicle is the first bone ossified during embryonic development (the fifth embryonic week) and later the first bone with which the developing thorax and the developing limbs of the upper extremity must conform.209,250 The theory is that the S-form develops as a result of these interactions. Since the thoracic diameter is well accepted to be larger in males than in females, this would explain gender differences. However, Kummer and Lohscheidt162 pointed out Pauwels’ developmental principles of long bones: They are unable to significantly change the axis of an ossified bone. The axes are finished prior to ossification, in the essential stages of development. Since clavicles ossify early, an essential bone-shape altering factor would have to exist very early in development.
Inman et al. have suggested that the curvature of the lateral third of the clavicle contributes to range of motion of the shoulder girdle by allowing approximately 30 degrees of motion between the scapula and clavicle through the acromioclavicular joint.126,127,179 According to their description, this motion occurs via inferior translation of the medial portion of the scapula leading to abduction of the scapula through the acromioclavicular joint, a motion that might be thought impossible considering the rigid interrelationship between the clavicle and scapula maintained by the stout coracoclavicular ligaments. However, the lateral curvature and 50-degree rotational motion of the clavicle on its longitudinal axis allow for inferior translation of the attachment of the coracoclavicular ligaments on to the posteriorly directed apex of the lateral clavicle along with the scapula. Inman et al. have likened this to the action of a crankshaft126,127 (Fig. 31-1).
Others dispute this description, claiming that little motion occurs at the acromioclavicular joint and that the scapula actually rotates along with the clavicle.48
The clavicle is made up of very dense trabecular bone lacking a well-defined medullary canal. In cross section the clavicle transitions gradually between a flat lateral aspect, a tubular midportion, and an expanded prismatic medial end.15,113 (Fig. 31-2)
The average measured diameter of the medullary canal over the course of the clavicle bone is depicted in Fig. 31-2. With its natural S-curve, the clavicle has a double funnel-shaped diameter. At the sternal end, the diameter measures
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approximately 18 mm, and decreases in a linear manner to approximately 6.7 mm at the midpoint. Continuing on, the diameter increases in a similar fashion, eventually reaching 15 mm. The narrowest diameter is measured exactly at the meeting point of the medial convexity with the lateral concavity, the most frequent location of clavicle fractures. These peculiarities of the bone’s curvature and cross-sectional anatomy as well as its bony structure become important when intramedullary fixation of the clavicle is considered167 (see Fig. 31-2).
Figure 31-1 There are three axes of clavicular motion: anterior–posterior, superior–inferior, and rotational. According to Inman’s description, the 50-degree rotational motion of the clavicle, in combination with the apex posterior curvature of the lateral clavicle, allows for inferior translation of the attachment of the coracoclavicular ligaments on the lateral clavicle. This in turn permits the medial aspect of the scapula to translate inferiorly, with the glenoid abducting through the acromioclavicular joint. This so-called crank-shaft mechanism provides 30 degrees of the total 60-degree contribution of scapulothoracic motion to shoulder abduction. It is important to note that other authors dispute this mechanism.
Figure 31-2 The diameter of the medullary canal cross section, the cortical thickness, and the position of the intramedullary nail within the clavicular canal: Contact point and the cortical thickness next to the respective positions become clear. In the medial and lateral portions of the bone are the danger zones for nail perforation, while in the middle third a relative narrowing is present.
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The clavicle is subcutaneous throughout its length and makes a prominent aesthetic contribution to the contour of the neck and upper chest. The supraclavicular nerves run obliquely across the clavicle just superior to the platysma muscle and should be identified and protected during operative exposure to offset the development of hyperesthesia or dysesthesia over the chest wall.
The articulation of the clavicle with the trunk is stabilized by the stout costoclavicular and sternoclavicular ligaments. The subclavius muscle may also contribute to stability in this region of the clavicle. The coracoclavicular and acromioclavicular ligaments stabilize the relationship of the distal clavicle with the scapula. The upper portion of the insertion of the trapezius muscle and the anterior portion of the origin of the deltoid further stabilize the lateral clavicle through their attachments to its posterior and anterior aspects, respectively. Fractures in these regions of the clavicle tend to be relatively stable, provided that the described ligamentous and muscular relationships are not disrupted in the traumatic injury.
In displaced fractures and ununited fractures of the clavicle, the most common deformity includes medial–lateral shortening, drooping, adduction, and protraction of the shoulder girdle. The forces contributing to persistence or worsening of deformity following fracture include the weight of the shoulder as transmitted to the distal fragment of the clavicle primarily through the coracoclavicular ligaments as well as the deforming forces of the attached muscles and ligaments. The medial fragment is elevated by the clavicular head of the sternocleidomastoid muscle, which inserts onto the posterior aspect of the medial portion of the clavicle. The pectoralis major contributes to adduction and inward rotation of the shoulder.121,122,123,124
Bone density correlates strictly with the dynamic and static loading forces applied to a bone.162,246 In the clavicle, the medial portion of the bone, where increased functional loading is most apparent, displays a clearly higher density. At the intersection of the middle to lateral thirds of the clavicle, there is a significant decrease of bone density. The midportion is the thinnest and narrowest portion of the bone and represents a transitional region, both in curvature and cross-sectional anatomy, making it a mechanically weak area.113 This, in part, explains the increased frequency of fractures occurring in the middle and lateral thirds of the bone (80% of clavicular fractures occur in the middle third, 10% to 18% occur in the lateral third, and 2% to 10% occur in the medial third). Fractures of the medial third of the clavicle are extremely rare.27,75,216,218,241,269
Considering the intimate relationship of the clavicle to the brachial plexus, subclavian artery and vein, and the apex of the lung, it is surprising that injury to these structures in association with fracture of the clavicle is so uncommon. Brachial plexus palsy may develop weeks or years following injury, due to hypertrophic callus with or without malalignment of the fracture fragments leading to compromise of the costoclavicular space.14,40,52,82,106,124,142,147,159,196,204,264,275,302,312 Narrowing of the costoclavicular space due to malunion or nonunion can also lead to a dynamic narrowing of the thoracic outlet.13,18,31,51,89,181,210,254,289
Function
A review of the comparative anatomy literature reveals that the clavicle has developed from the “os thoracale,” a construct of the sternum and clavicle. This “distance-maintainer” between the breastbone and scapula was first observed in fossils of the earliest reptiles, who lived approximately 350 million years ago (Devon). The abilities of the “walking fish,” of which the coelacanth is the most well known, were strictly dependent on the development of abduction in the front extremities. Further evidence for the phylogenetically early development of the clavicle is that it ossifies very early during ontogenesis. The functional consequence is, from an evolutionary perspective, the ability to abduct and raise the arms. Conversely, in animals without the ability to abduct the front extremities (i.e., sheep or horses), during ontogenesis the clavicle forms and is even temporarily ossified before completely disappearing by the time of birth.
A clavicle is not beneficial to running and jumping quadruped mammals.17,18,40,60,179,243,244 In contrast to the quadrupeds, who derive stability and strength from close association of the shoulder girdle with the trunk, in simians the clavicle enhances upper extremity function for swinging through trees. It holds the glenohumeral joint and the upper extremity away from the trunk in all positions. The clavicle enhances overhead activity (combination of shoulder abduction and elevation), particularly in actions requiring power and stability, and resists those tensile forces that become so prominent in activities required by arboreal mammals. It is not surprising then that in cases of clavicle fractures in humans where there is shortening of the sternum–scapula distance, there is a subsequent limitation in shoulder abduction and elevation. The clavicle also serves as a bony framework for muscular attachments, provides protection for the underlying neurovascular structures, transmits the forces of accessory muscles of respiration (e.g., the sternocleidomastoid) to the upper thorax; and contributes to the aesthetics of the base of the neck.179,209
It is of interest that children with cleidocranial dysostosis (clavicular aplasia) adapt surprisingly well to an absence of clavicles. However, limitations have been observed with regard to overhead activities requiring strength, stability, and dexterity in cleidocranial dysostosis patients.14,40,59,60,126,127,190,297 If these congenitally aclavicular children have notable functional deficiencies in comparison with normal children, then one must be concerned about what will happen when the learned coordinated
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manipulation of the complex interaction of various muscle groups, ligamentous attachments, and interarticulations of the shoulder girdle is disrupted by sacrificing clavicular continuity in adult patients.15,72 In fact, some studies have suggested that malunion alone (particularly shortening) can cause pain and inhibit function.84,85,88
Because some reports document good function following total or subtotal resection of the clavicle for infection, malignancy, or access to neurovascular structures in small series of patients,1,55,80,90,108,126,187,310 some authors went so far as to encourage consideration of the clavicle as an expendable or surplus part of the skeleton.108 Resection of the clavicle has been recommended both in the treatment of clavicular nonunion36,214 as well as in the treatment of fresh clavicular fractures.198,249
It is certainly clear that some patients do very poorly following clavicular resection,271,286 especially those with trapezial paralysis.57,142,247,310 We therefore feel strongly that this procedure should be reserved for the unusual situation in which a salvage procedure becomes necessary. The clavicle plays an important functional role in the shoulder girdle, and every effort should be made to preserve or restore normal length and alignment in the treatment of clavicular disorders.
Classification
Surgeons interested in clavicle fractures have long distinguished midclavicular fractures from fractures of the medial or lateral end.21,117 Following descriptions by Allman,3 Rowe,273 and Neer,216,217,218,119 the clavicle has been divided into thirds for purposes of classification. This proves somewhat arbitrary when one considers that the majority of clavicular fractures occur at a distance from the lateralmost aspect of the bone, which falls on a roughly Gaussian distribution between approximately 30% and 60% of the length of the bone.197 In the majority of reported series, separation of clavicular fractures as occurring in one of the thirds of the bone was most likely based upon interpretation from standard radiographs, rather than precise measurement. This implies that division of the large numbers of clavicular fractures occurring about the middle third–distal third junction as belonging to either the distal third or middle third group is often imprecise and may be arbitrary.
Figure 31-3 When the distal end of the clavicle is fractured, the ligaments may either (A) remain intact and serve to maintain apposition of the fracture fragments (type I) or (B) rupture, allowing wide displacement of the fragments (type II).
In Neer’s defining work on distal clavicular fractures,216,217,218,119 he considered fractures distal to the proximal limit of the trapezoid ligament as distal clavicular fractures and distinguished two types: Type I represents a fracture in which both the trapezoid and conoid ligaments remain intact and are attached to the medial fragment, thereby providing stable reduction of the fracture; a type II fracture consists of a fracture in which the trapezoid ligament remains attached to the distal fragment while the conoid ligament is ruptured and no longer maintains reduction of the medial fragment. In type II fractures, the loss of coracoclavicular ligament restraint on the medial fragment results in wide displacement of the fracture fragments, and in Neer’s experience, an increased risk of nonunion219 (Fig. 31-3).
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Rockwood subsequently recommended division of type II fractures of the distal clavicle into two subsets: fractures of the distal clavicle in which both the conoid and trapezoid ligaments remain attached to the distal fragment as type IIA and those in which medial fragment instability is a result of disruption of the coracoclavicular ligaments (Neer’s original description) as type IIB.270,272 It is unclear, however, how type IIA fractures differ from more distal midclavicular fractures, especially considering the fact that the most common site of midclavicular fracture is at the junction of the middle and distal thirds.293 We believe Neer’s classification to be more applicable as it serves the role of distinguishing fractures that might potentially be stabilized by ligamentous attachments as either stable (ligaments intact) or unstable (at least partial ligamentous disruption; see Fig. 31-3).
In unusual instances, fractures of the distal clavicle may be unstable in the absence of ligamentous injury. This occurs when both of the coracoclavicular ligaments remain attached to an inferior fracture fragment that lacks attachment to either of the primary medial and lateral fragments.247
Neer noted in his initial report that fractures of the distal clavicle are occasionally associated with extension into the acromioclavicular joint, and subsequently distinguished such fractures in his classification system as type III.216,217,218 It has been suggested that some injuries diagnosed as type I acromioclavicular joint separation may in fact be intraarticular distal clavicular fractures, and that posttraumatic osteolysis of the distal clavicle39,130,131,183,262 occurs in part as a result of an undetected intraarticular fracture.57,217
In children and adolescents, medial and lateral clavicular injuries most frequently take the form of physeal separation injuries, although metaphyseal fractures also occur.234,235,303 In distal clavicular physeal injuries and metaphyseal fractures (so-called pseudodislocation of the acromioclavicular joint), the proximal fragment may displace and separate from the surrounding periosteum, while the thin distal clavicular epiphysis, with or without an attached metaphyseal fragment, retains its anatomic relationship to the acromion and the remainder of the shoulder.90,146,183,184,235,254,304 The acromioclavicular and coracoclavicular ligaments are intact and remain attached to the periosteal sleeve.234,235,303,309 Analogous patterns of injury occur at the sternal end of the growing clavicle.36,143,176,258 Since both the medial and lateral physes typically remain open into the third decade of life,133,234,299 it is important to realize that apparent acromioclavicular or sternoclavicular dislocations in some young adults may actually be physeal separation injuries.36,54,143,176 As a result, these injuries can, in general, be expected to heal and become stable with nonoperative treatment. They may even remodel somewhat.
Fractures of the sternal end of the clavicle are uncommon and almost without exception treated symptomatically.3,52,57,84,120,143,172,217,273,314 Craig has subdivided these as minimally displaced (type I), displaced (type II), intraarticular (type III), physeal separation (type IV), and comminuted (type V) fractures. Fractures in this region of the clavicle are so uncommon that the patterns of medial clavicular injury have rarely been described and studied, and it remains unclear how different fracture patterns might influence treatment or prognosis.
Fractures occurring between the medial limit of the coracoclavicular ligaments and the lateral limit of the costoclavicular ligaments represent by far the most common type of clavicular fracture. These fractures have not to this point been subclassified in a universally acceptable manner. Current publications use the Comprehensive Classification of Fractures (CCF) (Fig. 31-4)47,141,274: Type A fractures are simple transverse fractures, type B fractures are wedge fractures, and type C fractures are those in which the main fragments are separated by a zone of comminution and have no contact. This classification turns out to be very useful for the decision of which operative procedure should be carried out (plate vs. intramedullary nail). (See section titled Operative Treatment.)
Figure 31-4 Type A fractures are simple transverse fractures, type B fractures are wedge fractures, and type C fractures are those in which the main fragments are separated by a zone of comminution and have no contact. (From
Classification, Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996;10(5–9):1–154.
)
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One important element of a midclavicular fracture is the amount of displacement or deformity. Distinguishing nondisplaced or minimally displaced fractures (including greenstick and plastic bowing-type28 fractures in children), which will heal with symptomatic treatment and little concern regarding either cosmesis or function, from displaced fractures, which may result in deformity, shoulder dysfunction, and an increased risk of nonunion, has been common practice up to now.298 However, as seen in Fig. 31-5, the fracture displacement changes depending on body posture. In this particular x-ray, the difference is significant. Therefore, the criterion of fracture displacement is clearly not useful information regarding the choice between operative or conservative management.
Pathologic fractures of the clavicle occur, although they are unusual. Rowe reported fractures through eosinophilic granuloma, Pagetoid bone, and metastatic carcinoma involving the clavicle.273 Fracture related to enchondroma25 and arteriovenous malformation208 have also been reported. Stress fractures of the clavicle have been described following radical neck dissection as a result of the devascularizing dissection and radiation osteitis that complicate the treatment of these tumors.58,143,239,253,290 Fatigue fracture was also reported in a 12-year-old boy who, while attempting to improve his grades, had apparently been carrying an inordinately large number of books under the arm on the involved side for several months.148 Stress fracture related to the use of a Dacron graft loop for coracoclavicular ligament reconstruction has also been reported.70
Figure 31-5 X-rays taken of a person with midshaft fracture in reclining (A) or standing (B) position. The position of the fracture elements changes dramatically depending on muscle tone.
Mechanism
In general, clavicle fractures suffered by adolescents and adults in all regions are the result of moderate or high-energy traumatic injury such as a fall from a height, motor vehicle accident, sport activity, or a blow to the point of the shoulder, and rarely a direct injury to the clavicle. Typical sports concerned include cycling, horseback riding, Alpine skiing, or motorcycling.154,155,156,226,227,228,230,231,233 In children and the elderly, clavicle fractures usually occur following low-energy trauma.3,52,119,136,137,139,140,141,228,229,231,273,277,284,287
It has become clear that the clavicle fails most commonly in compression. Failure in compression is seen following falls onto the shoulder and direct blows to the
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point of the shoulder.23,95,277,287 A direct blow to the clavicle, seen to occur in some stick-wielding sports such as lacrosse,284 may also fracture the clavicle. Although a fall onto the outstretched hand has traditionally been considered a common mechanism of midclavicular fracture,3 recent observations287 bring this into question.
Stanley et al. studied 122 of 150 consecutive patients presenting to one of two separate hospitals in Sheffield with fractured clavicles. The detailed accounts of their injuries showed that 87% were the result of a fall onto the shoulder, 7% the result of a direct blow to the point of the shoulder, and 6% the result of a fall onto an outstretched hand.287 Falls on the outstretched hand were the apparent mechanisms of 5 of 79 (6.3%) midclavicular fractures and 2 of 34 (5.9%) distal clavicular fractures, suggesting that direct injury to the shoulder is the most common mechanism of clavicular fracture at all sites. These authors hypothesized that even those patients who recall their injury as a fall onto the outstretched hand may have fallen secondarily onto the shoulder. This second impact may have been the injuring force, suggesting that isolated fall onto the outstretched hand is actually an unusual mechanism of injury.287
Neer has stated that distal clavicular fractures tend to be the result of a high-energy, direct blow to the shoulder.119,216 However, distal clavicular fractures have also been identified in the elderly following lower energy injuries.231
Epidemiology
An understanding of the frequency and distribution of clavicular fractures is provided by data collected in Malmo, Sweden. Four percent of all fractures occurring in Malmo in 1987 involved the clavicle. This represented 35% of all fractures in the shoulder region. The overall incidence of clavicle fractures increased from 52 per 100,000 persons per year in 1952 to 64 per 100,000 persons per year in 1987, mostly as a result of an increase in sports-related injury and injuries following a fall.231
Seventy-six percent of the fractures occurred in the middle third of the clavicle, a figure that is similar to previous reports.52,84,217,273 The average age overall in this subgroup was 21 years. However, the average age was 11 years for nondisplaced fractures, 25 years for simple displaced fractures, and 43 years for comminuted fractures.
Twenty-one percent of fractures in Malmo involved the distal clavicle with an average age of 47 years (median also 47 years). This is also comparable with the rate reported in some previous studies52,58,172 but is double the rate reported in others.79,119,217,218,273 The incidences of middle and lateral third fractures of the clavicle were comparable for middle-aged adults (approximately 35 to 60 years of age) in the Malmo experience.
Medial clavicular fractures represented only 3% of clavicular fractures.231 Although many of the published studies report an incidence of 4% to 6%, even 3% is probably an overestimate based on inclusion of many of the more medial midclavicular fractures in this group.79,119,217,218,273 Taylor measured the distance of 550 fractures from the lateral aspect of the clavicle and found only 0.5% in the medial third of the bone.292,293 According to the data of Nordqvist et al., the average age of a person sustaining a medial clavicular fracture was 51 years, with a large proportion of fractures occurring in adolescent and young adult males and the elderly. The incidence of both lateral and medial clavicular fractures rose sharply after age 75, suggesting that these areas become substantially more susceptible to fracture when osteoporotic.229
Evaluation
Clavicle fractures resulting from low- to moderate-energy traumatic injuries are easily diagnosed and are associated with few complications. The deformity and swelling associated with the fracture are usually apparent. The location of the fracture along the clavicle can usually be determined by close inspection and palpation, although distinction of fractures of the medial or lateral ends of the clavicle from dislocation of the adjacent joints can be difficult prior to radiographic examination. The patient typically resists all motion of the ipsilateral shoulder, is tender at the fracture site, and holds the arm against the trunk.
Open clavicular fractures are uncommon, even following high-energy traumatic injury, and are usually the result of a direct blow to the clavicle. Tenting of the skin by either one of the major fracture fragments or an intervening fragment of comminuted bone is not uncommon, but a true threat to the integrity of the skin is unusual.263
Neurovascular injury,123 pneumothorax,67,180,203,312 and hemothorax167 have been reported in association with fracture of the clavicle, but are uncommon. In contrast to late dysfunction of the brachial plexus following clavicle fracture in which medial cord structures are typically involved, acute injury to the brachial plexus at the time of clavicle fracture usually takes the form of a traction injury to the upper cervical roots. Such root traction injuries usually occur in the setting of high-energy trauma and have a relatively poor prognosis.17,169,282
Vascular injuries may not always be apparent. These may consist of an intimal injury or a small puncture wound and can present from weeks to years later in the form of an aneurysm or pseudoaneurysm or thrombosis of the involved vein or artery.
The combination of clavicle fracture and fracture of the first five ribs in severely injured patients is an important indication of high-energy upper thorax trauma. It is not uncommon in such cases that accompanying injuries
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of the mediastinal organs (i.e., aortic rupture, heart contusion, pericardial tamponade), the lungs (i.e., hemopneumothorax, lung contusions), and/or cervical and thoracic spine injuries occur.6,7 The prevalence of pneumothorax in association with fracture of the clavicle is often quoted as being 3%, based on Rowe’s study of over 600 fractures at Massachusetts General Hospital.273 In that study, Rowe did not distinguish between moderate- and high-energy injuries and he did not distinguish isolated fractures from those injuries associated with ipsilateral scapular fracture or dissociation from the thorax, or ipsilateral upper rib injuries.76,77,120,121,166,169,173,268,306 Again, the presence of these associated injuries indicates an extremely high-energy injury mechanism. Pneumothorax and hemothorax are more common in this situation and are likely to be a result of a more generalized chest wall injury rather than to a direct injury to the apical pleura by the fractured clavicle. Nonetheless, the importance of an evaluation for possible pneumothorax by both physical examination and close inspection of an upright film that includes the ipsilateral upper lung field should be emphasized.56,185,312 When a clavicle fracture occurs in the setting of a high-energy traumatic injury (such as a motor vehicle accident or a fall from a height), evaluation of life-threatening injury takes precedence and should follow the protocol promoted by the American College of Surgeons.5 Major vascular disruption can occur in association with fracture of the clavicle, but is extremely rare.56,64,67,68,69,107,123,132,195,197,215,236,257,291 Injury to the thoracic duct has also been reported.20,33 Death following a tear of the subclavian vein with resultant pseudoaneurysm was recorded in the famous case of the death of Sir Robert Peel.66,164 Arterial thrombosis may occur following intimal injury.128,168,301 Fracture of the clavicle or dislocation of either the sternoclavicular or acromioclavicular joint in association with lateral scapular translation represents a scapulothoracic dissociation, an injury often associated with severe neurovascular injury.76,77,102,103,166,240
Evaluation of the vascular status of the upper extremity should include an assessment of relative temperature and color as compared with the uninvolved extremity. Due to the extensive collateral blood supply to the upper extremity, these factors may appear normal in spite of the presence of a major vascular injury. A difference in peripheral pulses or blood pressure between injured and uninvolved upper extremities may be the only clue that a vascular injury is present. When the limb is threatened or there is persistent unexplained hemorrhage, angiography can help to detect and localize any vascular injury, thereby assisting with definitive management.
Compression61,83,96,97,106,265 and even thrombosis177,278,288 of the subclavian vein can occur in the early postinjury period. Pulmonary embolism has been reported in the setting of subclavian vein thrombosis following clavicular fracture.278,313
Radiographic Evaluation
An anteroposterior view in the coronal plane of the clavicle will identify and localize the majority of clavicular fractures. To further gauge the degree and direction of displacement of clavicular fractures, oblique views of the clavicle will be necessary.260,273 The film should be large enough to evaluate both the acromioclavicular and sternoclavicular joints as well as the remainder of the shoulder girdle and the upper lung fields. Quesada recommended 45-degree caudad and cephalad views, which he felt would facilitate evaluation by providing orthogonal views.260 Medial clavicular fractures may be difficult to characterize on this view, and computed tomography is often necessary.
Evaluation of distal clavicular fracture displacement in the anteroposterior plane requires a different set of radiographs because cephalad and caudad tilted views are hindered by overlap of the bones of the shoulder, overexposure of the distal clavicle, and frequent failure to accurately depict the degree of displacement. Neer has suggested a stress view (with 10 pounds of weight in each hand) to evaluate the integrity of the coracoclavicular ligaments and 45-degree anterior and posterior oblique views to gauge displacement.219 However, as we noted, differentiation between displaced and undisplaced fractures may mot be relevant. The position of the fracture elements changes dramatically depending on muscle tone (x-rays taken in standing or reclining positions) and the position of the arm (arm in a sling or free-hanging) (see Fig. 31-5). Instead the shape and number of fragments should be identified.
A radiograph taken with the x-ray source angled with a combination of both anteroposterior and cephalad–caudad obliquity has recently been advocated in the evaluation of midclavicular fractures.266,305 The so-called apical oblique view (45-degree anterior [plane of the scapula], 20-degree cephalad tilt) may facilitate the diagnosis of minimally displaced fractures (e.g., birth fractures and fractures in children).305 Ultrasound is also a very sensitive diagnostic tool in the evaluation of birth fractures (Fig. 31-6).145
The abduction–lordotic view, taken with the shoulder abducted above 135 degrees and the central ray angled 25-degrees cephalad, proves useful in evaluating the clavicle following internal fixation.266 The abduction of the shoulder results in rotation of the clavicle on its longitudinal axis, causing the plate to rotate superiorly and thereby exposing the shaft of the clavicle and the fracture site under the plate (Fig. 31-7).
Management of Specific Injuries
Birth Fractures
Fracture of the clavicle is the most common traumatic birth injury. Clavicle fracture must be distinguished from less
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common birth injuries including brachial plexus palsy, fracture–separation of the proximal humeral epiphysis, and fracture of the humeral shaft.238 High birth weight and shoulder dystocia are clearly associated with an increased risk of all types of traumatic birth injury.37,45,49,103,104,135,174,238 However, upwards of 75% of neonates with clavicle fractures are the product of a normal labor and delivery and weigh less than 4,000 grams.42,45,135
Figure 31-6 The apical oblique view is taken with the involved shoulder angled 45 degrees toward the x-ray source and the x-ray source angled 20 degrees cephalad.
Shoulder dystocia results in a wide separation of the head and shoulder as passage of the shoulder through the birth canal is blocked by the symphysis pubis. This may result in a traction injury to the upper roots of the brachial plexus (Erb’s palsy). Fracture of the clavicle may actually protect the brachial plexus by allowing passage of the fetus and decreasing tension on the upper roots.238 Identification of a clavicle fracture in a neonate that is not moving an upper extremity can be reassuring in that the fracture may explain the findings and generally will heal without long-term sequelae. However, between 1.8% and 5.3%174,238 of clavicle fractures will have associated brachial plexus injury, and approximately 13% of patients with birth injury to the brachial plexus also have clavicle fractures.104 Concurrent clavicular fracture apparently does not alter the prognosis of the brachial plexus injury.4
The incidence of birth fracture of the clavicle is uncertain as many fractures are asymptomatic and may not be detected. Prospective investigations of consecutive births using either radiography or serial physical examinations have detected birth fracture of the clavicle at an incidence of 1.7% and 2.9%,135 respectively. The prospective examination of neonates demonstrated that many fractures are not detectable until callus begins to form 1 to 2 weeks following the birth injury. The traditional signs of birth fracture of the clavicle—instability, motion, or crepitus at the fracture site; significant local swelling; and asymmetric Moro reflex—are commonly absent.135
Most birth fractures of the clavicle occur during a vertex delivery, although they may also occur with a breech presentation or cesarean section.238 The anterior shoulder is more commonly involved in most studies. However, in some reviews, the posterior shoulder was more commonly involved 238 and bilateral fracture may also occur. This suggests that both clavicles are subject to compressive forces during delivery as the widest part of the neonate (the shoulders) passes through the birth canal and that either clavicle may fracture, occasionally both.238
The level of experience of the obstetrician has been implicated in some studies49 and found to be unrelated in others.37 Considering the difficulty making the diagnosis, the benign nature of the injury, and the lack of a clear association with level of experience, the incidence of birth fracture of the clavicle is probably a poor indicator of quality of obstetric care, although it has been used as such.49,174 It is difficult to assess the risk of forceps delivery because it is now infrequently used and may have simply been associated with more difficult deliveries in prior investigations.49,174 Most studies demonstrate normal Apgar scores in neonates with birth fracture of the clavicle, indicating that this injury is not associated with postnatal difficulties. On the other hand, at least one study suggests that intrapartum fetal distress may be associated with an increased risk of clavicle fracture as the second stage of labor is iatrogenically shortened by a concerned obstetrician.
Despite a great deal of investigative effort, no reliable risk factors have been determined that distinguish neonates at high risk of birth fracture of the clavicle, and no management recommendations can be made. Recent studies concur that birth fracture of the clavicle may be an
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unavoidable, and fortunately inconsequential, complication of normal birth.45
Figure 31-7 The abduction lordotic view (A) takes advantage of the rotational motion of the clavicle with abduction of the shoulder to provide an alternative view of the clavicle. This radiographic projection is useful for visualizing the fracture site under the plate, which is often obscured in the routine anteroposterior view (B). (From
Browner B.D, Jupiter JG, Levine AM, Trafton PG, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
Isolated birth fractures of the clavicle heal quickly, remodeling any deformity. Immobilization is probably unnecessary but is commonly used for a brief period to reassure the parents. Careful handling of the infant is the most important measure for reducing discomfort and irritability. If treatment is instituted, a simple, safe method of holding the arm at the side, such as strapping the arm to the trunk with stockinet, a gauze roll, or an elastic bandage with the elbow flexed to 90 degrees and a cotton pad between the arm and trunk, should be used for about a week, after which spontaneous movement should return to the arm indicating that interval healing has increased the stability and decreased the pain associated with the fracture.
