Indications for Clavicle Fixation (Surgical)

MIDSHAFT CLAVICLE FRACTURES

Absolute Indications

Relative Indications (Fracture-Specific)

• Displacement >2 cm or shortening >2 cm (measured on upright radiographs; physiologic asymmetry of ~5 mm must be accounted for)
• Increasing comminution or segmental fracture
• Obvious clinical deformity (usually associated with significant shortening)
• Scapular malposition and winging on initial examination

Relative Indications (Associated Injuries)

• Progressive neurologic deficit (brachial plexus compression/laceration)
• Ipsilateral upper extremity injuries/fractures (humerus, forearm) - "ipsilateral upper extremity fracture" scenario
• Multiple ipsilateral upper rib fractures - associated with progressive displacement and chest wall instability; ipsilateral rib fractures are an independent risk factor for progressive clavicle displacement in the first 1-3 weeks
• "Floating shoulder" - ipsilateral clavicle + scapular neck fracture, disrupting the Superior Shoulder Suspensory Complex (SSSC); clavicle fixation is performed first, and if the glenoid remains unacceptably displaced, secondary posterior fixation of the glenoid neck is added
• Polytrauma with requirement for early upper extremity weight-bearing (e.g., crutch ambulation for lower limb injuries)
• Skin tenting threatening impending perforation

Relative Indications (Patient Factors)

• High functional demand (overhead workers, manual laborers)
• Elite athletes or self-employed professionals requiring rapid return of function
• Multiple risk factors for nonunion (female sex, unfavorable fracture pattern, smoking) - combination may tip balance toward surgery

LATERAL (DISTAL) CLAVICLE FRACTURES

• Displaced Neer Type II fractures with superior migration of the proximal fragment and intact CC ligaments to the distal fragment/coracoid
• Intra-articular fractures of the AC joint with significant articular step-off
• Surgical options include precontoured locking plates, hook plates, CC fixation (suture button, anchors, screw), and tension band wiring

MEDIAL (PROXIMAL) CLAVICLE FRACTURES

• Posterior displacement with mediastinal compression (trachea, esophagus, great vessels) - requires CT to define anatomy; approach with cardiothoracic surgical backup

KEY CLINICAL POINTS

• Most clavicle fractures (especially midshaft) can and should be treated non-operatively - the majority heal well
• Upright clavicle radiographs in two planes (AP + 15-40° cephalad tilt) are mandatory before deciding; supine trauma films underestimate displacement by ~89%
• In polytrauma, progressive displacement is common as supine radiographs underestimate deformity - repeat upright films as soon as the patient's condition allows
• In adolescents, operative indication is reserved for older, larger adolescents with severely displaced or shortened fractures; nonunion remains rare in this group
• Treatment decisions should be made shared with the patient after weighing risks (implant failure, infection, re-operation for implant removal) against benefits (faster return to function, lower nonunion risk)

Sources: Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1198-1227; Miller's Review of Orthopaedics 9th ed, p. 932