Injury 54 (2023) 110818

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Evidence on treatment of clavicle fractures✰

Christian von Rüden a, b, c, *, Julia Rehme-Röhrl b, Peter Augat c, d, Jan Friederichs b,
Simon Hackl b, c, Fabian Stuby b, Oliver Trapp b
a
Department of Trauma Surgery, Orthopaedics and Hand Surgery, Weiden Medical Center, Weiden/ Oberpfalz, Germany
b
Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
c
Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
d
Institute for Biomechanics, BG Unfallklinik Murnau, Murnau, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be
Clavicle treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been
Fracture treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher
Nonunion
than previously reported. In addition, publications reporting better functional outcomes following operative
Locking plate
Intramedullary nail
treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture
Outcome treatment.
The aim of this review article was to summarize the currently available evidence on the treatment of clavicle
fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, mid­
shaft, and lateral clavicles are presented and discussed.

Introduction shoulder girdle with an incidence of about 3–10% [12,13]. The mech­
anisms of injury are diverse and very heterogeneous (simple fall on the
Classically, displaced fractures of the clavicle shaft in adults have shoulder 30%, road traffic accident 25%, sports injuries 25%, others
been treated non-operatively [1,2]. However, the rate of nonunion after 20%) [14]. Interestingly, indirect trauma such as fall on the outstretched
non-operative treatment seems to be higher than reported in the past [3, arm is more frequent than direct impact trauma. Over 80% of fractures
4]. In addition, publications reporting better functional outcomes after result from ordinary falls [15]. In males, prevalence of fractures peak
operative treatment are increasing [5–9]. In recent years this has led to a during the first and second life decades, while the distribution almost
paradigm shift towards an increase of operative treatment [10,11]. equalizes for both genders during life [16].
Steady interest in literature covering the optimal treatment of these With a proportion of about 75%, most fractures involve the middle
fractures seem to have led to an upsurge of scientific data favoring third of the shaft. These are followed by fractures of the lateral third
operative management. Between 2000 and 2023 the number of publi­ with 20% and fractures of the medial third with under 5% [13]. The
cations visible in PUBMED have increased eightfold. The aim of this need for anatomic reconstruction results from the clavicle function it­
review article was to summarize the currently available evidence on the self. It is the only osseous connection of the shoulder girdle to the torso
treatment of clavicle fractures. Classifications, indications, and treat­ and performs all movements in the shoulder joint [17]. Hereby, rota­
ment options for different fracture patterns of the medial, midshaft, and tional movements in the acromioclavicular (AC) and sternoclavicular
lateral clavicles are presented and discussed. (SC) joints are conducted during all movements in the glenohumeral
joint.

Epidemiology

Clavicle fractures are one of the most common fracture entities in the

This paper is part of a Supplement supported by the Osteosynthesis and Trauma Care Foundation (OTCF) through a research grant from Stryker.
✰

* Corresponding author at: Department of Trauma Surgery, Orthopaedics and Hand Surgery, Kliniken Nordoberpfalz AG, Klinikum Weiden, Söllnerstraße 16,
Weiden 92637, Bavaria, Germany.
E-mail address: christian.vonrueden@kno.ag (C. von Rüden).

https://doi.org/10.1016/j.injury.2023.05.049
Accepted 12 May 2023
Available online 15 May 2023
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
C. von Rüden et al. Injury 54 (2023) 110818