Midclavicular Fractures
Nonoperative Treatment
Surviving writings from ancient Greece and Egypt document that for over 5,000 years humans have been concerned primarily with the deformity rather than healing of fractures of the clavicle. In fact, the method of closed reduction of clavicle fractures described in the Edwin Smith papyrus differs little from methods used today.2,32 Since that time more than 200 bandaging/strapping techniques have been described.10,160
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To effect a closed reduction, in most cases the distal fragment must be brought upward, outward, and backward while the medial fragment is depressed. A hematoma block (10 mL of 1% lidocaine injected into the fracture site) can provide adequate anesthesia, but in some cases conscious sedation or general anesthesia may prove necessary. The reduction technique described in the Edwin Smith papyrus,32 and still commonly used,261 involves placing a pillow between the shoulder blades of the recumbent patient while the shoulders are spread outward and upward.32,53,261 Another method for achieving reduction is to bring the shoulders backwards and upwards with the patient in a sitting position while the physician’s knee or clenched fist is placed between the shoulder blades to control the position of the trunk.245,300
Innumerable devices have been devised in an attempt to effect or maintain closed reduction and thereby minimize the deformity associated with fracture of the clavicle. The majority of these were cumbersome, painful, and even dangerous.224 Dupuytren in 1839 and Malgaigne in 1859 argued that despite these valiant attempts, deformity of the clavicle was inevitable.68,69,186 They emphasized the use of the simplest and most comfortable method of treatment, which for Dupuytren consisted of placing the arm on a pillow until healing occurred. It has long been suggested that excellent function can be expected despite residual deformity.94,95,167,212,245,277 Nonetheless, devices intended for the maintenance of reduction and immobilization of clavicle fractures have remained popular and commonly take the form of either the figure-eight bandage with or without a sling and only on rare occasions a figure-eight plaster (Billington yoke26) or a half-shoulder spica cast.3,245,261,273 Others have followed Dupuytren and Malgaigne in arguing that accurate reduction and immobilization of clavicular fractures is, as stated by Mullick, “neither essential nor possible.”77,78,132,172,212,277 These authors advocate the use of a simple sling for comfort, forgoing any attempts at reduction.
The advantage of the figure-eight bandage is that the arm remains free and can be used to a limited degree. Disadvantages include increased discomfort, the need for frequent readjustment and repeat office visits, and a potential for complications including axillary pressure sores and other skin problems, upper-extremity edema, venous congestion brachial plexus palsy worsening of deformity, and perhaps an increased risk of nonunion.9,78,94,200,216,255,276,308
Few investigations have compared treatment with a figure-eight (or reducing) bandage with the use of a simple sling (or supporting bandage).200 While the details of patient selection and evaluation in these investigations remain unclear based on the data published, these authors found no difference with regard to shoulder function, residual deformity, or time to return to full range of motion and full activity.9,10,172,200,287
It is important to emphasize that although the clavicle is one of the most commonly fractured bones, very little in the way of stringent, detailed analysis of clavicular fracture data has been performed. The existing literature regarding nonoperative treatment consists of relatively few series,52,88,172,277,294 relatively limited studies comparing treatment modalities,9,200,287 and some technique descriptions,26,53,115,172,245,300 anecdotal observations,85,94,224,261 and general reviews.3,120,121,220,221,222,223,224,225,226,227,228,229,230,231,232,233,234,235,236,237,238,239,240,241,242,243,244,245,246,247,248,249,250,251,252,253,254,255,256,257,258,259,260,261,262,263,264,265,266,267,268,269,270,271,272,273,257 That conservative management is not always uncomplicated has been reported already by many authors in the past.
Rowe pointed out that injury-related complaints in adults such as pain and injury-caused impediments in the first 3 weeks postinjury are frequently underestimated.273 On different x-ray series, Mullick showed that the goal of reduction and immobilization in figure-eight bandage was virtually never reached, and that in a few cases displacement actually increased.212 Petracic et al. proved that with increased tension on the figure-eight sling, venous congestion occurs even before reduction of the fracture.252 He calls this form of therapy a “symbolic treatment, performed in order to satisfy the patient’s need for a decorative bandage.” Fowler pointed out in 1968 that figure-eight slings can lead to more problems than the fracture itself due to chafing and pressure in the axilla.94 In 1982, Piterman reported a painful excoriated axillary wound caused by an overzealously applied figure-eight bandage.255
The rates of nonunion with conservative therapy are quoted in the literature with marked variation from 0.3% to 15%.122,219,273,307 Neer and Rowe reported nonunion rates of under 1% with conservative management of clavicle fractures, however, without differentiating the evaluated patient cohort regarding age and fracture location. Eskola reported a 3% nonunion rate in a predominantly adult population.85 White et al. reported a 13% nonunion rate and found a correlation with high-energy trauma.307 Hill et al. assessed nonunion in 15% of his patients and reported a significant correlation with an initial shortening of over 2 cm.122 Thirty-one percent of their investigated patients were dissatisfied with the outcome of their treatment. In a study of 157 patients, Matis et al. found that half of the cases with clavicular shortening of 1 cm and all cases with clavicular shortening of 2 cm exhibited a significant worsening of shoulder function.194 A randomized, controlled study investigating whether figure-eight slings really affect healing and function of postclavicular fracture has not yet been completed.
Few reports have attempted to evaluate the relationship between residual deformity and shoulder function.237 Eskola et al.85 invited all 118 patients treated for fracture of the clavicle at Helsinki University Central Hospital in 1982 to return for evaluation 2 years following the injury. Among the 89 who presented for the follow-up examination, 24 (27%) had either slight pain on exercise or restricted shoulder movement, with four identified as having
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major functional problems. Primary fracture displacement and shortening of the clavicle as compared radiographically with the opposite, uninvolved side at the 2 year follow-up were used as measures of deformity. Among the 15 patients with primary fracture displacement greater than 15 mm at the time of injury, eight (53%) had pain with exercise, whereas only 12 of the remaining 74 patients had pain (16%), a difference found to be statistically significant using chi-squared analysis (p = 0.02). Among 47 patients with demonstrable shortening at the final follow-up, 17 (36%) had pain with exercise as compared with 3 of 42 patients (7%) without shortening (p = 0.02 by chi-square analysis). Based on these findings, they recommend reduction of deformity associated with displaced clavicular fractures, particularly with regard to shortening. One might question the authors’ conclusions based on the simple fact that the more displaced fractures were those associated with higher-energy traumatic injury and might be expected to do worse regardless of residual deformity. The question of which clavicular fractures can be expected to do poorly and why remains uncertain. While the fact that 27% of their patients returning for 2 year follow-up reported problems with pain during exercise or restricted shoulder movement suggests that there may be room for improvement in the treatment of clavicle fractures, we must await more focused and rigidly controlled investigations for data that might alter our approach to treatment (Fig. 31-8).
Operative Treatment
With the development of more rigid implants, there has been some interest in the use of primary operative treatment for clavicle fractures.149,179,238,242,256,289,315 The good results with open reduction, internal fixation, and bone grafting of clavicular nonunion that have been documented in recent reports also support the contention that internal fixation of the clavicle, when performed properly, should not impede healing.28,142,188 A number of authors have reported good results using plate fixation of clavicular fractures for open fractures, for fractures with severe angulation that could not be reduced closed, or in multiple traumatic injury, especially in the setting of ipsilateral upper-extremity trauma or bilateral clavicular fracture.35,149,182,243,289 Kloen et al.152 favored antero inferior plating of the clavicle, but biomechanical studies revealed that plates fixed at the superior aspect of the clavicle exhibit significantly greater stability than those on the anterior aspect.125 Whether the new locking compression plates provide advantages due to biomechanical stability is not yet clear. In particular, scapulothoracic dissociation and the so-called floating shoulder, representing a combination of displaced clavicular and glenoid neck fractures, are felt to be important indications for open reduction and plate and screw fixation of the clavicular fracture.
Khan and Lucas noted no nonunions among 19 patients treated with primary plate fixation.149 Schwartz and Hocker289 used 2.7-mm plates and reported nonunion in 3 of 36 patients, which they attributed to using a plate of inadequate length. Poigenfürst et al.’s extensive experience with plate fixation of fresh clavicular fractures identified nonunions in 5 of 122 patients (4.1%) treated operatively.256 They also related these failures to technical errors including the use of a plate of inadequate length or strength or devitalization of fracture fragments during operative exposure.
External fixation has also been used for fixation of the clavicle. In a study by Schuind et. al.,280 good results were obtained in 15 fresh midclavicular fractures and in five delayed unions. However, considering the rarity of severe soft tissue injury in this area, the role of external fixation remains unclear.59
Within the past few years several publications have described poor outcomes after conservative treatment of severely displaced midclavicular fractures. It has been reported that between 10% and 30% of patients had clinically, radiographically, and subjectively unsatisfactory results because of shoulder shortening,18,75 nonunion,49 or impaired function.49 However, surgical procedures have also been associated with poor cosmetic results and higher incidences of nonunion and refracture when compared with conservative treatment. Therefore, surgery should be done only in specific situations.16
The standard treatment in surgical therapy of midclavicular fractures is plate fixation. To avoid breakage of the implant, the plate that is used must be relatively large compared with the bone size. A large incision causing additional soft tissue damage is necessary to position this implant, most commonly a small dynamic compression plate or a small reconstruction plate. Typical complications of plate fixation are infection, hypertrophic scars, implant loosening, nonunion, and refracture after hardware removal.139,149
From a biomechanical point of view, intramedullary positioning of the implant is ideal.259 The diameter of the titanium (Ti) nail Jubel et al.149 used for intramedullary fixation was small; however, no implant displacement or material breakage occurred. Because of anatomic features of the clavicle, devices for intramedullary fixation need to be flexible. Besides the need for flexibility, the implant needs to be stable enough to neutralize the potential disruptive forces acting on the fracture after stabilization. The implant also has to be small enough to enable its passage through the medullary space, which is narrow, especially in the middle third of the clavicle.8
Several authors have described various modifications of intramedullary stabilization.22,23,29,30,34,38,39 Jubel et al.136,141 performed a study using elastic stable intramedullary fixation for clavicle fractures (Fig. 31-9). In this study, patients showed significant improvement of shoulder function and
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reduction of pain on day 3 postoperatively, compared to the day prior to surgery. Even patients with bilateral fractures were able to do daily activities without assistance immediately after surgery.
Figure 31-8 A 30-year-old male presented with an ununited fracture of the clavicle associated with excessive callus formation. He had complaints of numbness and weakness in the ipsilateral upper extremity. (A) Anteroposterior radiograph demonstrates the nonunion and hypertrophic callous formation. (B) The supraclavicular nerves are preserved during exposure of the clavicle. (C) A distractor was used to restore clavicular length and alignment. A sculptured tricortical iliac crest graft is placed into the resulting bony defect. (D) The clavicle is then stabilized with a 3.5-mm limited contact dynamic compression plate. (E) Postoperative radiograph demonstrates restoration of length and alignment of the clavicle and stable plate fixation. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
Patients with additional injuries to the lower extremity were able to walk with crutches within the first week after surgery, enabling early mobilization. The original length of the clavicle was restored in all patients but one. Objectively and subjectively, good cosmetic results were achieved using this technique. All patients but one had good biologic fracture healing, so there was no refracture. Because of reduction and stabilization, excessive callus formation, typically seen after conservative treatment, was prevented and the shape of the long bone was restored. The incidence of nonunion was lower compared with the nonunion rate of similar displaced fractures after conservative treatment, plate fixation, or other intramedullary techniques.17,32,37 These results showed that intramedullary fixation of displaced midclavicular fractures with a flexible Ti nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results compared with plate fixation or conservative treatment. Intramedullary nailing of displaced midclavicular fractures is an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.
Author’s Preferred Treatment
Nondisplaced and minimally displaced fractures of the midclavicle require little more than symptomatic treatment. This is best achieved with a simple sling, which can be supplemented by a swathe component if necessary for added comfort early in postinjury. The majority of these nondisplaced fractures will be encountered in children who will heal quickly, and although they may not be compliant with sling wear, they usually self-regulate their activity level until healing has progressed and merely require gentler handling during the healing period. The clavicle typically heals sufficiently to discontinue immobilization within 3 to 4 weeks in young children, 4 to 6 weeks in older children, and 6 to 8 weeks in adults. Limitation of activity is usually encouraged for a minimum of 8 weeks following clinical and radiographic union to reduce the risk of refracture.
The optimal treatment of displaced and comminuted fractures of the clavicle is disputed. Wide displacement and soft tissue interposition have been implicated as risk factors for the development of nonunion,128,142 and at least one study has suggested that residual deformity may alter function.88 Open reduction and internal fixation of so-called irreducible fractures of the clavicle has been reported with good results.35,144,149,242,289,315 Our opinion is that displacement should no longer be used as the most important decision criterion for or against surgery. It is an invalid parameter and very difficult radiographically to objectively report (see Diagnosis). The patients themselves should be more involved in making the decision, and should make that decision together with the physician after detailed description of the advantages (pain reduction, immediate sling-free exercise stability) and risks of operative treatment are explained. The physical and vocational activities of the patient must also be considered for this decision.
However, further work is needed to determine the following: (a) What is the percentage of displaced midclavicular fractures that will go on to nonunion, and is it high enough to consider routine operative treatment? and (b) Does the potential loss of function related to persistent deformity justify the risks of routine operative intervention?
Figure 31-9 A professional 13-year-old motocross driver had a fall during a contest: (A) preoperative x-ray; (B) postoperative x-ray; (C) x-ray 6 weeks after the operation; and (D) x-ray after hardware removal. One week after the operation, he resumed the training on his motocross. In the second postoperative week, he participated again in a contest and, in the third week, became German Champion in his division. (Reproduced with permission from the
BMJ Publishing Group: Br J Sports Med 2003;37(6):480–483.
)
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The definitive indications for primary surgical intervention that we would consider are uncommon and include open fracture, scapulothoracic dissociation,76,77,166 so-called floating shoulder injuries,102,120,121,268 and associated major vascular injury in which an open approach will be necessary for vascular repair. While isolated fractures of the sternal end or middle third of the clavicle do well with nonoperative treatment, complex clavicular injuries involving dislocation or epiphyseal separation at one end of the clavicle in combination with a fracture of the middle third would probably benefit from open reduction and internal fixation.81,112,165,170,297,311 Likewise, the rehabilitation of associated ipsilateral upper-extremity trauma may be facilitated by operative fixation of the clavicle. In the absence of these indications, nonoperative treatment remains our preference.
