From the Guidelines
Surgery should be indicated for clavicle fractures in cases of widely displaced fractures, particularly those with shortening greater than 2 cm, complete displacement with no cortical contact, or significant comminution, as well as open fractures, fractures with skin tenting, neurovascular compromise, floating shoulder injuries, and distal clavicle fractures with coracoclavicular ligament disruption. According to the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1, surgical treatment of displaced clavicle fractures results in equivalent or improved short-term patient-reported outcomes and reduced rates of nonunion or symptomatic malunion when compared with nonsurgical treatment.
Key Indications for Surgery
- Widely displaced fractures with shortening greater than 2 cm
- Complete displacement with no cortical contact
- Significant comminution
- Open fractures
- Fractures with skin tenting that threatens skin integrity
- Neurovascular compromise
- Floating shoulder injuries
- Distal clavicle fractures with coracoclavicular ligament disruption
- High functional demands such as athletes or manual laborers
- Significant pain or functional limitation despite conservative management
The rationale for surgical intervention in these cases is to restore normal anatomy, improve functional outcomes, reduce the risk of malunion or nonunion, and allow earlier return to activities, as supported by multiple randomized controlled trials comparing surgical with nonsurgical treatment of displaced clavicle fractures regarding functional outcomes and rates of complications 1. However, most clavicle fractures, particularly minimally displaced ones, can be successfully treated non-operatively with a sling or figure-of-eight bandage for 2-6 weeks, followed by progressive rehabilitation.
Surgical Approaches
- Open reduction and internal fixation with plates and screws
- Intramedullary fixation with pins or rods These approaches aim to provide a faster functional and radiographic recovery, allowing for earlier return to work, which may be particularly relevant given that clavicle fractures typically affect healthy, active adults 1.
From the Research
Indications for Surgery
Surgery may be indicated for clavicle fractures in the following cases:
- Substantial displacement or comminution 2
- Far lateral fractures 2
- Fractures in the elderly 2
- Open fractures 2, 3
- Fractures occurring in polytrauma scenarios 2
- Posteriorly displaced proximal fractures 3
- Fractures with greater than 100% displacement 3
- Fractures with >2 cm of shortening 3
- Comminuted fractures 3
- Unstable distal fractures 3
- Floating shoulder 3
Surgical Techniques
The surgical technique for clavicle fractures involves:
- Open reduction and internal fixation (ORIF) 2, 4
- Plate fixation 5
- Intramedullary fixation 5
- The aim of the procedure is to reconstitute the initial curvature and length of the clavicle, restore a normal connection from the arm to the axial skeleton, and provide stable fixation of the proximal and distal fragments 2
Benefits of Surgery
Surgery may offer several benefits, including:
- Improved functional outcomes 4
- Reduced risk of treatment failure 5
- Reduced risk of symptomatic non-union or malunion 2, 6
- Improved cosmetic results 5
- Early pain relief and effective anatomical restoration 4
Risks and Complications
Surgery is associated with several risks and complications, including: