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Clavicle Fracture

Clavicle fractures — when conservative management is fine and when fixation is indicated.

127 citationsUpdated Oct 2026

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Overview

Clavicle fractures are predominantly managed nonoperatively, with most patients achieving excellent functional outcomes through conservative care [9]. If patients with medial clavicle fractures survive the initial trauma, good clinical and functional results are expected regardless of the treatment modality chosen [1]. While initial nonsurgical management is often reasonable given similar functional outcomes even when surgery is delayed [2], close follow-up is warranted due to a risk for persistent symptoms following nonoperative treatment that is far higher than expected [5, 3]. The most common complications following clavicle fractures, whether treated operatively or non-operatively, are non-unions and malunions [19].

Surgical intervention is indicated for a select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications, where fixation has been shown to improve outcomes compared with non-operative measures [75]. Treatment should be individualized based on fracture characteristics and patient expectations rather than broadly applied [18]. Although posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes, supporting routine operative reduction for shortened fractures based on functional arguments [54], displaced midshaft clavicular fractures with the intent of achieving a 'good' outcome must be managed non-operatively [67]. Complication rates following surgical clavicle fracture care averaged 8.1% [52].

In the adolescent population, the majority of clavicular fractures can and should be treated nonoperatively, which demonstrates lower complication rates and similar satisfaction and functional outcomes compared to operative treatment [36, 12]. However, an increasing trend toward stabilization and fixation of markedly displaced midshaft fractures exists due to concerns about symptomatic malunion, though definitive indications remain unclear [175]. Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications [30]. For distal clavicle fractures, both arthroscopic coracoclavicular button fixation and anatomic locking plate fixation can be used because they present similar, high union rates and minimal risk of complications [186]. The optimal management of type II distal clavicle fractures remains controversial, with many authors advocating surgical intervention due to a nonunion rate that has generally averaged 30% [88].

Anatomy & Pathophysiology

Bony Anatomy and Development

The clavicle is the only long bone to ossify by intramembranous ossification [26], beginning from two primary centers (medial and lateral) by 5 to 6 weeks of gestation [100]. By 7 to 8 weeks, the bone assumes its overall contour and “S” shape [100]. Approximately 80% of clavicular growth occurs from the medial physis [100]. The lateral epiphysis forms and fuses at around 18 to 19 years of age [100], while the medial epiphysis is the last in the body to ossify, completing this process between 23 and 25 years [100].

In the transverse plane, the clavicle resembles an italic S, appearing relatively straight when viewed anteriorly [103]. The greater radius of curvature occurs at the medial curve, which is anteriorly convex, while the smaller lateral curve is posteriorly convex [103]. The bone is somewhat rounded in its midsection and medially, and relatively flat laterally [103]. The medial end features a rhomboid fossa on its inferior surface in 30% of cases, where the costoclavicular ligaments insert, and an actual articular surface facing inferiorly toward the first rib in 2.5% of cases [103]. The middle portion contains the subclavian groove for the fleshy insertion of the subclavius muscle [103]. Laterally, the coracoclavicular process may be present [103].

The conoid ligament attaches to the conoid tubercle, while the trapezoid ligament attaches at the trapezoid line, which lies in an anteroposterior direction just lateral to the conoid tubercle [103]. The distance from the lateral edge of the clavicle to the medial edge of the conoid tubercle is approximately 45 mm in male and female specimens [103]. The distance from the lateral edge of the clavicle to the center of the trapezoid tuberosity is approximately 25 mm in male and female specimens [103]. The primary blood supply to the clavicle is periosteal, with no nutrient blood supply [26]. The bone is subcutaneous, enveloped by the platysma, pectoralis major, deltoid, and some of the strap muscles of the neck [26].

Muscular and Ligamentous Anatomy

The clavicle serves as the primary stabilizer between the axial skeleton via the sternoclavicular joint and the appendicular skeleton via the acromioclavicular joint [26]. The superior shoulder suspensory complex (SSSC) is a bone–soft-tissue ring providing a stable connection of the glenoid and scapula to the clavicle [26]. It is composed of four bony landmarks—distal clavicle, acromion, coracoid process, and glenoid neck—and the supporting ligamentous complexes of the AC joint and the CC ligaments [26]. The coracoclavicular ligaments, consisting of the conoid (medial) and trapezoid (lateral) components, are the primary stabilizers to superior (vertical) translation of the distal clavicle [26].

Muscular attachments include the pectoralis major, which originates from the clavicular shaft anteroinferiorly and merges with the anterior deltoid origin laterally [107]. The sternocleidomastoid originates superiorly on the clavicle [107]. The trapezius insertion blends superiorly with the deltoid origin at the lateral margin of the clavicle [107]. The subclavius muscle inserts on the undersurface of the clavicle [107], and the platysma usually envelopes the anterior and superior aspects of the bone in the subcutaneous tissues [107].

The supraclavicular nerves originate from cervical roots C3 and C4, exiting from a common trunk behind the posterior border of the sternocleidomastoid muscle [116]. There are typically three major branches (anterior, middle, and posterior) that cross the clavicle superficially from medial to lateral [116]. The subclavian vein runs directly below the subclavius muscle and above the first rib [116]. The subclavian artery and brachial plexus lie more posteriorly, separated from the vein and clavicle by the scalenus anterior muscle medially [116]. The brachial plexus is closest to the clavicle in its midportion [116]. In the middle third of the clavicle, the subclavian artery and vein are a mean of 17 and 13 mm from the clavicle, respectively, at an approximate angle of 60 degrees to the horizontal [116]. Laterally, the subclavian artery and vein are a mean of 63 and 76 mm, respectively, from the clavicle [116].