It is often stated that when the skin is threatened by pressure from a prominent clavicular fracture fragment, then closed reduction and internal fixation should be considered. Actually, it is extremely rare that the skin will be perforated from within.263 However, in the head-injured patient, operative stabilization may be required.
The merits of open or closed reduction and operative fixation in the setting of neurovascular compromise are also unclear. Certainly, when an open approach for vascular repair is required, internal fixation of the clavicle should be performed, but fortunately acute neurovascular injury is rare in association with clavicular fracture.96 The most frequent vascular disturbance encountered is venous congestion of the arm, which, in the absence of deep venous thrombosis, aneurysm, or pseudoaneurysm, can be treated expectantly.
Acute injury to the brachial plexus is extremely uncommon following fracture of the clavicle, and when present, is more likely to be the result of a traction injury to the upper roots of the brachial plexus. What may prove to be an indication for operative intervention is a plexopathy, which develops in relation to abundant callus in a malaligned fracture presenting at a time remote from the injury. In these instances, open realignment, reduction of callus bulk, and internal fixation of the fracture should be considered (Fig. 31-10).302
When performing closed or open reduction and internal fixation of the clavicle, we prefer minimally invasive intramedullary nailing with a 2.0- to 3.5-mm titanium nail (Prevot nail) for closed clavicular fractures (CCF) type A and B, and fixation with plate and screws for CCF type C fractures. Given the fact that intramedullary fixation of the clavicle is technically difficult owing to the curvature, high density, and small intramedullary canal of the bone, it is remarkable that good results with this technique have been observed.28,41,136,137,139,140,141
Our technique for internal intramedullary fixation of the clavicle is as follows: Patients are positioned on a radiolucent operating table in the supine position. A skin incision of 1 to 2 cm is made just above the sternal end of the clavicle. Approximately 1 cm distal to the sternoclavicular joint, a hole is drilled into the ventral cortex of the medial end of the clavicle with a 2.5-mm drill and widened using an awl. The Ti nail, 2.0 to 3.5 mm, is fixed in a universal chuck with a T-handle. With oscillating movements of the surgeon’s hand the unreamed Ti nail is advanced until it reaches the fracture site. To ensure correct placement of the nail, fluoroscopic control is used for reduction and insertion of the nail into the lateral fragment. If closed reduction fails, an accessory incision of 3 to 4 cm is made above
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the fracture site to enable direct manipulation of the fragments. Additional fragments are maintained in their positions, maintaining soft tissue connections. The protruding end of the nail is cut off at the site of its insertion.
Figure 31-10 Operative technique for plate fixation of the clavicle. (A) The patient is positioned in the beach-chair position. (B) Incision of the skin is chosen to respect the relaxed skin tension lines. (C) The supraclavicular nerves are identified under loupe magnification and protected. Schantz screws are placed medial and lateral to the fracture site. (D) A small distractor is used to restore the length and alignment of the clavicle. When comminution results in a bony defect after anatomic reduction, an autogenous iliac crest autograft is applied. (E) The clavicle is stabilized using a 3.5-mm limited contact dynamic compression plate. (F) When the fracture pattern allows, an interfragmentary lag screw is used to obtain compression between the fracture fragments. (G) Hypertrophy of the scar is uncommon. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
For postoperative treatment, patients are instructed to mobilize the affected extremity. Postoperative immobilization is not performed. Physical therapy is prescribed for patients with multiple trauma or accessory injuries.
Our technique for internal plate fixation of the clavicle is as follows:142,178 We apply a 3.5-mm limited contact dynamic compression plate (LCDC Plate, Synthes, Paoli, Pa.) or the locking compression plate (LC Plate, Synthes, Paoli, Pa.) to the anterior or superior aspect of the clavicle. A minimum of three screws should be placed in each major fragment. When the fracture pattern allows, an interfragmentary screw will greatly enhance the stability of the construct. In the presence of fracture comminution or gaps in the cortex opposite the plate, we recommend the addition of a small amount of autogenous iliac crest cancellous bone graft.
We prefer to close the wound over a suction drain, ensuring meticulous hemostasis. If the skin condition allows, wound closure is accomplished in an atraumatic fashion with a subcuticular suture. These measures will reduce the incidence of wound hematoma and promote cosmetic wound healing.
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Our current practice, provided we are confident with the security of fixation, is to use a sling for patient comfort during the initial 7 to 10 postoperative days. The sling may be removed for short periods of passive shoulder pendulum and overhead elbow-flexion range-of-motion exercises without resistance, which are continued until fracture union has been demonstrated, which usually occurs between 6 and 8 weeks postoperatively. Thereafter, progressive strengthening exercises are permitted, and full overhead activities are gradually resumed. A return to all occupational duties and recreational pursuits is usually possible by 3 months after operative treatment.
In most cases, plate removal is unnecessary; on occasion, however, hardware may cause skin problems due to its prominence. In those instances, we remove the plate, provided a minimum of 12 to 18 months have elapsed since the injury and the cortex under the plate has reconstituted as viewed from an apical lordotic projection.
Distal Clavicular Fractures
Fractures of the distal clavicle with little or no displacement are treated symptomatically with a sling. While some cases of nonunion following such fractures have been reported,227,263 the chance of this occurrence is extremely low.
Displaced distal clavicular fractures, on the other hand, are recognized as the only general type of clavicle fracture for which routine primary operative treatment should be considered. This is based on the work of Neer216,218 and others79,228 who have found that between 22% and 33% of these fractures will fail to unite following nonoperative treatment. An additional 45% to 67% will require more than 3 months to heal the fracture.
A number of surgeons have reported healing in 100% of operatively treated displaced lateral clavicle fractures within 6 to 10 weeks after surgery, with few associated complications. The period of disability in these cases was shortened, with a relatively rapid return to full shoulder mobility and function.79,100,218,228 Other authors have reported acceptable results with nonoperative treatment,204,205,269 stating that those few nonunions that become symptomatic can be treated with a reconstructive procedure at a time remote from the injury if necessary.
Neer recommended stabilization of displaced distal clavicular fractures using two Kirschner wires to control rotation. The wires are first passed into the distal fragment from proximal to distal through the fracture site, crossing the acromioclavicular joint and exiting the acromion and the skin on the lateral aspect of the shoulder. The protruding part of the wires is then engaged and advanced proximally across the fracture site and into the medial fragment. The wires are then bent to decrease the risk of migration, and are cut beneath the skin. Shoulder motion must be restricted to prevent pin breakage and migration. Others have used a single wire,119,247,273 threaded wires,119 or screws,220,222,223 and some have made a point of avoiding the acromioclavicular joint. Caution was urged in a recent report by Kona et al., who noted high rates of both nonunion and infection with transacromial wire techniques.158
Alternative techniques for operative fixation of distal clavicular fractures include coracoclavicular screw fixation11 or transfer of the coracoid to the clavicle.43,110 A combination of coracoclavicular ligament reconstruction and wire fixation of the fracture fragments,44,175 a transacromial Knowles pin fixation,91 or a hook plate fixation74,93,105,207,273 have also been described. The AO/ASIF group has recommended using a tension band wire construct with two Kirschner wires, which enter on the superior aspect of the clavicle, avoiding the acromioclavicular joint.118,281 In addition, they also suggest consideration of a small plate, either a small T-shaped plate or a hook plate, and occasionally direct one of the screws into the coracoid as described by Bosworth.11,29 A specially designed plate that is contoured so that its distal limit curves under the acromion through the acromioclavicular joint has also been utilized.116,274
We prefer to use a tension band wire technique. The distal clavicle and acromion are exposed through an incision in the relaxed tension lines of the skin with the development of thick flaps. Provisional fracture reduction can be held with a transacromial Kirschner wire. Definitive fixation consists of two stout smooth Kirschner wires passed through the outer edge of the acromion and crossing obliquely across the acromioclavicular joint and fracture to purchase in the solid cortex of the dorsal clavicle medial to the fracture. An 18-gauge wire is then looped through a drill hole medial to the fracture and around the tips of the wires, which are bent 180 degrees, turned downward, and impacted into the acromion (Fig. 31-11)
If a tear in either the trapezoid or conoid ligaments is identified, an attempt is made to perform a suture repair. The wound is closed over a suction drain. The postoperative management differs from that for midclavicular fractures in that patients are maintained in a sling for a minimum of 4 to 6 weeks.
Medial Clavicular Fractures
Little exists in the literature about fractures of the medial clavicle. These fractures are very uncommon and most surgeons have limited experience with them. The literature offers little more than case reports, the majority of which describe medial physeal separation injuries. While some authors recommend open reduction and internal fixation, the majority advocate nonoperative treatment initially with resection of the medial clavicle if symptoms persist.3,136,143,176,258 Considering the risks attendant with implant insertion and migration in this region, we rarely consider operative treatment. The generally good results of nonoperative treatment are related to the
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fact that fractures of the sternal end of the clavicle are often physeal separations that heal with stability and may even remodel somewhat. Displaced fractures must be evaluated with computed tomography scanning to be certain that posterior displacement of the fragments does not present a threat to neurovascular structures at the base of the neck.
Figure 31-11 (A) A 55-year-old female sustained a comminuted type II fracture of the distal clavicle in a motor vehicle accident. (B) Fixation was achieved using two transacromial Kirschner wires exiting through the thick dorsal cortex of the medial fragment in combination with a tension band wire. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
Floating Shoulder
Floating shoulder is an unstable combination of fractures that involves the scapular neck and the ipsilateral midclavicle, and it requires surgical treatment. According to Herscovici et al.,120 floating shoulder is a rare injury with an incidence of approximately 0.1% in all patients with fractures. They also reported that functional disorders sometimes remain when only the fracture of the clavicle is diagnosed, the fracture of the scapula is missed, and conservative treatment is performed. Floating shoulder is an unstable injury that is likely to displace as a result of muscle strength and upper-limb weight, and for which surgical treatment is considered to be appropriate. If the patient is treated conservatively, where sufficient reduction and maintenance of reduction are difficult to assess, nonunion and/or malunion will occur, breaking down the suspension mechanism of the clavicle and leading to a drooping shoulder. Leung et al.173 reported that open reduction and plate fixation procedures are necessary for both fractures of the scapula and the clavicle. On the other hand, Herscovici et al.120,127 reported that, if the clavicle is fixed by open reduction, an unstable fracture becomes stable, resulting in bony union for both fractures; therefore, plate fixation of only the clavicle is sufficient to correct a floating shoulder.114
Complications
Nonunion and Malunion
The percentage of nonoperatively treated clavicular fractures that fail to heal within 6 months of injury has been reported variously as 0% (of 342 patients),277 0.1%,216 0.47%,120 0.8%,239 0.9%,144 and 2.2%.84,88 White et al. reported that they had encountered eight nonunions (8%) and 18 delayed unions (16%) among 112 adult fractures of the clavicle proximal to the coracoid, the majority occurring as a result of a high-energy traumatic injury.307 Proposed risk factors for nonunion based on series of patients presenting with nonunion include the severity of the initial trauma,24,95,134,276,309 fracture comminution, and refracture. Jupiter and Leffert,142 as well as others,188,202 found that the degree of fracture fragment displacement was the most important risk factor for nonunion. These risk factors often are interrelated and reflect more severe soft tissue injury, decreased stability, and limited apposition of fracture fragments. The role of soft tissue interposition remains unclear.129,188 The fact that midclavicular nonunion is far more common than distal clavicular nonunion has been ascribed to the fact that midclavicular fractures are far more common overall. Primary operative treatment of fractures of the clavicle has been associated with a risk of nonunion (3.7% according to Rowe273 and 4.6% according to Neer219). While contemporary series report high union rates with internal fixation of fresh clavicular fractures,35,79,315 they identify improper technique including utilization of too small or too short a plate and excessive soft tissue stripping as reasons for operative failures256,281 (Fig. 31-12).
On occasion a clavicular nonunion may be asymptomatic and discovered incidentally on a chest radiograph.134
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Prior to more reliable means of internal fixation, some authors134,309 recommended against operative intervention. In fact, patients presenting with an ununited clavicle are more likely than not to have specific complaints regarding increasing deformity, consisting of adduction, shortening, and protraction of the shoulder girdle. Altered shoulder function occurs as a result of the deformity, pain, or local compression of the underlying brachial plexus or vascular structures.142,285 Occasionally patients will present decades after the original injury requesting treatment.142,309 Unfortunately, this may be partly due to the fact that these patients had been advised previously that nothing operative could or ought to be done (Fig. 31-13).
Figure 31-12 Implant loosening and nonunion are typically related to inadequate plate size and length. (With kind permission from Prof. Klaus Emil Rehm and Dr. Axel Jubel.)
The neurovascular problems that may accompany clavicular nonunion include thoracic outlet syndrome,13,19,31,51,89,210,254,289 subclavian artery or vein compression62,159 or thrombosis,62,106,312,313 and brachial plexus palsy.40,65,142 The prevalence of neurovascular dysfunction in patients presenting with clavicular nonunion has varied widely in reported series from as few as 6% to as many as 52% of patients.134,142,157,309
In the treatment of clavicular nonunions, we prefer to distinguish between reconstructive procedures in which the goals of both relief of pain and neurovascular compression as well as enhanced function are sought via restoration of the length, alignment, and continuity of the clavicle; and salvage procedures in which the clavicle is either resected, contoured, or avoided altogether (i.e., first rib resection61) with the limited goal of relieving symptoms. Although treatment of clavicular nonunion with electrical stimulation has been attempted,34,50,51,63 there are few indications for its use. Symptomatic clavicular nonunion typically has elements of both shoulder deformity and dysfunction as well as neurovascular compromise that are not addressed by electrical treatment,213 and the union rates do not approach those obtained by open reduction and internal fixation with provision of an autogenous bone graft.
With the advent of improved techniques of stable fixation, the results of reconstructive procedures have improved to the point that salvage operations are now largely of historical interest.202,285 The only situation in which we would consider partial resection of the clavicle is in a chronically infected clavicle in a medically compromised patient or in a very distal clavicular nonunion. A small distal clavicular fragment can be resected and the coracoclavicular ligaments securely attached to the outer end of the medial fragment.285
The treatment of clavicular nonunion has evolved from the screw fixation of tibial or iliac crest bone grafts used by early authors,16,98,276 to intramedullary fixation,111,134,181 which seems to be a good alternative technique to plating,28,41 to plate and screw fixation.105,142,157,192 One of us treated 29 hypertrophic malunions of the clavicle with intramedullary nailing (as described above; study is currently being published). Twenty-five cases required an additional incision over the fracture to cannulate the medullary canal with a 3.5-mm drill. The bone shavings produced from debulking the callus, with or without additional cancellous bone graft, facilitated bony healing. In all cases, however, the patient was additionally informed and consented for plate fixation with cancellous bone grafting, since it is often decided intraoperatively that conventional plate fixation is necessary. Our preference for plate fixation and our operative technique and rehabilitation protocol are described previously under Author’s Preferred Treatment. A few points regarding the treatment of midclavicular nonunions deserve further discussion.
