Aims. This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. . Methods . We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. . Results . The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. Discussion. Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. Take home message: Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion. Cite this article: Bone Joint J 2016;98-B:125–30

Lateral clavicular physeal injuries in adolescents are frequently misinterpreted as acromioclavicular dislocations. There are currently no clear guidelines for the management of these relatively rare injuries. Non-operative treatment can result in a cosmetic deformity, warranting resection of the non-remodelled original lateral clavicle. However, fixation with Kirschner (K)-wires may be associated with infection and/or prominent metalwork. We report our experience with a small series of such cases.

Between October 2008 and October 2011 five patients with lateral clavicular physeal fractures (types III, IV and V) presented to our unit. There were four boys and one girl with a mean age of 12.8 years (9 to 14). Four fractures were significantly displaced and treated operatively using a tension band suture technique. One grade III fracture was treated conservatively. The mean follow-up was 26 months (6 to 42).

All patients made an uncomplicated recovery. The mean time to discharge was three months. The QuickDASH score at follow-up was 0 for each patient. No patient developed subsequent growth disturbances.

We advocate the surgical treatment of significantly displaced Grade IV and V fractures to avoid cosmetic deformity. A tension band suture technique avoids the problems of retained metalwork and the need for a secondary procedure. Excellent clinical and radiological results were seen in all our patients.

Cite this article: Bone Joint J 2013;95-B:664–7.

Aim. The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. Method. All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. Results. We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n=6), free vascularized fibular graft (n=5), cancellous bone graft (n=1)) to reconstruct the bone defect. The median follow-up was 32.3 (P. 25. -P. 75. : 23.9–51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P. 25. -P. 75. : € 7.953–23.798) per patient. Conclusion. FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. Overall, the outcome of patients treated for FRI of the clavicle is good, when management of this complication is performed by using a multidisciplinary team approach. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Expert opinion considers factors such as the size of the bone defect, the condition of the soft tissue, and patient demand to guide surgical decision making

Implant removal after clavicle plating is common. Low-profile dual mini-fragment plate constructs are considered safe for fixation of diaphyseal clavicle fractures. The aim of this study was to investigate: (1) the biomechanical competence of different dual plate designs from stiffness and cycles to failure, and (2) to compare them against 3.5mm single superoanterior plating. Twelve artificial clavicles were assigned to 2 groups and instrumented with titanium matrix mandible plates as follows: group 1 (G1) (2.5mm anterior+2.0mm superior) and group 2 (G2) (2.0mm anterior+2.0mm superior). An unstable clavicle shaft fracture (AO/OTA15.2C) was simulated. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with torsion around the shaft axis and compared to previous published data of 6 locked superoanterior plates tested under the same conditions (G3). Displacement (mm) after 5000 cycles was highest in G3 (10.7±0.8) followed by G2 (8.5±1.0) and G1 (7.5±1.0), respectively. Both outcomes were significantly higher in G3 as compared to both G1 and G2 (p≤0.027). Cycles to failure were highest in G3 (19536±3586) followed by G1 (15834±3492) and G2 (11104±3177), being significantly higher in G3 compared to G2 (p=0.004). Failure was breakage of one or two plates at the level of the osteotomy in all specimens. One G1 specimen demonstrated failure of the anterior plate. Both plates in other G1 specimens. Majority of G2 had fractures in both plates. No screw pullout or additional clavicle fractures were observed among specimens. Low-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared to 3.5mm single plates, however, had significantly lower failure endurance. Low-profile 2.5/2.0 dual plates showed significant higher initial stiffness and similar resistance to failure compared to 3.5mm single locked plates and can be considered as a useful alternative for diaphyseal clavicle fracture fixation. These results complement the promising results of several clinical studies

Neer type 2 fractures of the distal third of the clavicle have a non union rate of 22-35% after conservative treatment. Open reduction and internal fixation has been recommended by most authors but there is no consensus about the best method of internal fixation. We retrospectively assessed the union and shoulder function following Hook plate fixation in 18 patients with Neer type 2 fractures of lateral end clavicle with more then a six month follow up after surgery. There were 14 males with a mean follow-up of 25.89 months (6-48 months) and the average age was 40.33 years (22-62 range). Fifteen had acute fractures and the rest were non unions. Complications included two non unions, one following a deep infection. There were no iatrogenic fractures. Acromial osteolysis was seen in five patients who had their plates in situ. The average pain score at rest was 1 (0-4) and the average pain score on abduction was 2.2 (0-5). The average Constant score was 88.5 (63-100). Patients were asked to rate their shoulder function; three said their shoulder was normal, eleven said it was nearly normal and one rated it as not normal. Hook plate fixation appears to be a valuable method of stabilising Neer type 2 fractures of the clavicle resulting in high union rates and good shoulder function. These plates need to be removed after union to prevent acromial osteolysis

