Background. A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. Aims. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. Methods. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted over a 12 month period, beginning July 2007. Demographic data were recorded prospectively for each patient presenting with an acute clavicle fracture including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson Classification system. Results. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. An association between age, mode of injury and fracture type was observed, with younger patients sustaining high energy injury associated with majority of the Type II midshaft fractures; whilst more than fifty-nine percent of Type III lateral one third fractures occur in elderly patients as a result of simple fall. Overall, Type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. Conclusions. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of Type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Purpose. In a previously published multicenter randomized clinical trial it was shown that young patients (16–60 years-old) with displaced mid-shaft clavicle fractures had superior limb specific outcomes when they were treated with primary plate fixation versus non operative treatment at one year follow-up. This study examines the general health status of this cohort of patients at two-years post injury. Method. We evaluated the general health of a cohort of patients with displaced mid-shaft clavicle fractures comparing non-operative versus plate fixation at two-years after injury. At the conclusion of our study, eighty-nine patients (fifty-four from the operative group and thirty-five from the non-operative group) completed the two-year follow-up. Outcome analysis included the standard clinical follow-up and SF-36 scores. Results. SF-36 scores were significantly improved in the operative fixation group at all time-points: 6 weeks, 3, 6, 12, 24 months (P<0.01). At two-years after the injury, the patients in the operative group had better patient oriented outcome scores, especially in the physical performance component of the SF-36 scores (Physical component (PCS) 57.1 versus 51.0, P<0.05). Conclusion. Operative treatment more reliably restored pre-operative levels of general health status compared to non-operative treatment. Operative fixation of a displaced mid-shaft clavicle fracture in young active patients resulted in improved patient oriented general health status at two-year follow-up. The improvement is especially pronounced in the physical component of the SF-36 scores. These findings support primary plate fixation of displaced mid-shaft clavicle fractures in young active adults

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. The aim of this study was to compare biomechanical properties of pre-contoured plate fixation using different screw fixation modes in a mid-shaft clavicle fracture model. Methods. Fourth generation biomechanical clavicle sawbones with a mid-shaft osteotomy were plated in one of three modes: nonlocking bicortical, locking bicortical and locking unicortical mode. The specimens were then tested to failure in four-point bending and pull-off tests. Results. Failure due to fracture through the sawbone was more common in nonlocking bicortical mode while plate bending was more common in the locking bicortical group. The ultimate load at failure was significantly lower in the locking bicortical group compared to the nonlocking bicortical group, however there was no significant difference between the locking unicortical group and nonlocking bicortical group. In the pull-off tests 100% of nonlocking bicortical and locking bicortical plates failed by fracture of the sawbone. 100% of the locking unicortical plates failed by plate and screw pull-off from the sawbone. The load at failure was highest for the locking unicortical plate but this was not significantly different to the other groups. Conclusion. This study shows that specimens fixed with locking unicortical screw fixation withstood comparable or superior loads in four-point bending and pull-off test when compared to nonlocking bicortical and locking bicortical screw fixation. In addition both locking screws and unicortical screws appear to provide a protective effect against periprosthetic sawbone fracture. Locking unicortical screw fixation of pre-contoured plates may be a viable alternative in the fixation of mid-shaft clavicle fractures

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

Despite the vast quantities of published artificial intelligence (AI) algorithms that target trauma and orthopaedic applications, very few progress to inform clinical practice. One key reason for this is the lack of a clear pathway from development to deployment. In order to assist with this process, we have developed the Clinical Practice Integration of Artificial Intelligence (CPI-AI) framework – a five-stage approach to the clinical practice adoption of AI in the setting of trauma and orthopaedics, based on the IDEAL principles (https://www.ideal-collaboration.net/). Adherence to the framework would provide a robust evidence-based mechanism for developing trust in AI applications, where the underlying algorithms are unlikely to be fully understood by clinical teams.

Cite this article: Bone Joint Res 2024;13(9):507–512.

Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked intramedullary fixation of clavicle shaft fractures that match the criteria for operative fixation continues to give good results. No non-unions were found and a high level of patient satisfaction was achieved. The operative technique continues to be refined leading to less fixation related complications. MULTIPLE DISCLOSURES

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

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

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

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Aim. Clavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand. Methods. A retrospective case series of patients who have undergone any shoulder arthroplasty for any indication between March 2017 to August 2022. This time period includes all patients who had clavicular osteotomy(OS) and patients over an equal time period prior to the routine use of osteotomy as a reference group (N-OS). Oxford Shoulder Score (OSS) and a Simple Shoulder Test (STT) were used to assess functional outcomes and were compared with the reported literature. Operative times and Complications were reviewed. Results. 66 patients were included in the study. 33 patients in the OS group and 33 in the N-OS group. No difference in age, sex, indications for operative intervention and the surgery provided was identified. No significant difference in operative time between groups (N-OS 121 minutes; OS 128 minutes). No clinically significant difference was identified in the OSS (N-OS; mean 38 vs OS 39) or the STT (N-OS 8.3 vs OS 9). The outcomes scores of both groups are in keeping with published literature. Two post operative clavicle fractures, one prominent surgical knot occurred in the OS that required further surgical intervention. Two cases of localized pain over the clavicle and one case of the prominent lateral clavicle were reported in the OS group. Two cases of localized pain over clavicle reported in the N-OS group. Conclusion. Use of clavicular osteotomy is not associated with inferior patient reported. The osteotomy introduces specific risks, however, the study provides evidence that these complications are infrequent and avoidable. Surgeons should feel confident in using this adjunct when exposure to the shoulder is difficult

Abstract. Introduction. In our quality improvement project we implemented a novel pathway, performing acute fixation in mid-third clavicle fractures with >15% shortening. Patients with <15% shortening reviewed at 6 weeks, non-union risk identified as per Edinburgh protocol and decision to operate made accordingly. Methods. Retrospective pre-pathway analysis of patients presenting 04/2017–04/2019. Prospective post-pathway analysis of patients presenting 10/2020–10/2021. Fracture shortening measured using Matsumura technique. QuickDASH and recovery questionnaires posted to >15% shortening patients and done post-pathway at 3 months. Results. Pre-pathway retrospective cohort included 141 patients; 69 <15%, 72 >15% shortening. Acute ORIF performed in 15(22%) <15% and 34(47%) >15%. In those conservatively managed, non-union occurred in 2 patients with <15% shortening, and 5 with >15% shortening. Union time was significantly longer in >15% treated non-operatively compared to those requiring ORIF and <15% (18.4 vs 13.4 vs 12.0 weeks; p<0.05). QuickDASH significantly worse in >15% managed conservatively than operatively (17.6 vs 2.8; p<0.05). >15% ORIF had significantly fewer number of weeks until undisturbed sleep than those treated non-operatively (2.3 vs 10.1; p<0.05). Post-pathway prospective cohort included 37 patients; 17 <15% (of which 1 underwent delayed ORIF), 20 >15% shortening (of which 15 underwent acute ORIF). No significant increase in proportion ORIF performed (43% vs 38%). No non-unions occurred. Conclusion. Acute fixation in >15% shortening was associated with better QuickDash scores and reduced union times than those treated non-operatively. Implementation of our pathway resulted in no nonunions compared to 5% pre-implementation and thus identifies patients benefitting from acute fixation

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

Background. This is an epidemiological study of patients with middle third clavicle fractures presenting to a tertiary hospital. The data is used to formulate a classification system for middle third clavicle fractures based on fracture configuration and displacement. Description of methods. Patients presenting primarily to a referral hospital with middle third clavicle fractures were identified using the PACS radiology system. The radiographs were reviewed to determine the fracture type, displacement, shortening and amount of comminution. The clinical notes of each patient were reviewed to determine the mechanism of injury, soft tissue status, neurovascular status and treatment rendered. A novel classification system was developed to describe the different fracture configurations seen in the group. The interobserver and intraobserver correlation of the classification system as well as the ability of the classification system to predict treatment were tested. Summary of results. Three hundred and three patients were included in the review, 223 males and 80 females. Middle third clavicle fractures were displaced in 69% of cases. Displaced fractures tend to have a significant amount of displacement and shortening in most cases with averages of 19.64mm (Std Dev. 6.901) and 19.15mm (Std Dev. 9.616) respectively. Acceptable interobserver and intraobserver correlation levels were shown for the proposed classification system. Conclusion. The epidemiology of middle third clavicle fractures found in the population studied differs substantially from first world populations. It underlines the high level of road traffic accidents and interpersonal violence seen in South Africa. Surgeons treating clavicle fractures are still divided on the indications for surgery with little correlation found between the fracture type and displacement on radiographs and the type of treatment rendered. The classification system provides guidelines to treating surgeons to the correct treatment modality. MULTIPLE DISCLOSURES

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

Although most uncomplicated paediatric fractures do not require routine long-term follow-up with an orthopaedic surgeon, practitioners with limited experience dealing with paediatrics fractures will often defer to a strategy of unnecessary frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway may help reduce unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. A retrospective analysis including patients who presented to SickKids hospital between October 2009 and October 2014 for management of clavicle fractures was performed. Patients with previous clavicle fractures, perinatal injury, multiple fractures, non-accidental injury, underlying bone disease, sternoclavicular dislocations, fractures of the medial clavicular physis and fractures that were managed at external hospitals were excluded from the analysis. Variables including age, gender, previous injury, fracture laterality, mechanism of injury, polytrauma, surgical intervention and complications and number of clinic visits were recorded for all patients. Radiographs were analysed to determine the fracture location (medial, middle or lateral), type (simple or comminuted), displacement and shortening. 339 patients (226 males, 113 females) with an average age of 8.1 (range 0.1–17.8) were reviewed. Diagnoses of open fractures, skin tenting or neurovascular injury were rare, 0.6%, 4.1%, and 0%, respectively. 6 (1.8%) patients underwent surgical management. All decisions for surgery were made on the first consultation with the orthopaedic surgeon. For patients managed non-operatively, the mean number of clinic visits including initial consultation in the emergency department was 2.0 (±1.2). The mean number of radiology department appointments was 4.1 (± 1.0) where patients received a mean number of 4.2 (±2.9) radiographs. Complications in the non-operative group were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Development of a paediatric clavicle fracture pathway may reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients' families without jeopardising patient outcomes

