Fractures of the clavicle are relatively common, occurring mostly in younger patients and have historically been managed non-operatively. Recent studies have shown an advantage to surgical reduction and stabilisation of clavicle fractures with significant displacement. Currently, fracture displacement is measured using simple anterior-posterior two-dimensional x-rays of the clavicle. Since displacement can occur in all three-dimensions, however, evaluation of the amount displacement can be difficult and inaccurate. The purpose of this study was to determine the view that provides the most accurate assessment. Nine CT scans of acute displaced clavicle fractures were analysed with AmiraDEV5.2.2 Imaging software. Measurements for degrees of shortening and fracture displacement of the fracture clavicle were taken. Using a segmentation and manipulation module (ITK toolkit), five digitally reconstructed radiographs (DRRs) mimicking antero-posterior x-rays were created for every CT, with each differing by projection angle (ranging from 20° upwards tilt to 20° downwards tilt). Measurements were taken on each DRR using landmarks of entire clavicle length, distance from vertebrae to fracture (medial fragment length), distance from fracture to acromium (lateral fragment length), and horizontal shortening, and then compared to the true measurement obtained from the original CT. For all 9 samples, after comparing the measurements of clavicle fracture displacement in each 2D image, we found that an AP view with a 20° downward tilt yielded displacement measurements closest to the 3D (“gold standard”) measurements. The results agree with previous data collected from cadaveric specimens using physical X-ray film images. DDRs enable creation of multiple standard AP radiographs from which accurate tilt can be measured. The large deviation in measurements on different DRR projections motivates consideration of standardising X-ray projections. A uniform procedure would allow one to correctly evaluate the displacement of clavicular fractures if fracture displacement information is to be utilized in motivating surgical decision-making

Purpose. The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods. Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results. The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p>0.05), sex (p>0.05), energy of injury (p>0.05), number of open fractures (p>0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p< 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p< 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion. There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results for delayed intervention in those who become symptomatic appear comparable

Introduction. Clavicle fractures can cause pain and functional impairment if not managed appropriately. This paper evaluates the prevalence of clavicular fractures, estimates number of cases requiring operative treatment, whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative group. Materials/Methods. Between November 2005 and November 2007 patients with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal, and functional outcome using the University of California Los Angeles (UCLA) shoulder scores were documented and analysed. Results. Out of 16,280 fractures presenting to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. Twenty patients were lost due to natural attrition, 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients operated upon, over half for symptomatic non-union. All clavicles united post operatively. Eighty one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative groups in mid shaft fractures. Under half (42.9%) required removal of metal implant sue to soft tissue irritation with complete resolution of symptoms. Conclusion. The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hard ware related symptoms

Thoracic Outlet Syndrome (TOS) is a complex of symptoms representing neurovascular compression in the supraclavicular area and shoulder girdle. Arterial thoracic outlet syndrome represents only 1% of all TOS's. We present two cases of arterial TOS's following internal fixation of clavicular fractures. Two cases of clavicular fractures managed with internal fixation and subsequently diagnosed with symptomatic, position dependent arterial occlusion are presented. The first case of a 16-year-old male treated with an intramedullary compression screw. He developed symptoms and was diagnosed with TOS using dynamic duplex examination performed by a vascular surgeon. Revision surgery was planned to decompress the subclavian artery from the hypertrophic callus at the fracture site. Before this could be performed the patient re-fractured his clavicle and bent the intramedullary screw. This resulted in resolution of the TOS symptoms. Following this second injury the patient went on to unite the fracture. The second case was of a 48-year-old male. He was initially treated non- operatively until the patient reported sensory and motor disturbances involving the hand and forearm. Excess callus was excised and the fracture was fixed using a locking plate. The symptoms improved, but worsened again eight weeks post operatively. Angiogram revealed vascular occlusion on arm abduction. Repeat surgery was performed in conjunction with a vascular surgeon. The plate was removed, vascular structures were released from fibrous tissue in the region of the fracture, and the posterior edge of the clavicle was debrided with a burr to reduce future impingement on vascular structures. Post operatively the TOS symptoms did not recur. Arterial thoracic outlet syndrome is an uncommon complication of trauma involving the clavicle. It can present in the presence or absence of surgical intervention, but can require surgical intervention to resolve

Background. Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications. Methods. We retrospectively reviewed a comprehensive Medicare (2005–2012) and Humana (2007–2014) patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for DHF and mid-shaft clavicle fractures, respectively. Non-operative management and open reduction internal fixation (ORIF) were reviewed for mid-shaft clavicle fractures. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. Total use and annual utilization rates were investigated using age limits defined in the original Level 1 studies. Results. A total of 4,929 clavicle patients between 15 and 59 years, and 106,535 DHF patients greater than 65 years of age were coded. There was no significant change in annual volume of mid-shaft clavicle fractures and DHF coded (p=0.078 and p=0.614, respectively). Among clavicle patients there was a significant increase in ORIF utilization following the publication of the Level 1 study (p=0.002), and a strong, positive correlation was evident (p=0.007). No significant change in annual TEA (p=0.515) utilization for DHF was seen. Conclusion. A significant increase in the utilization of ORIF for clavicular fractures was observed following the publication of supporting Level 1 evidence. This was not observed following similar evidence in managing DHF, as no increase in utilization of TEA was observed