Purpose. Plating remains the most widely employed method for the fixation of displaced diaphyseal clavicle fractures. The purpose of this study was to assess the efficacy and outcomes of diaphyseal clavicle fractures treated with intramedullary fixation using the Rockwood clavicle pin. Methods. We conducted a retrospective analysis of all diaphyseal clavicle fractures treated with intramedullary fixation using the Rockwood pin between February 2004 and March 2010. Sixty-eight procedures were carried out on 67 patients. Functional outcome was assessed using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and an overall patient satisfaction questionnaire. Results. There were 52 (77.6%) male and 15 (22.4%) female patients with an average age of 35.8 years. In 35 (51.5%) cases the injury was located on the dominant side. Fractures were classified according to the Edinburgh system with the commonest configuration being the Type 2B1 (47, 69.1%). The indications for fixation were; acute management of displaced fractures (56, 82.4%), delayed union (2, 2.9%), nonunion (8, 11.8%) and malunion (2, 2.9%). The average time to pin removal was 3.7 months and the average follow-up prior to discharge was 6.9 months. Sixty-six (97.1%) fractures united without consequence. Two (2.9%) cases of non-union were treated with repeat fixation using a contoured plate and bone graft. The most common problem encountered postoperatively was discomfort due to subcutaneous pin prominence posteriorly (12, 17.6%) which resolved following removal of the metalwork. The average DASH score was 6.04 (0–60) and 96.4% of patients rated their satisfaction with the procedure as good to excellent. Conclusion. Due to its minimally invasive technique, cosmetically favourable scar, preservation of periosteal tissue, avoidance of stress risers associated with screw removal and good clinical outcomes, the use of this device is the preferred method of treatment for displaced diaphyseal clavicle fractures in our hospital

Aims. Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. Methods. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages. Results. The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively. Conclusion. Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture. Cite this article: Bone Joint J 2023;105-B(7):801–807

Aims. Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK. Methods. A multicentre retrospective cohort collaborative study was conducted. All patients over the age of 18 with an isolated DTC fracture in 2019 were included. Demographic variables were recorded: age; sex; side of injury; mechanism of injury; modified Neer classification grading; operative technique; fracture union; complications; and subsequent procedures. Baseline characteristics were described for demographic variables. Categorical variables were expressed as frequencies and percentages. Results. A total of 859 patients from 18 different NHS trusts (15 trauma units and three major trauma centres) were included. The mean age was 57 years (18 to 99). Overall, 56% of patients (n = 481) were male. The most common mechanisms of injury were simple fall (57%; n = 487) and high-energy fall (29%; n = 248); 87% (n = 748) were treated conservatively and 54% (n = 463) were Neer type I fractures. Overall, 32% of fractures (n = 275) were type II (22% type IIa (n = 192); 10% type IIb (n = 83)). With regards to operative management, 89% of patients (n = 748) who underwent an operation were under the age of 60. The main fixation methods were: hook plate (n = 47); locking plate (n = 34); tightrope (n = 5); and locking plate and tight rope (n = 7). Conclusion. Our study is the largest epidemiological review of DTC fractures in the UK. It is also the first to review the practice of DTC fixation. Most fractures are being treated nonoperatively. However, younger patients, suffering a higher-energy mechanism of injury, are more likely to undergo surgery. Hook plates are the predominantly used fixation method followed by locking plate. The literature is sparse on the best method of fixation for optimal outcomes for these patients. To answer this, a pragmatic RCT to determine optimal fixation method is required. Cite this article: Bone Jt Open 2022;3(12):953–959

To determine the outcome of Clavicle Hook Plate fixation in terms of level of function achieved, healing of the fracture and the need for removal of the hook plate. Review of patient records and radiographs of all the fractured clavicles and acromioclavicular dislocations that were surgically treated with a Clavicle Hook Plate. The study population was identified using the operating theatre data. A total of 24 patients (19 lateral third-Neer type II-fractures and 5 type III acromioclavicular dislocations) were treated from January 1998 to December 2003. Eighteen of the 24 plates (75%) had been removed at the time of the study. In 72% restriction of the range of movement and pain due to plate impingement were the main causes for removal of the plate. Two of the plates (11%) were removed due to ‘mechanical failure’; the plate being levered off the bone or eroding the acromion. Mechanical failure of the plate was significantly associated with an older age group (P=0.01). At the time of discharge from the clinic 57% had more than 50% of their shoulder movements, while 55.5% had minimal or no pain. We suggest that Clavicle Hook Plates should be routinely removed as they cause impingement symptoms and they be used with caution (if at all) in the older age group given the tendency for the plate to lever off the bone