There is no clear consensus regarding the indications for surgical treatment of middle third clavicle fractures. An initial shortening of 2 cm or more of the clavicle was associated with poor clinical outcomes and higher rate of non-union. The number needed to treat (NNT) clavicle fractures in order to prevent non-union ranges in the recent literature from 4.5 to 9.2. A direct relationship between shortening of the clavicle and a poor clinical outcome has not yet been demonstrated. Prospective cohort study performed in a Level one trauma centre including 148 clavicle fractures treated conservatively. Eighty-five patients met the inclusion criteria (healed fracture in the middle third, no other upper limb lesions) and 63 were enrolled. A single assessment was realised at a minimum one year follow-up by an independent examiner and consisted in Constant and DASH scores, range of motion, strength in abduction (Isobex) and a specific radiographic evaluation using a calibrated AP radiographs of both clavicles. Two groups were constituted and analysed according to a radiologic shortening > 2 cm (patients and assessor blinded). Sub-analyses were performed to find any relevant clinical threshold. The rate of shortening > 2cm in this cohort is 16.1% (10 patients). No clinical differences between the two groups for Constant scores (shortened > 2 cm = 96.0 ± 6.0 vs 95.2 ± 6.6, p=0,73) and DASH scores (8.4 ± 11.9 vs 5.4 ± 8.1, p=0,32). A slight loss in flexion was observed with a shortening > 2cm (175 deg ± 8.5 vs 179.3 ± 3.4, p=0,007). No clinical threshold (in absolute or relative length) was associated with lower functional scores. No relationship between clinical results and patient characteristics. Interestingly, cosmesis was not an issue for patients. This study could not demonstrate any clinical impact of the shortening of the clavicle in patients treated conservatively for a fracture in the middle third. Functional scores are excellent and the slight difference in flexion is not clinically significant. We were not able to found patients unsatisfied with their treatment. The poor functional outcomes described in previous studies are mainly related to non-unions. Just after the trauma, protraction of the scapula and single AP views centered on the clavicle can overestimate the real shortening. An initial shortening of the clavicle > 2 cm is not a surgical indication for fractures in the middle third; patient selection for surgery should focus on risk factors for non-unions

Purpose. Open reduction and plate fixation of displaced mid-shaft clavicle fractures has gained significant popularity following a recent multi-center randomized control trial. The purpose of this study is to describe the incidence of reoperation following plate fixation of displaced mid-shaft clavicle fractures. The secondary objective is to determine if plate design influences the incidence of reoperation. Method. A retrospective search of our hospital database was performed to identify subjects treated with plate fixation for a displaced clavicle fracture between 2001 and 2009. Radiographs and medical records were used to identify demographic data, fracture classification, plate design, and reoperation events. Only mid-shaft (AO/OTA 15-B) fractures treated with either a Low-Contact Dynamic Compression (LCDC) plate or Pre-contoured Locking (PCL) plate were included. Results. 144 subjects were included in the study. The mean age was 36 years (95% CI 33 38 years) and the mean duration of follow-up was 60 weeks (95% CI 46 74 weeks). 60% of included fractures were wedge pattern (15-B2), followed by 35% simple (15-B1) fractures, and 5% complex (15-B3) fracture patterns. Pre-contoured locking plates were used in 92 cases (64%) and LCDC plates were used in the remaining 52 subjects (36%). 21 subjects (15%) underwent reoperation: 17% of subjects treated with LCDC plates and 13% of subjects treated with PCL plates (p=0.62). Indications for reoperation included painful hardware (86%), hardware failure (9%), and refracture (5%). There was no association between reoperation and age (p = 0.23), gender (p = 0.56), fracture type (p = 0.53), or plate design (p = 0.49). Conclusion. This study represents a large series of displaced clavicle fractures treated with open reduction and plate fixation. Reoperation following plate fixation is relatively common and is primarily due to painful hardware. No difference in reoperation rates between LCDC and pre-contoured plates could be detected in the current sample size

Purpose:. To review the union rates, outcomes and complications of angular stable plating of lateral third clavicle fractures. Method:. Between 2007 and 2010 angular stable plates were used in the fixation for seventeen patients with displaced lateral third clavicle fractures (Allman Group II, Type 2). These were identified from surgical log books and operation codes. The surgical and clinical notes as well as X-rays were reviewed. The patients were contacted telephonically. An Oxford Shoulder Score and questions relating to plate removal, scar pain and return to activities were asked. Three patients were not contactable. Results:. There were 16 males. The average age was 44. The average time to union was 3 months (range 2 to 4). There were no complications. The average Oxford Shoulder Score was 13 (range 12–19). No plates have required removal but 2 patients have requested removal for discomfort. All but 3 patients have returned to full activity. Conclusion:. The use of angular stable plates for fixation of type 2 lateral end of clavicle fractures results in excellent union rates by 3 months with only 3 patients requesting elective plate removal. This is in contrast to hook plates which require mandatory removal. No other complication was encountered