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

Tendons Around the Ankle Joint

Overview: Four Compartmental Groups

1. Medial Tendons — Tarsal Tunnel (Posteromedial)

"Tom, Dick, And Very Nervous Harry" Tibialis posterior → Digitorum longus (FDL) → posterior tibial Artery + Veins → tibial Nerve → flexor Hallucis longus (FHL)

Tibialis Posterior (TP)

• Largest of the three medial tendons (~twice the diameter of FDL on cross-section)
• Origin: proximal 2/3 of tibia, fibula, and interosseous membrane
• Runs behind medial malleolus in a dedicated groove
• Primary insertion: navicular tuberosity; also sends slips to cuneiforms, 2nd–4th metatarsal bases, cuboid, and sustentaculum tali
• Function: plantar flexion + inversion; primary supporter of the medial longitudinal arch
• Pathology: most common medial ankle tendon to be injured; rupture → progressive flat foot (pes planus)
• May be associated with an accessory navicular bone (types 1, 2, 3)

Flexor Digitorum Longus (FDL)

• Runs posterior to TP behind the medial malleolus; crosses TP (the "chiasma crurale") at the distal leg
• Within the tarsal tunnel: lies inferior to TP
• On the sole: crosses over FHL (the "Knot of Henry") and receives the quadratus plantae
• Divides into 4 slips → inserts on distal phalanges of toes 2–5
• Function: flexion of toes 2–5; also plantar flexion and inversion

Flexor Hallucis Longus (FHL)

• Lies most posteriorly in the tarsal tunnel (just behind the neurovascular bundle)
• Passes in a groove on the posterior surface of the talus and under the sustentaculum tali
• Inserts on the distal phalanx of the great toe
• Function: flexion of great toe; plantar flexion (important push-off power)
• Classic association: ballet dancers (FHL tenosynovitis)
• Separated from the Achilles tendon only by its own tendon; important surgical landmark

2. Lateral Tendons — Peroneal (Fibular) Tendons

Peroneus (Fibularis) Longus (PL)

• Origin: lateral condyle of tibia, proximal 2/3 of fibula, intermuscular septum
• In the retromalleolar groove: lies posterolateral to peroneus brevis (i.e., more superficial/posterior)
• Passes under the cuboid in a dedicated groove → runs obliquely medially → inserts on the lateral tubercle of 1st metatarsal and plantar surface of medial cuneiform
• Function: plantarflexion + eversion; supports the transverse arch and lateral longitudinal arch
• May contain an os peroneum (sesamoid bone) at the level of the cuboid

Peroneus (Fibularis) Brevis (PB)

• Origin: distal 2/3 of fibula; muscle belly is lower than peroneus longus
• In the groove: lies anteromedial to PL (deeper, closer to fibula)
• Inserts on the base of 5th metatarsal (styloid process)
• Function: plantarflexion + eversion; lateral ankle stabilizer
• Clinically: avulsion at base of 5th metatarsal is a common injury ("dancer's fracture")

Peroneal Tubercle (Calcaneus)

• The peroneal tubercle on the lateral calcaneus separates the two peroneal tendons distally:
  • PB passes above the peroneal tubercle
  • PL passes below the peroneal tubercle

Superior Peroneal Retinaculum (SPR)

• Inserts anteriorly on periosteum of lateral malleolus; covers tendons posterolaterally; attaches to lateral calcaneus
• A small fibrocartilaginous ridge at the anterior margin of the groove acts like a labrum to deepen the groove
• SPR rupture → peroneal tendon subluxation/dislocation (snapping over lateral malleolus)

Accessory: Peroneus Quartus

• Present in 12–22% of the population
• Most common accessory ankle muscle
• Origin: distal 1/3 fibula → variable insertion (retrotrochlear eminence of calcaneus most common)
• Can cause crowding in the retromalleolar groove → peroneal tenosynovitis

3. Anterior Tendons

The dorsalis pedis artery lies on the dorsum between EHL and the EDL tendon to the 2nd toe — the surface landmark for pulse palpation.

4. Posterior Tendons — Midline

Achilles (Calcaneal) Tendon

• Largest and strongest tendon in the body
• Formed by fusion of the gastrocnemius (two heads) and soleus aponeuroses = triceps surae
• The junction of the two aponeuroses is called the "conjoint junction"
• Fibers undergo a 90° internal rotation from proximal to distal (medial → posterior; lateral → anterior); this torsion increases mechanical resistance
• Inserts on the posterior surface of the calcaneus, below the posterosuperior angle
• No synovial sheath — instead surrounded by a paratenon (connective tissue derived from crural fascia)
• Retrocalcaneal bursa lies between tendon and posterosuperior calcaneal angle (clinically important in Haglund's deformity)
• Kager's fat pad fills the triangular space anterior to the tendon
• Poorest vascularization at the midportion (2–6 cm above insertion) → typical site of rupture and tendinopathy
• Tests S1–S2 reflex when tapped

Plantaris Tendon

• Long, slender tendon running medial to the Achilles tendon
• Inserts on the medial aspect of the calcaneus
• Absent in ~7–10% of people
• Clinically: rupture mimics Achilles injury; also used as a graft

Clinical Mnemonics

Tarsal Tunnel (medial, anterior to posterior):

• Tibialis posterior
• Digitorum longus (FDL)
• Artery (posterior tibial)
• Veins (posterior tibial)
• Nerve (tibial nerve)
• Hallucis longus (FHL)

Posteromedial ankle surgical approach:

Clinical Significance Summary