Introduction. The Constant Score (CS) and the Oxford Shoulder Score (OSS) are shoulder scoring systems routinely used in the UK. Patients with Acromio-Clavicular Joint (ACJ) and Sterno-Clavicular Joint (SCJ) injuries and those with clavicle fractures tend to be younger and more active than those with other shoulder pathologies. While the CS takes into account the recreational outcomes for such patients the weighting is very small. We developed the Nottingham Clavicle Score (NCS) specifically for this group of patients. Methods. We recruited 70 patients into a cohort study in which pre-operative and 6 month post-operative evaluations of outcome were reviewed using the CS, the OSS the Imatani Score (IS) and the EQ-5D scores which were compared with the NCS. Reliability was assessed using Cronbach's alpha. Reproducibility of the NCS was assessed using the test/re-test method. Each of the 10 items of the NCS was evaluated for their sensitivity and contribution to the total score of 100. Validity was examined by correlations between the NCS and the CS, OSS, IS and EQ-5D scores pre-operatively and post-operatively. Results. Significant correlations were demonstrated post-operatively between the NCS and OSS (p< 0.001), CS (p=0.001), IS (p< 0.001) and the ‘self-care’ (p=0.013), ‘pain’ (p< 0.001) and ‘usual activities’ (p< 0.001) sub-categories of EQ-5D. Internal consistency was excellent (Cronbach's alpha=0.87). Removal of an item measuring cosmetic satisfaction improved the alpha to 0.90. Significant agreement was found on test/re-test examination. Differences in NCS were directly related to differences in all 4 comparative outcome measures and 91% of patients with improved post-op NCS values reported improvements in their symptoms. Conclusions. The NCS has been proven to be a valid, reliable and sensitive outcome measure that can accurately measure the level of function and disability in the joint, SC joint and clavicle. We recommend its future use for clinical evaluation

Abstract. Aim. The aim of this study was to present the results of treatment of displaced lateral clavicle fractures by an arthroscopically inserted tightrope device (‘Dogbone’, Arthrex). Methods. We performed a retrospective series of our patients treated with this technique between 2015 and 2019. Patients were identified using the ‘CRS Millennium’ software package and operation notes/clinic letters were analysed. We performed an Oxford Shoulder Score (OSS) on all the patients at final follow-up. Our electronic ‘PACS’ system was used to evaluate union in the post-operative radiographs. Results. We treated 26 patients with displaced lateral clavicle fractures between 2015 and 2019. There were 4 patients who were treated with a ‘dogbone’ and supplementary plate fixation and the remaining 22 were treated with a ‘dogbone’ alone. Radiological union was seen in 22 (84%) patients. The mean Oxford Shoulder Score (OSS) was 46. Apart from one patient who required removal of the superior endobutton and knot under local anaesthetic there was no other secondary surgery. There were no cases of infection, nerve injury or frozen shoulder. Conclusions. Arthroscopic ‘dogbone’ treatment of lateral clavicle fractures is a safe, cosmetically friendly technique with promising high rates of fracture union and return to normal function. We recommend its use over the more conventional treatment of a hook plate

Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model. Therefore, the aim of the current study was to compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates. Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking. Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047. From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations

Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively

Aims. To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. Methods. Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph. Results. A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R. 2. = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three. Conclusion. Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113–121

This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the 3D group (p < 0.05). The percentage comparisons of cortical bone area showed that cortical bone in the superior distal segment is thicker than in the inferior segment, it is also thicker in the anterior mid-section than in the posterior (p < 0.05). If fixation of midshaft fractures of the clavicle with a plate is indicated, a 3D reconstruction plate is better than one placed superiorly, because it is consistent with the stress distribution and shape of the clavicle

This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle

Background. Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting intramedullary fixation of adolescent clavicle fractures. 2) Review current management in a major trauma center (MTC) with a view to assess feasibility for a randomised controlled trial (RCT). Methods. The MEDLINE, EMBASE and AMED databases were searched in October 2014 to identify all English language studies evaluating intramedullary fixation in children aged 10–18 years using MeSH terms. Data was extracted using a standardised data collection sheet and studies were critically appraised by aid of the PRISMA checklist. All patients aged 9–15 attending an MTC receiving clavicle radiographs in 2014 were retrospectively reviewed for type of fracture, management and outcome. Results. Literature search identified 54 articles. After application of exclusion criteria 3 studies were selected for final review. 47 adolescent patients received intramedullary clavicle fixation from a prospective and two retrospective case series. 61 adolescents presented to our unit with a clavicle fracture in 2014, 2 were lost to follow-up, 54 were managed non-operatively, 3 received titanium-elastic nailing, 1 plate osteosynthesis and 1 bone suture. 0 and 19 patients reported a palpable lump, mean time to pain resolution was 4 and 6 weeks and time to full range of motion was 4 and 5 weeks following operative and conservative management respectively. All patients reached radiographic union. Conclusion. Current evidence supporting intramedullary fixation of clavicle fractures in adolescents is poor. There remains clinical equipoise on the best management of these patients, however they are predominantly treated conservatively. A future multi-center RCT may be feasible. Level of Evidence. 1