In hypertrophic nonunions, the exuberant callus can be resected and saved for use as bone graft, making harvest of an iliac crest graft unnecessary in some cases. The nonunion site does not require débridement, as the fibrocartilage will progress to union following stable internal fixation. If the fracture line is oblique, it is sometimes possible to secure the fragments using an interfragmentary screw in addition to the superiorly placed plate.
Atrophic nonunions present sclerotic ends with interposed fibrous tissue while pseudoarthroses will have a false synovial-lined cavity. Resection of the ends of the
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fracture fragments and the intervening tissue is required in both situations. In this situation a small distractor often proves invaluable in helping to control the fragments as well as to attain the desired length and alignment. A sculptured tricortical iliac-crest bone graft will be useful to ensure restoration of length and alignment and to promote healing.
Figure 31-13 A 56-year-old woman presented with complaints of increasing shoulder pain, stiffness, and deformity after injuring her clavicle at age 14. (A) An anteroposterior radiograph demonstrated an ununited fracture of the clavicle with widely displaced, atrophic fragments. (B) The supraclavicular nerves were identified under loupe magnification and protected throughout the operative procedure. (C) A distractor was used to restore the anatomic length and alignment of the clavicle and a tricortical bone graft from the iliac crest was used to bridge the residual bony defect. (D) One of the screws through the plate transfixes the bone graft. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
We harvest the iliac graft from the crest through an oblique incision along the midpoint of the ilium. The crest is exposed subperiosteally and a tricortical section, measuring one and one-half times the anticipated size of the final graft, is removed with either osteotomes or a small oscillating saw. The graft is then sculptured to create large cancellous pegs at each end, which plug into the medullary canals of the clavicular fragments (Fig. 31-14).
This interdigitation increases the stability of the construct and facilitates plate fixation. The graft is positioned so that the dorsal cortical margin of the iliac crest lies on the inferior surface of the clavicle, affording the advantages of better purchase of a screw as well as more resistance to bending forces at the nonunion site. Additional cancellous graft from the iliac crest is compacted into the medullary canals of each fragment prior to the final impaction of the corticocancellous segmental graft.
A 3.5-mm limited contact dynamic compression plate (Synthes, Paoli, Pa.) is then applied with a minimum of three screws in each major fragment and a single screw transfixing the graft. Compression is applied to both surfaces of the graft to enhance its incorporation. The wound is closed with a subcuticular suture over suction drainage.
Malunion has traditionally been considered primarily a cosmetic concern.224 However, it is not surprising that some reports exist of difficulties in shoulder function in patients with overriding of clavicular fragments.84,85,88 In addition, compression of underlying neurovascular structures has been reported in association with malaligned clavicle fractures due to narrowing of the costoclavicular space and compression of the brachial plexus and subclavian artery or vein. Malunited fractures typically may give rise to neurovascular symptoms weeks or months following the injury due to proliferative callus.13,50,51,89,264
The senior author (JBJ) has treated four patients with malunited clavicular fractures for deformity associated with ipsilateral glenohumeral dysfunction either alone or in combination with scapulothoracic dysfunction (unpublished series). The malunion was osteotomized through the plane of deformity, realigned using a small distractor, and secured with a plate and screws. In each case, function was improved and the outcome deemed satisfactory (Fig. 31-15).
Some patients are unhappy with the appearance of their healed clavicular fractures due to a prominent bump at the apex of the deformity. These patients should be advised that an operation to smooth the contour of the deformity would essentially trade a bump for a scar. There is a risk that the scar could be hypertrophic and more unsightly than the bump. Furthermore, the removal of bone places the clavicle at an increased risk for refracture.
Neurovascular Complications
Acute neurovascular complications are rare and typically occur in association with scapulothoracic dissociation56,123,215 or are unrelated to the clavicular fracture (e.g., brachial plexus traction injury).123,169 Neurovascular dysfunction as a result of narrowing of the thoracic outlet can occur within the first 2 months of injury when the fracture is malaligned or many months or even years later as a result of hypertrophic callus in the setting of nonunion.
Further mention should be made here of thrombosis and pseudoaneurysm of the subclavian or axillary artery or subclavian vein presenting at a time remote from the injury. Cases of axillary or subclavian artery thrombosis presenting late with symptoms of atrophy and cold intolerance of the involved upper extremity most likely represent missed acute intimal injury,123,128,283 but may also result from compression in a narrowed costoclavicular space.295 Cerebral embolism has been reported following subclavian artery thrombosis in this setting.312
True aneurysms of the subclavian artery may occur as poststenotic aneurysms when the costoclavicular space is narrowed.64,395 Displaced clavicular fracture fragments may very rarely cause a small perforation injury of the subclavian artery. Occasionally a pseudoaneurysm develops that may present months to years later with brachial plexus dysfunction due to compression.
Neurovascular symptoms related to compression by hypertrophic nonunion have been mistaken for sympathetically maintained pain (shoulder–hand syndrome) in the past. Damage to the supraclavicular nerves can cause anterior chest wall pain.259
Complications of Operative Treatment
Despite the proximity of important anatomic structures beneath the clavicle, intraoperative complications are rare. Eskola et al. reported tearing of the subclavian vein, pneumothorax, air embolism, and brachial plexus palsy all in a single patient during dissection of a clavicular nonunion.84,151 On the other hand, wires and pins show a remarkable ability to migrate once inserted182 and may ultimately be found in the abdominal aorta,213 ascending aorta,225 and pericardium causing fatal tamponade46; the pulmonary artery174; the mediastinum38; the heart248; the lung199,207,267 (sometimes the opposite lung267); or the spinal canal.232 A patient presenting to Kremens and Glauser161 brought in a Steinman pin that he reported having expectorated 1 month following fixation of his medial clavicular fracture.
Figure 31-14 Sculpturing of the tricortical iliac crest autograft allows interdigitation of the graft with the fracture fragments increasing the stability of the construct and enhancing healing. (A) Following resection of the nonunion back to viable bone and distraction of the clavicle to restore length and alignment, a substantial bony defect is common. (B) A tricortical graft is harvested from the iliac crest and cancellous pegs are sculpted at the medial and lateral aspects. The medullary canals of the fracture fragments are opened with a drill and the pegs interdigitate with the fragments. (C) The harvested iliac crest graft prior to sculpturing. (D) The graft following sculpturing. (E) The interdigitation of the graft with the fracture fragments provides a measure of stability, facilitating plate fixation. One of the screws transfixes the plate. (F) Intraoperative photograph demonstrating plate fixation following graft interposition. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
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Poigenfürst et al. documented superficial infections in 9 (7.4%) and deep infections in 2 (1.6%) of 122 patients undergoing plate fixation of fresh clavicular fractures,256 but other authors have had little trouble with infections following plate fixation.35,141,142,188,242 Many authors cite hypertrophic scar formation as one of the potential complications of operative treatment of clavicular fractures,147 particularly the proponents of intramedullary fixation who advocate a more oblique incision in alignment with Langer’s lines.220,222,223 We have had no particular problem with cosmetically displeasing scars.
Figure 31-15 A 35-year-old male presented with complaints of restricted shoulder motion, weakness, and discomfort after healing of his fractured clavicle with 2 cm of shortening. (A) Anteroposterior radiograph demonstrating malunion of the clavicle. (B) An oscillating saw is used to create a long oblique osteotomy of the clavicle. (C) A distractor is used to restore length and alignment. (D) Fracture reduction forceps help maintain alignment while an anterior plate incorporating an interfragmentary screw is applied. (E) Radiograph demonstrates stable plate fixation with restoration of clavicular length. (From
Browner, Jupiter, Levine, Trafton, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1998.
)
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Refracture
Repeat fracture of the clavicle usually occurs upon premature resumption of full activity, in particular contact sports activity. The typically vigorous healing response of the clavicle results in a rapid decrease in pain and return of shoulder function so that overenthusiastic patients will often ignore their physician’s admonition to avoid contact sports for at least 2 to 3 months or longer following healing of the fracture. Refracture following plate removal is unusual if the plate remains in place a minimum of 12 to 18 months following healing of the fracture.256,285
Failed Internal Fixation
The standard method of fixation for the clavicle is plate fixation. The particular problem with this technique is that the tension-held side of the clavicle, and thus the optimal position for the plate, changes with each direction of stress and rotation of the arm. Tensile forces against the implant cannot be prevented using plate fixation. To avoid plate breakage, a very large plate in proportion to the size of the bone must be chosen. However, using a typical narrow 3.5-mm LCDC plate or 3.5-mm reconstruction plate, the desired screw anchoring is not always possible. Typical complications after plate fixation include implant fracture, implant loosening, malunion, and refracture after removing the hardware. In cases of implant breakage or loosening, normally refixation is indicated if the fracture is not yet consolidated and the soft tissues allow for another procedure.
Fractures are not expected to heal independently when implants break or loosen. The goals of refixation are to achieve more proportionate stability of the fracture to avoid nonunion and to restore the clavicular length.
For refixation, a 3.5- mm LCDC plate, a 3.5-mm LC plate, or a corresponding reconstruction plate should be chosen; a one-third tubular plate is not appropriate. At least six, and preferably eight, cortical screws should be inserted into each major fragment. Particularly in cases of screw loosening, the fixed-angle plates should be used since in such cases (as well as in cases of poor bone quality), better bony anchoring can be achieved. However, if an adequate position cannot be found using a straight plate despite bending, the molded reconstruction plate is better. Because of the osteoporosis present in refixation procedures of the clavicle, titanium implants should be used exclusively (due to biocompatibility). Intramedullary support in the form of elastic titanium nails is an alternative to refixation with a plate for simple (two-fragment) fractures. After refixation procedures, elevation and abduction of the affected arm should be limited to 90 degrees for a period of 6 weeks to limit the rotation of the clavicle on the longitudinal axis.
In cases of implant fracture or loosening in combination with soft tissue infection or wound-healing disturbances, therapeutic measures should be taken in stepwise fashion. The first procedure should be simple implant removal. Once the soft tissues have revitalized, bony refixation is indicated. However, in such cases it should be explained to the patient that operative refixation may be delayed posthardware removal and postinfection recovery, in anticipation of spontaneous healing. In the case of bony consolidation, potential outcomes should be estimated as for nonoperative management. If bony healing does not occur spontaneously, the nonunion can always be treated operatively.
The development of nonunion after plate fixation, when the plate remains intact, is always the expression of a biologic (cellular), as opposed to mechanical, problem. Operative therapy for such cases requires placement of a corticocancellous bone strut graft from the iliac crest to be anchored ventrally across the fracture site with minifragment screws. (See section on Nonunion and Malunion.) This should be performed after the nonunion tissue has been débrided. If the plate is found to be loosened intraoperatively, the refixation should be performed according to the principles described previously with a 3.5-mm plate.
In cases of loose implants with radiographic evidence of delayed union or nonunion, we believe ultrasonic therapy is indicated prior to performing further operative measures.
Implant fractures, implant loosening, and nonunion postlateral clavicle fractures are usually evidence of a combination of mechanical and cellular problems. The local cellular problem is solved by débriding the nonunion tissue and attaching a corticocancellous iliac crest strut graft that can be fixed to the medial and lateral fragments with mini- or small-fragment screws. (See Nonunion and Malunion.) If there is sufficient bony anchoring for the lateral fragment, the mechanical problem can be solved by using a fixed-angle small fragment plate for refixation. The medial fracture fragment should additionally be fixed to the coracoid with a 1.5-mm Polydioxanonacid (PDS) cord figure-eight suture. If the lateral fragment is too short for good anchoring, we stabilize the fracture using a titanium nail introduced over the acromion, which enters the medullary canal of the clavicle from lateral (Fig. 31-16) or using two plates fixed from the dorsal and anterior aspect (Fig. 31-17).
As a last resort for chronic pain secondary to lateral malunion, there remains the option to resect the lateral third of the clavicle. The problem with sternal-end clavicular fractures is normally the short medial fragment. In these cases, implant loosening and subsequent fracture can occur as a result of insufficient anchoring. For refixation, we choose a fixed-angle 2.7-mm minifragment plate in L- or T-form. With such a plate, it is normally possible to anchor two to three screws in the medial fragment. Additionally, the lateral fragment is fixed near the sternum to the second or third rib with a 1.5-mm PDS-cord figure-eight suture.
Figure 31-16 If the lateral fragment is too short for good anchoring, we stabilize the fracture using a titanium nail introduced over the acromion. The medial fracture fragment should additionally be fixed to the coracoid with a 1.5-mm PDS-cord figure-eight suture. (With kind permission from Prof. Klaus Emil Rehm and Dr. Axel Jubel.)
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When refracture of the clavicle occurs after implant removal, indications for refixation depend on the complaints of the patient and the conditions of the local soft tissue. Again, this appears to come from a (preoperatively present) cellular problem. It can therefore, in principle, be treated like the case of a nonunion. Alternatively, with suitable fracture forms, intramedullary stabilization can be performed. Intramedullary fixation is performed with the goal of avoiding further compromise of the periclavicular soft tissue.
In fractures with a large wedge fragment or a comminuted zone (CCF type C), intramedullary fixation is not indicated. Possible complications postintramedullary stabilization of the clavicle are lateral perforation, painful protrusion of the medial nail end, implant displacement, and nonunion. In cases of painful, moderately prominent medial nail ends, a so-called pseudobursa can develop in a period of 4 to 6 weeks postfixation. Only in such a case, where a pseudobursa develops and the patient continues to complain of pain, or in the case of a very long nail end with impending skin perforation should a nail-shortening procedure (under local anesthesia) be performed.
Figure 31-17 Another option in the case of a small lateral fragment is the use of two limited contact plates in combination with a bone graft.
Lateral perforation alone is not a problem, and does not require a corrective procedure. Only cases where lateral displacement of the implant occurs during the course of healing require therapy. Premature removal of the implant should be performed from the lateral side. Indications for refixation should depend on the further course and complaints of the patient; however, only seldom is reoperation necessary, since healing results are similar to those after conservative management. When indications for refixation exist such as increased displacement, absence of bony healing, and/or increased subjective complaints from the patient, it should be performed as described previously with a plate.
References
1. Abbott LC, Lucas DB. The function of the clavicle; its surgical significance. Ann Surg 1954;140(4):583–599.
2. Adams CF. The genuine works of Hippocrates. Baltimore: Williams & Wilkins, 1939.
3. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49(4):774–784.
4. al-Qattan MM, Clarke HM, Curtis CG. The prognostic value of concurrent clavicular fractures in newborns with obstetric brachial plexus palsy. J Hand Surg Br 1994;19(6):729–730.
