From the Guidelines
Clavicle fractures typically need open reduction and internal fixation (ORIF) when they are significantly displaced, shortened, or comminuted, as well as in cases of open fractures, neurovascular compromise, floating shoulder injuries, and skin tenting that threatens skin integrity. The decision to perform ORIF should consider both radiographic criteria and patient factors, including age, activity level, and occupation 1. Patients with high functional demands, such as athletes or manual laborers, may benefit from surgical fixation even with less displacement to ensure optimal alignment and faster return to activities. Lateral third fractures with coracoclavicular ligament disruption and medial third fractures with sternoclavicular joint involvement often require surgical intervention 1.
Some key considerations for ORIF include:
- Significantly displaced or shortened fractures
- Comminuted fractures
- Open fractures
- Fractures with neurovascular compromise
- Floating shoulder injuries
- Skin tenting that threatens skin integrity
- High functional demands, such as athletes or manual laborers
- Lateral third fractures with coracoclavicular ligament disruption
- Medial third fractures with sternoclavicular joint involvement
According to the American Academy of Orthopaedic Surgeons clinical practice guideline summary, surgical treatment of displaced clavicle fractures results in higher union rates and better early patient-reported outcomes compared to nonsurgical treatment 1. However, long-term patient-reported outcomes are similar after surgical versus nonsurgical treatment, making both valid treatment options. The current evidence suggests that surgical fixation helps prevent malunion, nonunion, and persistent functional limitations in specific scenarios, and surgery typically involves plate and screw fixation, with rehabilitation beginning with early range of motion exercises after wound healing 1.
From the Research
Indications for Open Reduction and Internal Fixation (ORIF) of Clavicle Fractures
- Neurovascular compromise due to posterior displacement and impingement of the bone fragments on the brachial plexus, subclavian vessels, and even the common carotid artery 2
- Fracture of the distal third of the clavicle with disruption of the coracoclavicular ligament 2
- Severe angulation or comminution of a fracture in the middle third of the clavicle 2
- The patient's inability to tolerate prolonged immobilization (required by closed treatment) because of Parkinson's disease, a seizure disorder, or other neuromuscular disease 2
- Symptomatic non-union following treatment by closed methods 2
- Substantial displacement or comminution, far lateral fractures, fractures in the elderly, open fractures, or those occurring in polytrauma scenarios 3
Treatment Outcomes
- ORIF for clavicle fractures ensures a high rate of bone union and improved functional outcomes after six months of surgery, with early pain relief and effective anatomical restoration 4
- Significant reduction in nonunions and favorable early functional outcomes are associated with ORIF, although late functional outcomes, subsequent surgeries, and pain scores are similar to those of nonsurgical treatment 5
Current Concepts and Available Evidence
- A paradigm shift towards an increase in operative treatment has occurred in the last 20 years due to higher non-union rates after conservative treatment and more evidence regarding operative treatment 6
- Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient 6
- A treatment algorithm is proposed for medial, shaft, and lateral clavicle fractures, with non-displaced fractures typically treated conservatively 6