Clavicle Fractures: Surgical Treatment

Anatomy & Deforming Forces

• Sternocleidomastoid pulls the proximal fragment superiorly and posteriorly
• Pectoralis major, deltoid, and gravity pull the distal fragment anteriorly, medially, and inferiorly
• The scapula protracts as a result, shortening the shoulder girdle

Classification

Surgical Indications

Absolute Indications

• Open fracture
• Vascular injury requiring repair
• Progressive neurologic deficit (brachial plexus tethering)
• Scapulothoracic dissociation

Relative Indications — Midshaft

Most clavicle fractures can and should be treated nonoperatively. Operative repair is reserved for medically well, physically active patients who stand to benefit most from rapid restoration of anatomy. — Rockwood and Green's, p. 1209

Timing of Surgery

• Ideally within 2–3 weeks of injury for easiest reduction
• Delayed fixation (>3 weeks) risks brachial plexus tethering to the inferior clavicle surface — iatrogenic brachial plexus injury has been reported as a complication of delayed fixation
• For IM nailing specifically, closed reduction is often only possible within the first week

Surgical Options: Midshaft Fractures

1. Plate Fixation (ORIF) — Gold Standard

Plate Position Options

• Precontoured anatomic plates are preferred — fit the S-shape of the clavicle, reduce need for intraoperative bending, lower subsequent hardware removal rates
• Modern plates combine locking and dynamic compression holes (variable-angle locking options available)
• 3.5-mm plates are standard; 2.7-mm dual mini-plating is an emerging option with similar union rates and lower implant-related irritation in meta-analysis
• Locking screws are useful in osteoporotic bone or to reduce periosteal blood supply compromise
• Cerclage wires in isolation are inadequate and should be avoided

1. Beach-chair/semisitting position, small pad behind shoulder to elevate it
2. Oblique or vertical incision centered over fracture
3. Preserve supraclavicular nerve branches (peri-incisional numbness is a common postop complaint)
4. Reduce with small-fragment forceps; lag screw for anterosuperior wedge fragment if present
5. Apply precontoured plate with ≥3 bicortical screws on each side of fracture
6. Close platysma and skin in separate layers

• Sling for comfort, pendulum exercises immediately
• Wound check at 10–14 days
• Full ROM (no strengthening) until 6 weeks
• Radiographs at 6 weeks; if healing evident, progressive strengthening begins
• Return to contact sport/heavy labor typically at 3–4 months

2. Intramedullary (IM) Pinning

• Smaller, more cosmetic incisions
• Less soft tissue stripping and periosteal devascularization
• Potential for easier hardware removal

• Poor rotational and axial control with unlocked/smooth pins — unsuitable for unstable or comminuted fractures
• High hardware migration and prominence rates with older devices
• Must be performed early (within ~1 week) for closed reduction
• Higher hardware removal rates than plate fixation

• Ensure IM canal is large enough for planned device
• Avoid using IM device as a joystick (iatrogenic comminution)
• Do not pass instruments extraosseously posterior/inferior (neurovascular risk)
• Preserve supraclavicular nerve branches

3. External Fixation

• Technically feasible; avoids retained hardware
• Useful for severely compromised soft tissue envelope
• Limited acceptance due to pin prominence and practical difficulties; rarely used in routine practice

Surgical Options: Lateral (Distal) Clavicle Fractures

• Precontoured locking plate (most popular currently)
• Hook plate — "hook" inserts into subacromial space posteriorly; provides stable fixation but requires planned removal (risk of subacromial impingement if left in)
• Coracoclavicular (CC) fixation — suture-button device, suture anchor, or cortical screw through the CC interval
• Tension band wiring
• Transacromial K-wire fixation
• Arthroscopically assisted techniques

1. Beach-chair position; fluoroscopy is mandatory to confirm screws do not violate the AC joint
2. Expose fracture, reduce distal fragment (elevate to meet proximal), provisional K-wire or lag screw
3. Apply anatomic precontoured lateral plate with multiple 2.7-mm locking/variable-angle screws distally
4. Assess stability; convert to hook plate or add CC fixation if inadequate
5. Final fluoroscopic check before closure

Medial Clavicle Fractures

• Rare; often physeal fractures in adolescents/young adults
• Posterior displacement is an emergency — CT first to evaluate mediastinal impingement; may require cardiothoracic surgery backup
• Anterior: can often manage with closed reduction; unstable cases may need ORIF with mini-fragment LCP or CC reconstruction plate spanning sternum

Complications

Outcomes Summary

• Plate fixation produces higher union rates, faster return to function, and lower nonunion rates than nonoperative treatment in displaced fractures — supported by multiple RCTs and systematic reviews
• Anteroinferior vs. anterosuperior plating: equivalent clinical outcomes; slight advantage for anteroinferior regarding hardware removal
• IM nailing with locked devices produces comparable results to plate fixation in appropriately selected (non-comminuted) fractures, with smaller scars
• For adolescents, operative treatment is not routinely superior; reserve for older, larger adolescents with severe displacement/shortening

• PMID 38281678 (Sys Rev, 2024): Displaced distal clavicle fractures may have inferior outcomes with nonoperative management
• PMID 40087117 (Sys Rev, 2025): Hook plates vs. locking plates for Neer IIB fractures — comparative systematic review (2025)
• PMID 40022180 (Sys Rev, 2025): Midshaft fractures with associated ipsilateral AC joint injuries — surgical management nuances

TENS/TEN Nailing in Clavicle Fractures

What Is a TEN?