Diagnostic work-up

Fracture diagnosis is made by means of the anamnesis, in which the

course of accident and the trauma mechanism are explicitly ascertained.
The aim is to identify any concomitant injuries at an early stage to adjust
the treatment concept. In the clinical examination, it is important to be
aware of classical clinical fracture signs. A complete physical examina­
tion and respective documentation is recommended. An important
aspect of the inspection including palpation is the detection of
impending skin perforation of the fracture ends. In this case, immediate
operative treatment is recommended to reduce the risk of an open
fracture situation. Functional examination of the fracture is usually
difficult or impossible due to the patient´s pain levels and should not be
enforced. Furthermore, peripheral blood flow, the motor function and
the sensitivity should be given special attention.
Falls can be responsible for other injuries of the shoulder girdle and
upper extremity in up to 50% [18]. Limited glenohumeral range of
motion or persistent discomfort in the shoulder region should lead to
further clarification using MRI, computed tomographic (CT) arthrog­
raphy or others [19–21]. Neurovascular injuries are rare, but they Fig. 1. a-b: (a) Displaced midshaft clavicle fracture with intermediate frag­
sometimes aggravate complications that may require further surgical ment. (b) Internal fixation with precontoured locking plate including secure
care. Especially in the medial third of the clavicle, the risk of additional screw fixation of at least six cortices in each main fracture fragment and use of
two (not radiolucent) suture cerclages for the intermediate fragments.
injury is high due to the proximity of the subclavian vessels [22]. In case
whole-body CT scan has not been performed, diagnostics is completed
by biplanar radiographs of the clavicle. Additionally, for the detection of systems are intended to be used, as they have proven to be more effective
injuries around the AC joint, the Alexander image has proven effective than previously utilized non-angular stable systems [34,35]. In the
where the affected side of the patient is maximally adducted depending recent literature, anatomically precontoured plating systems have
on the pain [23]. In this way, horizontal instabilities in the AC joint, demonstrated to achieve exceptionally good mid- and long-term results
which require operative treatment can be visualized. This exposure is [36–39]. The previously used non-locking plate systems were not suit­
not required in all acute situations but refers specifically to additive able due to the frequent formation of nonunion and refractures [40,41].
injuries of the AC joint, which frequently require operative management Furthermore, biomechanical studies demonstrated significantly higher
even in young and athletic patients. Stress radiographs in which patients pullout forces for locking compared to non-locking constructs [42].
carry a weight on the affected or both sides for better visualization are However, regarding the biomechanical primary stability, more impor­
no longer recommended in the acute situation, as this is often painful for tant than the angular stability is the secure screw fixation of at least six
patients [24]. In chronic AC joint injuries, however, they continue to be cortices in each main fracture fragment (Fig. 1a-b) [43]. No significant
important since a height difference becomes apparent. As a further ad­ differences in terms of the duration of surgery, osseous consolidation, or
ditive radiological examination technique, the panoramic image can clinical and radiological results have been observed when anteroinferior
provide information about the healthy contralateral side. For example, plate position was compared to superior plate position [42,44].
an elevation of the lateral clavicle in the case of an AC joint involvement Although the superior plate position potentially might be responsible for
can be easily visualized by site-to-site comparison. Comminuted frac­ an increased prominence of the plate and may sometimes lead to irri­
tures or nonunions are further indications for performing a CT tation, the removal rates have been the same independently of the plate
examination. position [33,36,45].

Classifications Treatment indications

There are a number of classification systems for clavicle fractures Treatment indications should be considered on an individual patient
[25]. A rough distinction provided by Allman is made between the basis including careful assessment of the relative benefits and harms of
medial, the middle and the lateral third. In addition to the Allman every intervention and of patient preferences [46]. For the
classification, different clinically common classifications among others decision-making process on which further procedure to choose, it is
are those according to Neer, Craig, Nordqvist and Petersson, Robinson important to take individual patient factors such as age, activity level
(Edinburgh classification), or AO/OTA [12,26–30]. Although the All­ prior to the accident or concomitant injuries and diseases into account.
man classification with Neer modification may be the most widely Radiological aspects such as osseous shortening or dislocation are also
accepted classifciation, the Edinburgh classification has become mandatory due to the risk of skin perforation. The extent of fracture
increasingly popular in recent years. Additionally, open fractures can be dislocation has been identified as a major risk factor for nonunion for­
classified according to the Gustilo and Anderson or to the Tscherne and mation. The incidence of nonunion in dislocated fractures can be as high
Oestern classification [31,32]. Recommendations on the preferred as 15%. Other risk factors are multifragmentary fracture and shortening
classifications depending on the localization can be found in the of the clavicle by more than 2 cm. The incidence for the development of
respective sections. nonunion after shortened dislocated multifragmentary fractures
increased significantly to up to 33% [47].
Osteosynthesis material Non-operative treatment is more commonly linked with adverse
events such as symptomatic nonunion or shoulder stiffnesss but con­
Although each fracture fixation concept has biomechanical advan­ tinues to be the golden standard with good to particularly superior re­
tages and disadvantages, exact thresholds of stiffness for inducing sults in non-displaced or minimally displaced fractures and in pediatric
healing and failure strength to withstand refractures are still unknown fractures. The nonunion rate of lateral and medial clavicle fractures after
[33]. There is common consent that plate fixation is suitable for frac­ non-operative therapy is significantly higher than that of shaft fractures,
tures of all sections of the clavicle in adults. Nowadays, locking plate being up to 11.5% for the lateral clavicle fracture and up to 8.5% for the

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C. von Rüden et al. Injury 54 (2023) 110818

Fig. 2. Treatment algorithm for lateral clavicle fractures according to Cho’s classification [77] (use in accordance with the Elsevier user license).

