Evidence is mounting, however, in support of operative treatment for displaced midshaft clavicle fractures. A prospective, multicenter, randomized trial by the Canadian Orthopaedic Trauma Society found that operative repair for these injuries provided better results than did nonoperative treatment. In the study, involving 132 patients with a displaced midshaft fracture, outcome and complication rates were compared for nonoperative treatment and plate fixation. [33]
The investigators determined that mean time to radiographic union was significantly shorter in the operative group (16.4 wk vs 28.4 wk). Additionally, functional outcomes were improved at all time points measured in the operative group. This study provided level I evidence in support of plate fixation for completely displaced midshaft clavicle fractures in the active adult population. [33]
Similarly, a study by Smekal et al found better results with another operative procedure, elastic stable intramedullary nailing (ESIN), than with nonoperative treatment in the repair of fully displaced midshaft clavicle fractures. Outcomes with regard to the rate of successful bone union, functional outcome, time required for patients to resume their daily activities, and overall patient satisfaction were superior in the operative group than in nonoperative patients. There was also significantly less posttraumatic clavicular shortening in the surgical group.
-
A posterior view demonstrating a closed clavicle fracture tenting the skin (arrow), which can potentially lead to an open fracture.
-
Comparison of both clavicles, with the left tenting the skin (wide arrow).
-
Close-up view of clavicle tenting the skin (arrow).
-
Comminuted fracture in a hockey player. Note the medial fragment tenting the skin.
-
Additional view of fracture displacement and comminution in a hockey player. The sternocleidomastoid is the deforming force of the medial fragment.
-
Radiographs after open reduction and internal fixation of a comminuted fracture in a hockey player.
-
Anteroposterior view of middle third clavicle fracture illustrating a relatively typical fracture pattern.
-
Anteroposterior view of distal clavicle fracture, type II, showing wide displacement.
-
The displacing forces on a midshaft clavicle fracture.
-
The displacing forces on a distal clavicle fracture.
-
Type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place.
-
A type II distal clavicle fracture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, while the proximal segment, without ligamentous attachments, is displaced.
-
A type IIB fracture of the distal clavicle. The conoid ligament is ruptured, while the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced.
-
Anatomy of the clavicle indicating potential fracture sites.
-
Nondisplaced middle clavicle fracture.
-
Displaced fracture of middle clavicle.
-
Displaced middle clavicle fracture.
-
Clavicle fracture with rib fractures. Remember to look for associated injuries.