5. American Surgeons Co., Trauma Co. Advanced Trauma Life Support Course, 1990.
6. Andermahr J, Greb A, Hensler T, et al. Pneumonia in multiple injured patients: a prospective controlled trial on early prediction using clinical and immunological parameters. Inflamm Res 2002;51(5):265–272.
7. Andermahr J, Hensler T, Sauerland S, et al. [Risk factors for the development of pneumonia in multiple injured patients. Results of a prospective clinical trial]. Unfallchirurg 2003;106(5):392–397.
8. Andermahr JJA, Elsner A, Johann J, Prokop A, Rehm KE, Koebke J. Anatomy of the clavicle. With special respect to the intramedular nailing of midclavicular fractures. Clin Anat, 2006, in press.
9. Andersen H. Histochemistry and development of the human shoulder and acromioclavicular joints with particular reference to the early development of the clavicle. Acta Anat 1963;55:124–165.
P.971

10. Anderson K. Evaluation and treatment of distal clavicle fractures. Clin Sports Med 2003;22(2):319–326, vii.
11. Ballmer FT, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle. J Bone Surg 1991;73B:291–294.
12. Bardeleben K. In Fick R, Jena G, eds. Anatomie der Gelenke. Fischer-Verlag, 1904.
13. Bargar WL, Marcus RE, Ittleman FP. Late thoracic outlet syndrome secondary to pseudarthrosis of the clavicle. J Trauma 1984;24:857–859.
14. Bartosh RA, Dugdale TW, Nielsen R. Isolated musculocutaneous nerve injury complicating closed fracture of the clavicle. A case report. Am J Sports Med 1992;20(3):356–359.
15. Basmajian JV. The surgical anatomy and function of the armtrunk mechanism. Surg Clin North Am 1963;43:1471–1482.
16. Basom WC, Breck LW, Herz JR. Dual grafts for non-union of the clavicle. South Med J 1947;40:898–899.
17. Bateman JE. Nerve injuries about the shoulder in sports. J Bone Joint Surg Am 1967;49(4):785–792.
18. Bateman JE. Neurovascular syndromes related to the clavicle. Clin Orthop 1968;58:75–82.
19. Bateman JE. The shoulder and neck. Philadelphia: W.B. Saunders, 1978.
20. Beatty OA. Chylothorax: case report. J Thoracic Surg 1936;6:221–225.
21. Bechtol CO. Biomechanics of the shoulder. Clin Orthop 1980;(146):37–41.
22. Beckman TA. A case of simultaneous luxation of both ends of the clavicle. Acta Chir Scand 1934;56:156–163.
23. Bennett EH. The mechanism of fractures of clavicle. Ann Surg 1885;1:293–303.
24. Berkheiser EJ. Old ununited clavicular fractures in the adult. Surg Gynecol Obstet 1937;64:1064.
25. Bernard RN Jr, Haddad RJ Jr. Enchondroma of the proximal clavicle. An unusual cause of pathologic fracture-dislocation of the sternoclavicular joint. Clin Orthop 1982;167:239–241.
26. Billington RW. A new (plaster yoke) dressing for fracture of the clavicle. South Med J 1931;24:667–670.
27. Blömer J, Muhr G, Tscherne H. Ergebnisse konservativ und operativ behandelter Schlüsselbeinbrüche. Unfallheilkunde 1977;80:237–242.
28. Boehme D, Curtis RJ, DeHann JT, et al. Non-union of fractures of the mid-shaft of the clavicle. J Bone Joint Surg 1991;73A:1219–1226.
29. Bosworth BM. Acromioclavicular separation: a new method of repair. Surg Gynecol Obstet 1941;73:866–871.
30. Bowen A. Plastic bowing of the clavicle in children. A report of two cases. J Bone Joint Surg Am 1983;65(3):403–405.
31. Braun RM. Iatrogenic compression of the thoracic outlet. Johns Hopkins Med J 1979;145:94–97.
32. Breasthead JH. The Edwin Smith surgical papyrus [published in facsimile and hieroglyphic transliteration and commentary in two volumes, Vol. 1]. Edited, 596, Chicago: University of Chicago Press, 1930.
33. Brewer LAI. Surgical management of lesions of the thoracic duct. Am J Surg 1955;90:210–227.
34. Brighton CT, Pollack SR. Treatment of recalcitrant non-union with a capacitively coupled electrical field. J Bone Joint Surg 1985;67A:577–585.
35. Bronz G, Heim D, Pusterla C, et al. Die stabile claviculaosteosynthese. Unfallheilkunde 1981;84:319–321.
36. Brooks AL, Henning GD. Injury to the proximal clavicular epiphysis. J Bone Joint Surg 1972;54A:1347–1348.
37. Brown BL, Lapinski R, Berkowitz GS, Holzman I. Fractured clavicle in the neonate: a retrospective three-year review. Am J Perinatol 1994;11(5):331–333.
38. Burman M, Grossman S, Rosenak M. The migration of a fracture-transfixing pin from the humerus into the mediastinum. AJR Am J Roentgenol 1956;76:1061.
39. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am 1982;64(7):1053–1058.
40. Campbell E, Howard WP, Burkland CW. Clinical notes, suggestions and new instruments. JAMA 1949;139:91–92.
41. Capicotto PN, Heiple KG, Wilber JH. Midshaft clavicle nonunions treated with intramedullary Steinmann pin fixation and onlay bone graft. J Orthop Trauma 1994;8:88–93.
42. Carter G, Park JW, Tarvin C. Clavicular fractures in neonates. Am J Dis Child 1991;145(3):251–252.
43. Caspi I, Ezra E, Oliver S, Lin E, Lotan G, Horoszowski H. Treatment of avulsed clavicle and recurrent subluxations of the ipsilateral shoulder by dynamic fixation. J Trauma 1987;27(1):94–95.
44. Chen CH, Chen WJ, Shih CH. Surgical treatment for distal clavicle fracture with coracoclavicular ligament disruption. J Trauma 2002;52(1):72–78.
45. Chez RA, Carlan S, Greenberg SL, Spellacy WN. Fractured clavicle is an unavoidable event. Am J Obstet Gynecol 1994;171(3):797–798.
46. Clark RL, Milgram JW, Yawn DH. Fatal aortic perforation and cardiac tamponade due to a Kirschner wire migrating from the right sternoclavicular joint. South Med J 1974;67:316–318.
47. Classification, Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996;10(5–9):1–154.
48. Codman EA. The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: Thomas Todd, 1989.
49. Cohen AW, Otto SR. Obstetric clavicular fractures. A three-year analysis. J Reprod Med 1980;25(3):119–122.
50. Connolly JF. Electrical treatment of nonunions. Its use and abuse in 100 consecutive fractures. Orthop Clin North Am 1984;15(1):89–106.
51. Connolly JF, Dehne R. Nonunion of the clavicle and thoracic outlet syndrome. J Trauma 1989;29:1127–1133.
52. Conwell HE. Fractures of the clavicle: a simple fixation dressing with a summary of the treatment and results attained in ninety-two cases. JAMA 1928;90:838–839.
53. Cook TW. Reduction and external fixation of fracture of the clavicle in recumbency. J Bone Joint Surg Am 1954;36-A(4):878–879.
54. Cope R, Riddervold HO, Shore JL, Sistrom CL. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma 1991;5:379–384.
55. Copeland SM. Total resection of the clavicle. Am J Surg 1946;72:280–281.
56. Costa MC, Robbs JV. Nonpenetrating subclavian artery trauma. J Vasc Surg 1988;8:72–75.
57. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Matsen FA III, eds. The shoulder. Philadelphia: W.B. Saunders, 1990:367–412.
58. Cummings CW, First R. Stress fracture of the clavicle after a radical neck dissection. Plast Reconstr Surg 1975;55:366–367.
59. Dameron TB Jr. External fixation of the clavicle for fracture or non-union in adults. J Bone Joint Surg Am 1989;71(8):1272.
60. Dameron TB Jr, Rockwood CA Jr. Fractures of the shaft of the clavicle. In: Rockwood CAW, King RE, eds. Fractures in children. Philadelphia: J.B. Lippincott, 1984.
61. Dash UN, Handler D. A case of compression of subclavian vessels by a fractured clavicle treated by excision of the first rib. Am J Orthop 1960;42-A:798–801.
62. Daskalakis E, Bouhoutsos J. Subclavian and axillary vein compression of musculoskeletal origin. Br J Surg 1980;67(8):573–576.
63. Day L. Electrical stimulation in the treatment of ununited fractures. Clin Orthop 1981;161:54–57.
64. DeBakey ME, Beall AC, Wukasch DC. Recent developments in vascular surgery with particular reference to orthopedics. Am J Surg 1965;109:134–142.
65. Della Santa D, Narakas A, Bonnard C. Late lesions of the brachial plexus after fracture of the clavicle. Ann Chir Main Memb Super 1991;10(6):531–540.
66. Dickson JW. Death following fractured clavicle. Br Med J 1952;2:266.
67. Dugdale TW, Fulkerson JP. Pneumothorax complicating a closed fracture of the clavicle: a case report. Clin Orthop 1987;221:212–214.
68. Dupuytren G. Fracture de la clavicule en plusieurs fragments par cause indirecte. Gaz des hopitaux 1831;4:315.
P.972

69. Dupuytren G. Injuries and disease of bone. Selections from the collected edition of the clinical lectures of Baron Dupuytren, 1847.
70. Dust WN, Lenczner EM. Stress fracture of the clavicle leading to nonunion secondary to coracoclavicular reconstruction with Dacron. Am J Sports Med 1989;17(1):128–129.
71. Dvir Z, Berme N. The shoulder complex in elevation of the arm: a mechanism approach. J Biomech 1978;11(5):219–225.
72. Dvir Z, Berme N. The shoulder complex in elevation of the arm: a mechanism approach. J Biomech 1978;11:219–225.
73. Dzhigora S. On the sexual dimorphism of the clavicle. Sud Med Exp 1962;5:16.
74. Eberle C, Fodor P, Metzger U. [Hook plate (so-called Balser plate) or tension banding with the Bosworth screw in complete acromioclavicular dislocation and clavicular fracture]. Z Unfallchir Versicherungsmed 1992;85(3):134–139.
75. Eberle H. Klinik und Behandlung der frischen Klavikulafraktur. Hefte zur Unfallheilkunde, 1972;114:165–175.
76. Ebraheim NA, An HS, Jackson WT, et al. Scapulothoracic dissociation. J Bone Joint Surg Am 1988;70(3):428–432.
77. Ebraheim NA, Mekhail AO, Darwich M. Open reduction and internal fixation with bone grafting of clavicular nonunion. J Trauma 1997;42:701–704.
78. Edvardsen P, Odegard O. Treatment of posttraumatic clavicular pseudoarthrosis. Acta Orthop Scand 1977;48:456–457.
79. Edwards DJ, Kavanaugh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23:44–46.
80. Elkin DC, Cooper FW. Resection of the clavicle in vascular surgery. J Bone Joint Surg 1946;28A:117–119.
81. Elliot AC. Tripartite injury of the clavicle: a case report. S Afr Med J 1986;70:115.
82. Enker SH, Murphy KK. Brachial plexus compression by excessive callus formation secondary to a fractured clavicle: a case report. Mt Sinai J Med 1972;37:678–682.
83. Erichsen J. Clinical lecture on a case of comminuted fracture of the clavicle with compression of the subclavian vein by one of the fragments. Br Med J 1873;1:637–638.
84. Eskola A, Vaininonpaa S, Myllynen P, et al. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105:337–338.
85. Eskola A, Vaininonpaa S, Myllynen P, et al. Surgery for ununited clavicular fracture. Acta Orthop Scand 1986;57:366–367.
86. Eskola A, Vaininonpaa S, Myllynen P, Patiala H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105(6):337–338.
87. Eskola A, Vaininonpaa S, Myllynen P, Patiala H, Rokkanen P. Surgery for ununited clavicular fracture. Acta Orthop Scand 1986;57(4):366–367.
88. Eskola A, Vaininonpaa S, Patiala H, Rokkanen P. Outcome of operative treatment in fresh lateral clavicular fracture. Ann Chir Gyn 1987;76:167–169.
89. Falconer MA, Weddell G. Costoclavicular compression of the subclavian artery and vein: relation to the scalenus anticus syndrome. Lancet 1943;1:539–543.
90. Falstie-Jensen S, Mekkelsen P. Pseudodislocation of the acromioclavicular joint. J Bone Joint Surg 1982;64B:368–369.
91. Fann CY, Chiu FY, Chuang TY, Chen CM, Chen TH. Transacromial Knowles pin in the treatment of Neer type 2 distal clavicle fractures: a prospective evaluation of 32 cases. J Trauma 2004;56(5):1102—1105; discussion 1105–1106.
92. Fawcett J. The development and ossification of the human clavicle. J Anat 1913;47:225–234.
93. Flinkkila T, Ristiniemi J, Hyvonen P, Hamalainen M. Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand 2002;73(1):50–53.
94. Fowler AW. Fracture of the clavicle. J Bone Joint Surg 1962;44B:440.
95. Fowler AW. Treatment of the fractured clavicle. Lancet 1968;1:46.
96. Gardner E. The embryology of the clavicle. Clin Orthop 1968;58:9–16.
97. Gardner E, Gray DJ. Prenatal development of the human shoulder and acromioclavicular joint. Am J Anat 1953;92:219–276.
98. Ghormley RK, Black JR, Cherry JH. Ununited fracture of the clavicle. Am J Surg 1941;51:343–349.
99. Gibson DA, Carroll N. Congenital pseudarthrosis of the clavicle. J Bone Joint Surg Br 1970;52(4):629–643.
100. Golser K, Sperner G, Thoni H, Resch H. [Early and intermediate results of conservatively and surgically treated lateral clavicular fractures]. Aktuelle Traumatol 1991;21(4):148–152.
101. Gordon M, Rich H, Deutschberger J, Green M. The immediate and long-term outcome of obstetric birth trauma. I. Brachial plexus paralysis. Am J Obstet Gynecol 1973;117(1):51–56.
102. Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma 1993;7(2):99–106.
103. Goss TP. Fractures of the scapula: diagnosis and treatment. In: Iannotti JP, Williams GR, eds. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams & Wilkins, 1999:597–637.
104. Greenwald AG, Schute PC, Shiveley JL. Brachial plexus birth palsy: a 10-year report on the incidence and prognosis. J Pediatr Orthop 1984;4(6):689–692.
105. Gryska PF. Major vascular injuries: principles of management in selected cases of arterial and venous injury. N Engl J Med 1962;266:381–385.
106. Guilfoil PH, Christiansen T. An unusual vascular complication of a fractured clavicle. JAMA 1967;200:72–73.
107. Guillemin A. Dechirure de la veine sous-claviere par fracture fermee de la clavicule. Bull et Mem Soc Nat Chir 1930;56:302–304.
108. Gurd FB. The treatment of complete dislocation of the outer end of the clavicle: a hitherto undescribed operation. Ann Surg 1941;113:1094–1097.
109. Hackenbruch W, Regazzoni P, Schwyzer K. [Surgical treatment of lateral clavicular fracture with the “clavicular hooked plate”]. Z Unfallchir Versicherungsmed 1994;87(3):145–152.
110. Hansky B, Murray E, Minami K, Korfer R. Delayed brachial plexus paralysis due to subclavian pseudoaneurysm after clavicular fracture. Eur J Cardiothorac Surg 1993;7(9):497–498.
111. Hanson FB. The history of the earliest stages in the human clavicle. Anat Rec 1920;19:309–325.
112. Hardy JRW. Complex clavicular injury in childhood. J Bone Joint Surg 1992;74B:154.
113. Harrington MA Jr, Keller TS, Seiler JG 3rd, Weikert DR, Moeljanto E, Schwartz HS. Geometric properties and the predicted mechanical behavior of adult human clavicles. J Biomech 1993;26(4–5):417–426.
114. Hashiguchi H, Ito H. Clinical outcome of the treatment of floating shoulder by osteosynthesis for clavicular fracture alone. J Shoulder Elbow Surg 2003;12(6):589–591.
115. Hawley GW. A method of treating fracture of the clavicle. J Bone Joint Surg 1937;19B:232.
116. Heim U, Pfeiffer KM. Internal fixation of small fractures: technique recommended by the AO-ASIF Group, 3rd ed. New York: Springer-Verlag, 1987.
117. Heinz WM, Misamore GW. Mid-shaft fracture of the clavicle with grade III acromioclavicular separation. J Shoulder Elbow Surg 1995;4:141–142.
118. Hentschel U. Tabellarische Aufstellung der wichtigsten Knochenmerkmale des Menschen zum Zwecke der Zuordnung zu Geschlecht und Alter. Z ärztl Fortb 1963;57:484.
119. Heppenstall RB. Fractures and dislocations of the distal clavicle. Orthop Clin North Am 1975;6(2):477–486.
120. Herscovici D Jr, Fiennes AGTW, Allgower M, Ruedi T. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg 1992;74B:362–364.
121. Herscovici D Jr, Sanders R, Dipasquale T, Gregory P. Injuries of the shoulder girdle. Clin Orthop 1995;318:54–60.
122. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg 1997;79B:537–539.
123. Howard FM, Shafer SJ. Injuries to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg Am 1965;47(7):1335–1346.
124. Howard FM, Shafer SJ. Injuries to the clavicle with neurovascular complications: a study of 14 cases. J Bone Joint Surg 1965;67A:1335–1346.
P.973

125. Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study. J Shoulder Elbow Surg 2002;11(5):457–462.
126. Inman VT, Saunders JB. Observations on the function of the clavicle. Calif Med 1946;65:158–166.
127. Inman VT, Saunders JB, De CM. Observations of the function of the shoulder joint. J Bone Joint Surg 1944;26A:1–30.
128. Iqbal O. Axillary artery thrombosis associated with fracture of the clavicle. Med J Malaya 1971;26:68–70.
129. Jablon M, Sutker A, Post M. Irreducible fracture of the middle third of the clavicle: report of a case. J Bone Joint Surg 1979;61A:296–298.
130. Jacobs B, Wade PA. Acromioclavicular joint injury: an end-result study. J Bone Joint Surg 1966;46:475–486.
131. Jacobs P. Post-traumatic osteolysis of the outer end of the clavicle. J Bone Joint Surg Br 1964;46:705–707.
132. Javid H. Vascular injuries of the neck. Clin Orthop 1963;28:70–78.
133. Jit I, Kulkarni M. Times of appearance and fusion of epiphysis at the medial end of the clavicle. Indian J Med Res 1976;64:773–781.
134. Johnson EW, Collins HR. Nonunion of the clavicle. Arch Surg 1963;87:963–966.
135. Joseph PR, Rosenfeld W. Clavicular fractures in neonates. Am J Dis Child 1990;144(2):165–167.
136. Jubel A, Andemahr J, Bergmann H, Prokop A, Rehm K. Elastic stable intramedullary nailing of midclavicular fractures in athletes. Br J Sports Med 2003;37(6):480–483; discussion 484.
137. Jubel A, Andermahr J, Faymonville C, Binnebosel M, Prokop A, Rehm K. [Reconstruction of shoulder-girdle symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage]. Chirurg 2002;73(10):978–981.
138. Jubel A, Andermahr J, Prokop A, Bergmann H, Isenberg J, Rehm K. [Pitfalls and complications of elastic stable intramedullary nailing (ESIN) of femoral fractures in infancy]. Unfallchirurg, 2004;107(9):744–749.
139. Jubel A, Andermahr J, Prokop A, Isenberg J, Rehm K. [Minimal invasive biological osteosynthesis of the clavicle with a titanium nail]. Kongressbd Dtsch Ges Chir Kongr 2002;119:485–490.
140. Jubel A, Andermahr J, Schiffer G, Rehm KE. [Technique of intramedullary osteosynthesis of the clavicle with elastic titanium nails]. Unfallchirurg 2002;105(6):511–516.
141. Jubel A, Andermahr J, Schiffer G, Tsironis K, Rehm KE. Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail. Clin Orthop 2003;408:279–285.
142. Jupiter J, Leffert R. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69(5):753–760.
143. Kanoksikarin S, Wearne W. Fracture and retrosternal dislocation of the clavicle. Aust N Z J Surg 1978;48:95–96.
144. Karaharju E, Joukainen J, Peltonen J. Treatment of pseudarthrosis of the clavicle. Injury 1982;13(5):400–403.
145. Katz R, Landman J, Dulitzky F. Fracture of the clavicle in the newborn: an ultrasound diagnosis. J Ultrasound Med 1988;7:21–23.
146. Katznelson A, Nerubay J, Oliver S. Dynamic fixation of the avulsed clavicle. J Trauma 1976;16:841–844.
147. Kay SP, Echardt JJ. Brachial plexus palsy secondary to clavicular nonunion: case report and literature survey. Clin Orthop 1986;206:219–222.
148. Kaye JJ, Nance EP Jr, Green NE. Fatigue fracture of the medial aspect of the clavicle. Radiology 1982;144:89–90.
149. Khan MA, Lucas HK. Plating of fractures of the middle third of the clavicle. Injury 1977;9:263–267.
150. Kite JH. Congenital pseudarthrosis of the clavicle. South Med J 1968;61(7):703–710.
151. Kitsis CK, Marino AJ, Krikler SJ, Birch R. Late complications following clavicular fractures and their operative management. Injury 2003;34(1):69–74.
152. Kloen P, Sorkin AT, Rubel IF, Helfet DL. Anteroinferior plating of midshaft clavicular nonunions. J Orthop Trauma 2002;16(6):425–430.
153. Koch AR. [The early development of the clavicle in man]. Acta Anat (Basel) 1960;42:177–212.
154. Kocher MS, Dupre MM, Feagin JA Jr. Shoulder injuries from alpine skiing and snowboarding. Aetiology, treatment and prevention. Sports Med 1998;25(3):201–211.
155. Kocher MS, Feagin JA Jr. Shoulder injuries during alpine skiing. Am J Sports Med 1996;24(5):665–669.
156. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000;30(2):117–135.
157. Koelliker F, Ganz R. [Results of the treatment of clavicular pseudarthrosis]. Unfallchirurg 1989;92(4):164–168.
158. Kona J, Bosse MJ, Staeheli JW, Rosseau RL. Type II clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 1990;4:115–120.
159. Koss SD, Goitz HT, Redler MR, Whitehill R. Nonunion of a midshaft clavicle fracture associated with subclavian vein compression. A case report. Orthop Rev 1989;18(4):431–434.
160. Kreisinger V. Sur le traitement des fractures de la clavicule. Rev Chir 1927;46:376.
161. Kremens V, Glauser F. Unusual sequela following pinning of medial clavicular fracture. AJR Am J Roentgenol 1956;76:1066–1069.
162. Kummer B, Lohscheidt K. Mathematical model of the longitudinal growth of long bones. Anat Anz 1985;158:377–393.
163. Kuner EH, Schlickewei W, Mydla F. Operative therapie der claviculafrakturen, indikation, technik, ergebnisse. Hefte Unfallheilkunde 1982;160:76–77.
164. Lancet. Sir Robert Peel’s death (Editorial). Lancet 1850;2:19.
165. Lancourt JE. Acromioclavicular dislocation with adjacent clavicular fracture in a horseback rider. Am J Sports Med 1990;18:321–322.
166. Lange RH, Noel SH. Traumatic lateral scapular displacement: an expanded spectrum of associated neurovascular injury. J Orthop Trauma 1993;7(4):361–366.
167. Le Vay D. Treatment of midclavicular fractures. Lancet 1967;1:723.
168. Leese G, Blech JJF, Rickhos P, Nimmo M. Post-traumatic axillary artery thrombosis dissolution with low-dose intra-arterial streptokinase. Injury 1993;24:212–213.
169. Leffert RD, Seddon HJ. Infraclavicular brachial plexus injuries. J Bone Joint Surg 1965;47B:9–22.
170. Lemire L, Rosman M. Sternoclavicular epiphyseal separation with adjacent clavicular fracture: a case report. J Pediatr Orthop 1984;4:118–128.
171. Leonard JW, Gifford RW Jr. Migration of a Kirschner wire from the clavicle into the pulmonary artery. Am J Cardiol 1965;16:598–600.
172. Lester CW. The treatment of fractures of the clavicle. Ann Surg 1929;89:600–606.
173. Leung KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75(7):1015–1018.
174. Levine MG, Holroyde J, Woods JR Jr, Siddiqi TA, Scott M, Miodovnik M. Birth trauma: incidence and predisposing factors. Obstet Gynecol 1984;63(6):792–795.
175. Levy O. Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg 2003;12(1):24–28.
176. Lewonowski KB, Bassett GS. Complete posterior sternoclavicular epiphysial separation: a case report and review of the literature. Clin Orthop 1992;281:84–88.
177. Lim EV, Day LJ, Subclavian vein thrombosis following fracture of the clavicle: a case report. Orthopedics 1987;10:349–351.
178. Lipton HA, Jupiter JB. Nonunion of clavicular fractures: characteristics and surgical management. Surg Rounds Orthop 1988;July:17–25.
179. Ljunggren AE. Clavicular function. Acta Orthop Scand 1979;50(3):261–268.
180. Lloyd-Roberts GC, Apley AG, Owen R. Reflections upon the aetiology of congenital pseudarthrosis of the clavicle. With a note on cranio-cleido dysostosis. J Bone Joint Surg Br 1975;57(1):24–29.
181. Lusskin R, Weiss CA, Winer J. The role of the subclavius muscle in the subclavian vein syndrome (costoclavicular syndrome) following fracture of the clavicle. Clin Orthop 1967;54:75–83.
182. Lyons FA, Rockwood CA Jr. Migration of pins used in operations on the shoulder. J Bone Joint Surg Am 1990;72(8):1262–1267.
183. Madsen B. Osteolysis of the acromial end of the clavicle following trauma. Br J Radiol 1963;36:822–828.
P.974

184. Madsen ET. Fractures of the extremities in the newborn. Acta Obstet Gynecol Scand 1955;34(1):41–74.
185. Malcolm BW, Ameli FM, Simmons EH. Pneumothorax complicating a fracture of the clavicle. Can J Surg 1979;22:89.
186. Malgaigne JF. A treatise of fractures. Philadelphia: J.B. Lippincott, 1859:374–401.
187. Mall FP. On ossification centers in human embryos less than one hundred days old. Am J Anat 1906;5:433–458.
188. Manske DJ, Szabo RM. The operative treatment of mid-shaft clavicular non-unions. J Bone Joint Surg Am 1985;67(9):1367–1371.
189. Marie P, Sainton P. The classic: Sur la dysostose cleido-cranienne herediataire. Rev Neurol 1898;6:835. On hereditary cleido-cranial dysostosis. Clin Orthop 1968;58:5–7.
190. Marie P, Sainton P. The classic: on hereditary cleido-cranial dysostosis. Clin Orthop 1968;58:5–7.
191. Marsh HO, Hazarian E. Pseudarthrosis of the clavicle. J Bone Joint Surg 1970;52B:793.
192. Marti RK, Nolte PA, Kerkhoffs GM, Besselaar PP, Schaap GR. Operative treatment of mid-shaft clavicular non-union. Int Orthop 2003;27(3):131–135.
193. Martin R, Saller K. Lehrbuch der Antropologie. Stuttgart: Gustav Fischer, 1959.
194. Matis N, Kwasny O, Gaebler C, Vecsei V. Effects of clavicle shortening after clavicle fracture. Hefte Unfallchirurg 1999;275:314–315.
195. Matry C. Fracture de la clavicule gauche au tiers interne: Blessure de la veine sous-claviere. Osteosynthese. Bull et Mem Soc Nat Chir 1932;58:75–78.
196. Matz SO, Welliver PS, Welliver DI. Brachial plexus neuropraxia complicating a comminuted clavicle fracture in a college football player: case report and review of the literature. Am J Sports Med 1989;17:581–583.
197. Maunoury G. Fracture de la clavicule compliquee de dechireure de la veine sousclaviere: Operation. Mort par hemorrhagie et entree de l’air dans les veines. Progres Med Paris 1881;10:302.
198. Mayer JH. Non-union of fractured clavicle. Proc R Soc Med 1965;58:182.
199. Mazet R Jr. Migration of a Kirschner wire from the shoulder region into the lung: report of two cases. J Bone Joint Surg 1943;25A:477–483.
200. McCandless DN, Mowbray MAS. Treatment of displaced fractures of the clavicle: sling versus figure-of-eight bandage. Practitioner 1979;223:266–267.
201. McCaughan JS, Miller PR. Migration of Steinmann pin from shoulder to lung. JAMA 1969;207:1917.
202. McKee MD. Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. Surgical technique. J Bone Joint Surg Am 2004;86-A Suppl 1:37–43.
203. Meeks RJ, Riebel GD. Isolated clavicle fracture with associated pneumothorax: a case report. Am J Emerg Med 1991;9:555–556.
204. Miller DS, Boswick JA. Lesions of the brachial plexus associated with fractures of the clavicle. Clin Orthop 1969;64:144–149.
205. Miller MR, Ada JR. Injuries to the shoulder girdle. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal trauma, 1st ed. Philadelphia: E.B. Saunders, 1991:1291–1310.
206. Mital MA, Aufranc OE. Venous occlusion following greenstick fracture of the clavicle. JAMA 1968;206:1301–1302.
207. Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. J Nippon Med Sch 2000;67(1):32–34.
208. Mnaymneh W, Vargas A, Kaplan J. Fractures of the clavicle caused by arteriovenous malformations. Clin Orthop 1980;148:256–258.