Fractures of the clavicle remain common in clinical practice. The main changes that have occurred in the last five years are in the indications for surgical intervention. The traditional indications remain. For example, complex cases such as compound fractures, those in which the skin is threatened, fractures of the clavicle associated with a floating shoulder, fractures of the clavicle associated with vascular injury and unstable lateral clavicle fractures. Fractures of the middle 1/3 of the clavicle with displacement of greater than 2 cm have been identified as having a poorer outcome based on patient related factors. In adults these fractures are now recommended for surgical stabilisation. A number of surgical techniques have been described including internal fixation with plates and intramedullary pins. It is the author's preference to use plate fixation as it provides stable fixation of the clavicle including rotational control. Although there are some authors that do recommend pin fixation, insertion of these pins can be technically demanding and there is a risk of displacement of undisplaced fragments. The intramedullary pins do not provide rotational control of the fracture. When performing internal fixation of clavicle fractures it is important to be aware of the risk of major neurovascular compromise. In the second quarter (from the medial edge of the clavicle) the major neurovascular structures are at risk and care is required to ensure that drills and screws do not penetrate the inferior cortex of the clavicle and violate these neurovascular structures. Adolescents with fractures of the clavicle are often managed without surgical intervention even if there is significant displacement. However, further work is required to identify the natural history of this group. Non-union of the clavicle is a relatively uncommon event. For those patients who have a persistent symptomatic non-union, surgical stabilisation and bone grafting is recommended

Neer Type-IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. A novel plating technique using a superior lateral locking plate with antero-posterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment has been designed to enhance stability. The purpose of this study was to biomechanically compare three different clavicle plating constructs. 24 fresh-frozen cadaveric shoulders were randomised into three groups (n=8 specimens). Group 1: lateral locking plate only (Medartis Aptus Superior Lateral Plate); Group 2: lateral locking plate with CC stabilisation (Nr. 2 FiberWire); and Group 3: lateral locking plate with two AP locking screws stabilising the lateral fragment. Data was analysed for gap formation after cyclic loading, construct stiffness and ultimate load to failure, defined by a marked decrease in the load displacement curve. After 500 cycles, there was no statistically significant difference between the three groups in gap-formation (p = 0.179). Ultimate load to failure was significantly higher in Group 3 compared to Group 1 (286N vs. 167N; p = 0.022), but not to Group 2 (286N vs. 246N; p = 0.604). There were no statistically significant differences in stiffness (Group 1: 504N/mm; Group 2: 564N/mm; Group 3: 512N/mm; p = 0.712). Peri-implant fracture was the primary mode of failure for all three groups, with Group 3 demonstrating the lowest rate of peri-implant fractures (Group 1: 6/8; Group 2: 7/8, Group 3: 4/8; p = 0.243). The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications

Abstract. Objectives. Clavicle fractures are common, yet debate exists regarding which patients would benefit from conservative versus operative management. Traditionally shortening greater than 2cm has been accepted as an indicator for surgery. However, clavicle length varies between individuals. In a cadaveric study clavicle shortening greater than 15% was suggested to affect outcomes. There is no clinical correlation of this in the literature. In this study we investigate outcomes following middle third clavicle fractures and the effect of percentage shortening on union rates. Methods. We identified a consecutive series of adults with primary midshaft clavicle fractures presenting to our institution from April 2015-March 2017. Clinical records and radiographs were reviewed to elicit outcomes. Time to union was measured against factors including; percentage shortening, displacement, comminution and smoking. Statistical significance was calculated. Results. 127 patients were identified, of whom 90 were managed conservatively and 37 operatively. Fractures were displaced in 86 patients (68%). Mean age was 41.7 years (range 18–89). Mean time to union for displaced fractures was longer than for undisplaced at 13.4 and 8.9 weeks respectively (p=0.0948). Displaced fractures treated operatively had mean time to union of 12.8 weeks, three weeks shorter than those managed conservatively (p=0.0470). Mean time to union for fractures with >15% shortening was 16.0 weeks, nearly double the 8.7 weeks with <15% shortening (p= 0.0241). Smokers had 8 weeks longer time to union (p=0.0082). Nonunion rate was 10% in fractures managed conservatively and 0% in those treated operatively. Complications following operative management were plate removal (13.5%), frozen shoulder (8.1%) and infection (2.9%). Conclusions. Nonunion rate is higher in fractures managed conservatively. Shortening >15% leads to significantly longer union time and should therefore be used as an indicator for surgery. Displacement and smoking also lengthen time to union and should be considered in the operative decision process. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project