medial clavicle [47]. as intramedullary implants are suitable for retention. In practice,
Operative treatment does not seem to have relevant additional osteosynthesis material removal is currently indicated in cases of cor­
benefits in terms of function, pain, and quality of life compared with responding patient request, which among others usually derives from
non-operative treatment [46]. Therefore, it may only be considered in functionally interfering implants. Patients perceive such restrictions, for
cases of concomitant neurovascular damage, open fractures, or severely example triggered by carrying backpacks. Metal removal should not be
displaced fractures with a substantial risk for secondary skin perfora­ performed until at least 18 months postoperatively due to the high
tion, or comminuted fractures of the shoulder girdle involving the su­ refracture rate. Thereby, plate osteosynthesis is associated with a higher
perior shoulder suspensory complex, since a discontinuity results in a probability of reoperation for material removal compared to intra­
floating shoulder and thus an unstable shoulder girdle [48–50]. medullary stabilization [64].
The recent popularity of operative treatment in clavicle fractures
may be explained on the one hand by the increasing prevalence of
Midshaft clavicle fractures
clavicle fractures and certainly also by the high reliability of modern
implants and the associated good functional results [51]. Treatment of
The classifcation systems of the AO/OTA, Robinson and Neer are
clavicle fractures is aiming to avoid shortening as this can result in
most often used in midshaft clavicle fractures [1,12,27]. All of them are
painful and restricted mobility. There is consensus that clavicle short­
anatomical classifcations. The advantage of the Edinburgh classifcation
ening of more than 20 mm results in chronic pain and discomfort.
might be that in midshaft fractures it has demonstrated a relationship
Therefore, shortening of more than 14 mm in females and 18 mm in
with clinical outcomes [12].
males should not be accepted. In young patients shortening of more than
Although the healing rates in adults are significantly worse than in
10 mm should not be tolerated [17,52–54]. Another aim is to avoid
children and adolescents [65], there are still good indications for
development of nonunion as it may lead to instability and pain and re­
non-operative treatment. In addition to a high healing rate, midshaft
quires further surgical interventions [55]. Operative and non-operative
clavicle fractures with little to no displacement demonstrated excellent
treatment concepts may be balanced and discussed with the patient
clinical outcome following immobilization for three to four weeks
during the decision-making process with special consideration of any
following active movements slowly up to 90◦ and maximum loading
comorbidities [56]. Besides, factors detrimental to a good healing pro­
after 6 weeks [66,67]. On the other hand, displaced midshaft fractures
cess such as nicotine abuse or Diabetes mellitus must be considered
are associated with high nonunion rates of up to 15%, and functional
before a possible surgical procedure. Patients are advised to abstain
outcomes were also significantly worse in cases of displacement by more
from smoking, and optimal glycemic control can be established preop­
than one shaft width [68]. In a study provided by Virtanen et al. one year
eratively [57,58].
after displaced midshaft clavicular fracture non-operative treatment has
The development of anatomically precontoured locked plating sys­
resulted in significantly higher nonunion rate of about 25%, but with
tems and the increasing awareness of the blood supply to the clavicle
similar functional results and disabilities compared with operative
and of biomechanical factors resulted in significant reductions in
treatment [41]. Recent studies have reported that plate fixation signif­
nonunion rates [59–62]. Decreased nonunion rates are associated with
icantly reduced the risk of nonunion but did not have any clinically
the increased stability of locked plating and the internal fixator principle
relevant advantage regarding long-term functional outcomes [69].
and not necessarily with the anatomical fit of the precontoured plates.
Furthermore, revision surgery was commonly required following both
Preservation of periosteal blood flow from avoiding extensive detach­
treatment concepts. Fuglesang et al. has compared non-operative
ment of the periosteum and the limited bone plate contact support an
treatment with plate fixation and intramedullary nailing and has
undisturbed fracture healing process [63].
found comparable nonunion rates for the surgical strategies, but
In healed fractures, modern anatomically preformed implants as well
significantly higher nonunion rates in the non-operative group [53].

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C. von Rüden et al. Injury 54 (2023) 110818

better clinical results with less frequent need for implant removal.
From the biomechanical perspective, each fracture fixation has ad­
vantages and disadvantages. Exact thresholds of stiffness for inducing
healing and failure strength to withstand refractures are still unknown
[33]. Locking plate fixation is more stable than IM nailing especially in
comminuted situations and has better overall rotational stability
compared with IM nailing [72]. The results of these techniques in terms
of clinical outcomes, duration of surgery, and complication rates did not
demonstrate significant differences [71]. Nevertheless, secondary frac­
tures after implant removal are more likely following plate fixation and
rarely occur after IM nailing. Similar strength of the constructs has been
measured for superior compared to anteroinferior plating [73].
Finally, the question of whether plate fixation or IM nailing is clearly
superior could not be answered conclusively even after a systematic
review of recent literature [74]. Nevertheless, there is no doubt that
operative treatment enables early functional aftercare leading to faster
return to previous activity levels [74,75]. On the other hand, there is still
not enough evidence to support operative management routinely for all
patients suffering a displaced midshaft clavicle fracture.