Biomechanical Principle & Limitations

• ✅ Restoration of length and alignment in simple, stable fracture patterns
• ❌ Poor rotational control — the clavicle can rotate around the nail
• ❌ Poor axial control — the nail cannot prevent telescoping/shortening
• ❌ Unsuitable for comminuted or unstable fractures — loss of length and rotation are major risks

Patient Selection (Indications)

Surgical Technique

Preoperative Planning Checklist

• Radiolucent or shoulder table
• Semisitting position with small pad between scapulae (lets shoulder fall back, aiding reduction)
• C-arm placed contralaterally or cranially
• Confirm IM canal diameter pre-op on X-ray — select nail diameter accordingly
• If older than ~10–14 days: plan for open reduction

Positioning

• Semisitting / beach-chair on radiolucent table
• Head turned to contralateral side and taped
• Pad between scapulae
• Arm may be free-draped if difficult reduction anticipated (significant shortening)

Insertion: Retrograde Technique (most common)

1. Entry portal: Small incision (~1–2 cm) over the posterolateral clavicle, 2–3 cm medial to the AC joint
2. Breach the posterior cortex with a drill or awl (entry must be confirmed fluoroscopically)
3. Pass TEN retrograde through the lateral/distal fragment toward the fracture site
4. Reduce the fracture — either percutaneously (preferred) using:
   • Percutaneous reduction clamp on the medial fragment
   • TEN as a joystick in the distal fragment (caution: risk of bending/breaking the nail)
   • Or "inside-out" technique: pass nail out through fracture site, reduce, then drive into medial fragment
5. Under fluoroscopic control, advance TEN across the fracture and seat it in the medial fragment
6. Verify length, alignment, and rotation clinically and fluoroscopically
7. Cut nail flush with the insertion site posterolaterally
8. Close in layers (typically 2 layers)

Closed reduction is usually only achievable in the first 7–10 days post-injury. Beyond that, open reduction is required. — Rockwood and Green's, p. 1210

Antegrade Technique

• Entry at the anteromedial clavicle near the SC joint
• Less commonly used
• Advantage: may be technically easier in certain body habitus

Postoperative Protocol

• Simple sling for comfort postoperatively
• Wound check at 2 weeks
• Gentle ROM instituted early if reduction is stable
• Radiographs at 6 weeks — if healing satisfactory, progressive active exercises begin
• Hardware removal is planned once union is confirmed (typically 3–4 months); often done under local anesthetic given the subcutaneous position

Radiographic Appearances

Outcomes vs. Plate Fixation

Complications

Surgical Pitfalls & Prevention

Locking IM Nails — The Next Step

• Threaded/locked ends prevent migration and rotation
• Axial control allows use in more comminuted patterns
• Hardware removal rates are lower than smooth TENs (~22% vs. routine removal)
• One meta-analysis showed superior functional outcomes with locked IM nails vs. plates — not seen with unlocked TENs

Locking IM pins represent a promising alternative that may finally make nailing a serious competitor for plate fixation in clavicle fractures. — Rockwood and Green's, p. 1211

Summary: When to Choose TEN

• Simple transverse/short oblique midshaft fracture
• Canal accommodating (confirm on pre-op imaging)
• Patient values cosmesis (smaller scar) and accepts planned hardware removal
• Early presentation allowing closed reduction
• Pediatric/adolescent patients

• Comminuted, segmental, or butterfly fragment fractures
• Narrow or tortuous medullary canal
• Delayed presentation (>2 weeks) with difficult reduction anticipated
• Large, high-demand patient requiring rigid fixation

TEN (Titanium Elastic Nail) in Clavicle Fractures — Summary

What It Is

Key Biomechanical Facts

• Works by 3-point bending inside the canal
• Unlocked → poor rotational AND axial control
• Cannot prevent telescoping/shortening
• Biomechanically inferior to plate fixation in all loading modes (Golish et al.)
• Best suited only for simple, stable fracture patterns

Ideal Patient

Technique (Retrograde — Most Common)

1. Small incision (~1–2 cm) posterolateral clavicle, 2–3 cm medial to AC joint
2. Breach posterior cortex with drill or awl
3. Pass TEN retrograde through distal fragment to fracture site
4. Reduce fracture — percutaneously (preferred, especially within first week) or open
   • Percutaneous clamp on medial fragment
   • TEN as joystick in distal fragment (caution: bending/breaking risk)
   • Or "inside-out": pass nail out at fracture site → reduce → drive into medial fragment
5. Advance TEN across fracture, seat in medial fragment under fluoroscopy
6. Verify length, alignment, rotation clinically + fluoroscopically
7. Cut nail flush with posterolateral cortex
8. Two-layer closure

Postoperative Protocol

• Sling for comfort
• Wound check at 2 weeks
• Early ROM if stable
• X-ray at 6 weeks → progressive strengthening
• Planned hardware removal once united (~3–4 months), often under local anesthetic

Outcomes vs. Plate

Key finding: A meta-analysis of 895 patients showed better functional outcomes with IM nailing vs. plates — but sensitivity analysis showed this was solely due to locking IM nails, not smooth TENs. — Rockwood and Green's, 10th ed.

Complications

Surgical Pitfalls

Locking IM Nails — Evolution Beyond TEN

• Prevent migration and rotation
• Maintain axial length → usable in more comminuted patterns
• Removal rates ~22% (vs. near 100% for smooth TENs)
• The only IM devices shown to outperform plates in meta-analysis