209. Moseley HF. The clavicle: its anatomy and function. Clin Orthop 1968;58:17–27.
210. Mulder DS, Greenwood FAH, Brooks CE. Posttraumatic thoracic outlet syndrome. J Trauma 1973;13:706–715.
211. Mullaji A, Jupiter J. Low-contact dynamic compression plating of the clavicle. Injury 1994;25:41–45.
212. Mullick S. Treatment of mid-clavicular fractures. Lancet 1967;1:499.
213. Naidoo P. Migration of a Kirschner wire from the clavicle into the abdominal aorta. Arch Emerg Med 1991;8:292–295.
214. Naidu SH, Heppenstall RB, Brighton CT, et al. Clavicle nonunion: results of treatment with electricity, AO dynamic compression plating and autogenous bone grafting, and excision of the nonunion in 43 patients. Orthop Trans 1994;18:1072.
215. Natali J, Maraval M, Kieffer E, Petrovic P. Fractures of the clavicle and injuries of the subclavian artery: report of 10 cases. J Cardiovasc Surg 1975;16:541–547.
216. Neer CS. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma 1963;3:99–110.
217. Neer CS. Fractures about the shoulder. In: Rockwood CA Jr, Green DP, eds. Philadelphia: J.B. Lippincott Co., 1984:707–713.
218. Neer CS. Fractures of the distal third of the clavicle. Clin Orthop 1968;58:43–50.
219. Neer CS. Nonunion of the clavicle. JAMA 1960;172:1006–1011.
220. Neviaser JS. Injuries of the clavicle and its articulations. Orthop Clin North Am 1980;11:233–237.
221. Neviaser JS. The treatment of fractures of the clavicle. Surg Clin North Am 1963;43:1555.
222. Neviaser RJ. Injuries to the clavicle and acromioclavicular joint. Orthop Clin North Am 1987;18:433–438.
223. Neviaser RJ, Neviaser JS. A simple technique for internal fixation of the clavicle: a long-term evaluation. Clin Orthop 1975;109:103–107.
224. Nicoll EA. Miners and mannequins. J Bone Joint Surg 1954;36B:171–172.
225. Nordback I, Markula H. Migration of Kirschner wire from clavicle into ascending aorta. Acta Chirop Scand 1985;151:177–179.
226. Nordqvist A, Petersson C. Fracture of the body, neck or spine of the scapula. Clin Orthop 1992;283:139.
227. Nordqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture: 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand 1993;64:87–91.
228. Nordqvist A, Petersson CJ. Shoulder injuries common in alcoholics. An analysis of 413 injuries. Acta Orthop Scand 1996;67:364–366.
229. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma 1998;12:572–576.
230. Nordqvist A, Redlund-Johnell I, von Scheele A, Peetersson CJ. Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients. Acta Orthop Scand 1997;68:349–351.
231. Nordqvist AP, Peterson C. The incidence of fractures of the clavicle. Clin Orthop 1994;300:127–132.
232. Norrell H Jr, Llewellyn RC. Migration of a threaded Steinmann pin from an acromioclavicular joint into the spinal canal. J Bone Joint Surg 1965;47A:1024–1026.
233. Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353–358.
234. Ogden JA. Distal clavicular physeal injury. Clin Orthop 1984;188:68–73.
235. Ogden JA, Conlongue GJ, Bronson ML. Radiology of postnatal skeletal development III. The clavicle. Skeletal Radiol 1979;4:196.
236. Ogle, JW. Laceration of the internal jugular vein by a portion of fractured clavicle. Br Med J 1873;2:82–83.
237. Olsen BO, Vaesel MT, Sojbjerg JO. Treatment of midshaft clavicular nonunion with plate fixation and autologous bone grafting. J Shoulder Elbow Surg 1995;4:337–344.
238. Oppenheim WL, Davis A, Growdon WA, Dorey FJ, Davlin LB. Clavicle fractures in the newborn. Clin Orthop 1990;250:176–180.
239. Ord RA, Langdon JD, Stress fracture of the clavicle: a rare late complication of radical neck dissection. J Maxillofac Surg 1986;14:281–284.
240. Oreck SL, Burgess A, Levine A. Traumatic lateral displacement of the scapula: a radiographic sign of neurovascular disruption. J Bone Joint Surg 1984;66A:758–763.
241. Oroko PK, Buchan M, Winkler A, Kelly IG. Does shortening matter after clavicular fractures? Bull Hosp Joint Dis 1999;58:6–8.
242. O’Rourke IC, Middleton RWD. The place and management of operative management of fractured clavicle. Injury 1974;6:236–240.
P.975

243. Oxnard CE. The architecture of the shoulder in some mammals. J Morphol 1968;126:249–290.
244. Oxnard CE. The functional morphology of the primate shoulder as revealed by comparative anatomical, osteometric and discrimination function techniques. Am J Phys Anthropol 1967;26:219–240.
245. Packer BD. Conservative treatment of fracture of the clavicle. J Bone Joint Surg 1944;26B:770–774.
246. Pannicke A. Klavikulafrakturen - Entstehung, Einteilung, Diagnose. In: Hefte zur Unfallheilkunde. Berlin: Springer-Verlag, 1982:43–54.
247. Parkes JC, Deland JT. A three-part distal clavicle fracture. J Trauma 1983;23:437–438.
248. Pate JW, Whilhite JL. Migration of a foreign body from the sternoclavicular joint to the heart: a case report. Am Surg 1969;35:448–449.
249. Patel CV, Adenwalla HS. Treatment of fractured clavicle by immediate partial subperiosteal resection. J Postgrad Med 1972;18:32–34.
250. Pauwels F. Gesammelte Abhandlung zur Biomechanik des Stütz und Bewegungsapparates. Berlin: Heidelberg; New York: Springer-Verlag, 1965.
251. Penn I. The vascular complications of fractures of the clavicle. J Trauma 1964;4:819.
252. Petracic B, Durr W, Schauwecker F. [Therapeutic results following dislocation fractures in the shoulder joint]. Hefte Unfallheilkd 1975;126:98–100.
253. Pfeifle K, Rhehrman A, Nwoke AL. Pseudotumors of the clavicle following neck dissection. J Maxillofac Surg 1974;2:14–18.
254. Pipkin G. Tardy shoulder hand syndrome following united fracture of the clavicle. J Missouri State Med Assoc 1951;48:643–646.
255. Piterman L. The fractured clavicle. Aust Fam Physician 1982;11:614.
256. Poigenfurst J, Rappold G, Fischer W. Plating of fresh clavicular fractures: results of 122 operations. Injury 1992;23:237–241.
257. Post M. Current concepts in the treatment of fractures of the clavicle. Clin Orthop 1989;245:89–101.
258. Prime HT, Doig SG, Hooper JC. Retrosternal dislocation of the clavicle: a case report. Am J Sports Med 1991;19:92–93.
259. Proubasta IR, Itarte JP, Caceres EP, et al. Biomechanical evaluation of fixation of clavicular fractures. J South Orthop Assoc 2002;11(3):148–152.
260. Quesada F. Technique for the roentgen diagnosis of fractures of the clavicle. Surg Gynecol Obstet 1926;42:424–428.
261. Quigley TB. The management of simple fractures of the clavicle. N Engl J Med 1950;243:286–290.
262. Quinn SF, Glass TA. Posttraumatic osteolysis of the clavicle. South Med J 1983;76:307–308.
263. Redmond AD. Letter to the editor. Injury 1982;13:352.
264. Reichenbacher D, Siebler G. Early post-traumatic plexus lesions: a rare complication after clavicle fractures. Unfallchirurg 1987;13:91–92.
265. Reid J, Kennedy J. Direct fracture of clavicle with symptoms simulating cervical rib. Br Med J 1925;2:608–609.
266. Reimer BL, Butterfield SL, Daffner RH, et al. The abduction lordotic view of the clavicle: a new technique for radiographic visualization. J Orthop Trauma 1991;5:392–394.
267. Rey-Baltar E, Errazu D. Unusual outcome of Steinmann wire: case of fractured clavicle. Arch Surg 1964;89:1024–1025.
268. Rikli D, Regazzoni P, Renner N. The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation. J Orthop Trauma 1995;9:93–97.
269. Robinson CM. Fractures of the clavicle in the adult. J Bone Joint Surg 1998;80B:476–484.
270. Rockwood CA. Fractures and dislocations of the ends of the clavicle, scapula, and glenohumeral joint. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in children. Philadelphia: J. B. Lippincott, 1984:624–681.
271. Rockwood CA Jr. Fractures of the outer clavicle in children and adults. J Bone Joint Surg 1982;64B:642.
272. Rockwood CA, Williams GR, Young DC. Disorders of the acromioclavicular joint. In: Rockwood CA, Matsen FA, eds. The shoulder. Philadelphia: W. B. Saunders, 1998:483–543.
273. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968;58:29–42.
274. Rüedi TP, Murphy WM. AO principles of fracture management. Thieme, 2001.
275. Rumball KM, Da Silva VF, Preston DN, Carruthers CC. Brachial-plexus injury after clavicular fracture: a case report and literature review. Can J Surg 1991;34:264–266.
276. Sakellarides H. Pseudarthrosis of the clavicle: a report of twenty cases. J Bone Joint Surg 1961;43A:130–138.
277. Sankarankutty M, Turner BW. Fractures of the clavicle. Injury 1975;7:101–106.
278. Scarpa FJ, Levy RM. Pulmonary embolism complicating clavicle fracture. Conn Med 1979;43:771–773.
279. Schmittinger K, Sikorski A. [Experiences with the Balser plate in dislocations of the acromioclavicular joint and lateral fractures of the clavicle]. Aktuelle Traumatol 1983;13(5):190–193.
280. Schuind F, Pay-Pay E, Andreiann Y, et al. External fixation of the clavicle for fracture or nonunion in adults. J Bone Joint Surg 1988;70A:692–695.
281. Schwarz N, Hocker K. Osteosynthesis of irreducible fractures of the clavicle with 2.7 millimeter ASIF plates. J Trauma 1992;33:179–183.
282. Seddon HJ. Nerve lesions complicating certain closed bone injuries. JAMA 1947;135:691–694.
283. Siffre A. Thrombose post-traumatique de l’artere sous-claviere gauche. Lyon Chir 1956;51:479–481.
284. Silloway KA, Mclaughlin RE, Edlich RF. Clavicular fractures and acromioclavicular joint injuries in lacrosse: preventable injuries. J Emerg Med 1985;3:117–121.
285. Simpson NS, Jupiter JB. Clavicular nonunion and malunion: evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1–8.
286. Spar I. Total claviculectomy for pathological fractures. Clin Orthop 1977;129:236–237.
287. Stanley D, Trowbridge EA, Norris SH. Recovery following fractures of the clavicle treated conservatively. Injury 1988;19:162–164.
288. Steinberg I. Subclavian vein thrombosis associated with fractures of the clavicle: report of two cases. N Engl J Med 1961;264:686–688.
289. Storen H. Old clavicular pseudarthrosis with late appearing neuralgias and vasomotoric disturbances cured by operation. Acta Chir Scand 1946;94:187.
290. Strauss FM, Bushey MJ, Chung C, Baum S. Fracture of the clavicle following radical neck dissection and postoperative radiotherapy: a case report and review of the literature. Laryngoscope 1982;92:1304–1307.
291. Sturm JT, Strate RG, Mowlem A, et al. Blunt trauma to the subclavian artery. Surg Gynecol Obstet 1974;138:915–918.
292. Taylor AR. Non-union of fractures of the clavicle: a review of thirty-one cases. J Bone Joint Surg 1974;51B:568–569.
293. Taylor AR. Some observations on fractures of the clavicle. Proc R Soc Med 1969;62:33–34.
294. Taylor W. Traumatic aneurysm of the left subclavian artery produced by fracture of the clavicle. Ann Surg 1903;38:638–651.
295. Telford ED. Pressure at the cervico-brachial junction: an operative and anatomical study. J Bone Joint Surg 1948;30B:249–265.
296. Terry R. The clavicle of the american negro. Am J Phys Anthropol 1932;16:351–377.
297. Thomas CB, Friedman RJ. Ipsilateral sternoclavicular dislocation and clavicular fracture. J Orthop Trauma 1989;3:355–357.
298. Thompson JS. Operative treatment of certain clavicle fractures in orthopedic controversy. Orthop Trans 1988;12:141.
299. Todd TW, D’Errico J Jr. The clavicular epiphysis. Am J Anat 1928;41:25–50.
300. Trynin AH. The Bohler clavicular splint in the treatment of clavicular injuries. J Bone Joint Surg 1937;19:417–423.
301. Tse DHW, Slabaugh PB, Carlson PA. Injury to the axillary artery by a closed fracture of the clavicle. J Bone Joint Surg 1980;62A:1372–1374.
302. Van Vlack HG. Comminuted fracture of the clavicle with pressure on brachial plexus. J Bone Joint Surg 1940;22A:446–447.
P.976

303. Webb LX. Fractures and dislocations about the shoulder. In: Swiontkowski MGN, ed. Skeletal trauma in children. Philadelphia: W.B. Saunders, 1992:257–281.
304. Weber BG. Pseudarthrosis. New York: Grune & Stratton, 1976.
305. Weinberg B, Seife B, Alonso P. The apical oblique view of the clavicle: its usefulness in neonatal and childhood trauma. Skeletal Radiol 1991;20:201–203.
306. Weiner DS, O’Dell HW. Fractures of the first rib associated with injuries to the clavicle. J Trauma 1989;9:412–422.
307. White RR, Anson PS, Kristiansen T. Adult clavicle fractures: relationship between mechanism of injury and healing. Orthop Trans 1989;13:514–515.
308. Wilkes JA, Hoffer MM. Clavicle fractures in head-injured children. J Orthop Trauma 1987;1:55–58.
309. Wilkins RM, Johnston RM. Ununited fractures of the clavicle. J Bone Joint Surg 1983;65A:774–778.
310. Wood VE. The results of total claviculectomy. Clin Orthop 1986;207:186–190.
311. Wurtz LD, Lyons FA, Rockwood CA Jr. Fracture of the middle third of the clavicle and dislocation of the acromioclavicular joint: a report in four cases. J Bone Joint Surg 1992;74A:133–137.
312. Yates AG. Complications of fractures of the clavicle. Injury 1976;7:189–193.
313. Yates AG, Guest D. Cerebral embolism due to an ununited fracture of the clavicle and subclavian thrombosis. Lancet 1928;2:225.
314. Zaslav KR, Ray S, Neer CS. Conservative management of a displaced medial clavicular physeal injury in an adolescent male. Am J Sports Med 1989;17:833–836.
315. Zenni EJ, Krieg JK, Rosen MJ. Open reduction and internal fixation of clavicular fractures. J Bone Joint Surg 1981;63A:147–151.