Lateral clavicle fractures

Neer was one of the first to establish his classification for lateral
clavicle fractures. Neer‘s classification divided these into a stable type I
and unstable type II and III fractures [28]. Jäger and Breitner incorpo­
rated their experience of the lateral clavicle fracture localization and
classified the fractures into a total of five types [76]. In addition to these
established classification systems, the Cho classification has recently
gained considerable attention, as clear treatment recommendations can
be derived from it, which is advantageous in comparison to earlier
classifications (Fig. 2) [77]. Cho et al. reported nonunion development
in one third of patients following non-operative treatment. Luckily,
clinical results were good when osseous union had been achieved.
Therefore, non-operative treatment is recommended only in case of
undisplaced or barely (<5 mm) displaced fractures [78]. Suture fixation
is intended for fractures with potentially involved CC ligaments.
Biomechanical analyses did not demonstrate any significance in terms of
load to failure or displacement following cyclic loading in different su­
ture techniques [79]. All treatments were effective in preventing supe­
rior translation, while cortical button, suture anchor and plate button
demonstrated increased horizontal stability. Concomitant injuries of the
AC joint, the coracoclavicular complex (CCC), or the glenohumeral joint
are nowadays very well addressed by open by or arthroscopically
assisted procedures [80]. In case of sufficient bone stock precontoured
locked plating combined with CC fixation is recommended as the first-
and second-line treatment for unstable lateral clavicle fractures
demonstrating convincing results following CCC disruption (Fig. 3a-c)
[74,81–85]. Hook plate fixation was frequently used in the past but was
associated with high reoperation rates in up to two thirds of cases,
mostly owing to a higher incidence of material removal due to the
prominence of these plates in the subacromial space [55,86,87].
Fig. 3. a-c: (a) Bicycle accident resulting in a displaced multi-fragmentary Requiring the subsequent removal of material, it has increasingly beeing
laclavicle fracture type IID according to Cho’s classification [77] in a 61-year-­ replaced by innovations such as modern lateral locked plating systems.
old male with healed previous ipsilateral proximal humeral fracture. (b) ORIF This is sometimes since compromising the AC joint is often not neces­
with precontoured locking plate and c) additional FiberWire® cerclage (Arthrex sary. Therefore, the hook plate today might be reserved for cases with
Inc., Naples, FL, USA). insufficient lateral fracture fragments or osteopenia [88,89].

Missing cortical apposition, fracture comminution and displacement, Medial clavicle fractures
smoking and elderly female gender have been identified as risk factors
for nonunion development. Open reduction and internal fixation (ORIF) There is still no unambiguous evidence for the best treatment of
with plates and intramedullary (IM) nailing demonstrated similar clin­ medial clavicle fractures [1,12]. The AO/OTA and Edinburgh classifi­
ical outcomes [70]. Incisional numbness was associated with ORIF in cations might be suitable for these fractures [1]. The Edinburgh classi­
more than 50% of cases [71]. Therefore, IM nailing after closed reduc­ fication provided by Robinson et al. is a more simplified classification
tion technique is recommended for simple fractures, while in cases of system and has a predictive value regarding functional outcome while
comminution plate fixation is preferred enabling faster recovery and can be recommended as first choice for medial clavicle fractures. The
sparse literature suggests the following treatment algorithm:

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C. von Rüden et al. Injury 54 (2023) 110818

Conclusion

Depending on the severity of the injury and the involvement of the

soft tissue envelope, clavicle fractures can be treated non-operatively or
operatively. The current literature suggests that primary surgical fixa­
tion allows for a more rapid functional recovery and minimizes early
residual disability particularly in patients with displaced fractures. In
addition, operative treatment significantly reduces the prevalence of
symptomatic delayed union or nonunion. However, poorly fitting
osteosynthesis material frequently causes implant-induced soft tissue
irritations resulting in the need for operative intervention and removal
of symptomatic implants. Therefore, the routine use of primary surgical
fixation for all displaced clavicle fractures may not be recommended.
Instead, individualized treatment with careful consideration of the ad­
vantages and disadvantages of each method and of patient preferences is
proposed. As scientific evidence for the best treatment of clavicle frac­
tures is still lacking, sophisticated and high-quality controlled clinical
trials are required to provide sufficient evidence for justified decision
making.

Declaration of Competing Interest

All authors have significantly contributed to the work and the

writing of the manuscript. None of the authors received benefits for
personal or professional use from a commercial party related directly or
indirectly to the subject of this manuscript.
Fig. 4. a-b: (a) Displaced medial clavicle fracture type B according to the
Edinburgh classification [12]. (b) Situation after ORIF with the first commer­ Supplementary materials
cially available anatomically precontoured locking plate specifically designed
for medial clavicle fractures (VA-LCP® Clavicle Plate 2.7 System, DePuy Syn­ Supplementary material associated with this article can be found, in
thes GmbH, Oberdorf, Switzerland). the online version, at doi:10.1016/j.injury.2023.05.049.

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