Mechanism of Injury and Deformity

Most clavicle fractures result from a fall onto the shoulder or a direct blow, with the majority occurring in males and associated with vehicular trauma, falls, or sporting injuries [7]. A direct blow on the point of the shoulder is the commonest reported mechanism producing a midshaft fracture [105]. The most common mechanism is a direct blow to the shoulder, whether following a fall or due to direct trauma [63]. Although a fall on an outstretched hand can result in fracture, this was initially thought to be the most common cause [63]. Classical injury mechanisms include a simple fall on the shoulder (31%), road traffic accidents (27%), and sports (23%) [94]. Clavicle fractures are rarely open, despite being caused by high-energy trauma [63].

When the shoulder girdle is subjected to compression force directed from laterally, failure can occur in the acromioclavicular articulation, the clavicle may break, or the sternoclavicular joint may dislocate [105]. Steroclavicular injuries are rare and typically associated with more posteriorly directed blows against the medial clavicle or posteriorly directed blows to the distal shoulder girdle [105]. Simple falls from a standing height are unlikely to produce a displaced fracture in a healthy young person but can result in injury in elderly, osteoporotic individuals, typically seen in the distal third of the clavicle [105].

Fractures of the clavicle shaft have the highest incidence, accounting for 69% of all clavicle fractures [94]. Lateral clavicle fractures account for 28% of all clavicle fractures [94], while medial clavicle fractures account for 3% [94]. Most (85%) clavicle fractures occur in the midshaft of the bone where the bone is narrowest and enveloping soft tissue structures are most scarce [105]. Medial clavicle fractures occur more often as part of a high-energy trauma or trauma with multiple injuries [94].

The direction of the initial deforming force, and both gravitational and muscular forces on the clavicle, result in the typical deformity seen after fracture [105]. The lateral fragment of a fractured clavicle is pulled down by the weight of the arm, while the medial fragment is held up by the sternomastoid muscle [11]. Specifically, the medial clavicular fragment is elevated by the unopposed pull of the sternocleidomastoid muscle, while the distal fragment is held inferiorly by the deltoid and medially by the pectoralis major [107]. The typical deformity of middle-third fractures is caused by a medial fragment pulled superiorly by the sternocleidomastoid muscle, with the weight of gravity pulling downward on the lateral fragment [26].

Pathophysiology of Displacement and Malunion

The more lateral the fracture, the more potential there is for significant angulation [86]. The greatest angulation usually occurs at the point at which the clavicle is subtended by the coracoid [86]. Angulation is more acute the closer the break is to the pivot points of clavicoscapular motion [86]. The predominant influence on displacement involves the lateral segment of the clavicle being carried forward by virtue of its retained acromioclavicular and residual coracoclavicular attachments [86]. In medial-third fractures, the lateral shaft fragment was situated anteriorly to the medial one, usually forming a prominent anterior spike [86].

The shoulder is a closed chain mechanism constituting the combined function of four joints: the sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joint [14]. Two of these four joints are articulations of the clavicle; therefore, clavicle malunion affects the whole shoulder girdle [14]. Symptomatic malunion after midshaft clavicular fractures has been recognized in the last 15 years to be a cause of shoulder dysfunction [14]. Clavicle malunion is a distinct clinical entity that can be treated successfully [14].

Medialization of a clavicular fracture more than 20 mm is associated with a measurable decrease in functional outcome [26]. Conversely, posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes [54]. The observed association of glenohumeral internal rotation deficit after operative treatment of mid-shaft clavicle fractures, with a tendency toward scapular protraction, may provide insight into this phenomenon [21]. Clavicle fractures do not increase the occurrence of later subacromial pain syndrome [10], and results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome [10].

The clavicle is essential for positioning the scapula during arm movement and transmitting forces of attached muscles [82]. Significant remodeling was observed across all measurements in teenagers with nonoperatively treated completely displaced midshaft clavicular fractures, with improvements of 70% in shortening, 73% in superior displacement, and 83% in angulation [6]. Malunion is inevitable in displaced fractures; in children, the bone is soon remodelled, but in adults the slight deformity has to be accepted unless there is a very unsightly bump with skin irritation [11]. Non-union sometimes occurs in middle-third fractures and is treated by bone graft and plating [11]. Vascular and neurological complications are rare in clavicle fractures [11], and despite deformity, damage to the lung or vessels beneath the clavicle is very rare [11].

Classification

General Classification Systems

Allman: The Allman classification divides the clavicle into thirds, with lateral third fractures including those from medial to the coracoclavicular ligaments to the acromioclavicular joint itself [183].

Edinburgh: The Edinburgh classification divides clavicular fractures by anatomic location into Type I (medial third), Type II (middle third), and Type III (lateral third) [63]. Subgroup A indicates displacement less than 100% and subgroup B indicates displacement more than 100% [63]. Articular involvement determines further subdivision of Types I and III, with subgroup 1 indicating no articular involvement and subgroup 2 indicating intra-articular extension [63]. Type II fractures are subdivided into subgroup 1 for simple or wedge-type fractures and subgroup 2 for comminuted or segmented fractures [63]. Clavicle fractures were initially classified in 1967 based on anatomic location and descending order of incidence, with Type I involving the middle third, Type II the lateral third, and Type III the medial third [63].

Prognostic Utility: A 2011 study reported that the Craig classification best predicted nonunion or delayed union of lateral third clavicle fractures [63]. A 2011 study reported that the Robinson classification had the best prognostic potential for middle third clavicle fractures [63]. Midshaft clavicular fractures should be classified according to the Robinson classification on two-plane radiography to optimize treatment decisions [157].

Lateral (Distal) Clavicle Fractures

Neer: The Neer classification separates distal third clavicle fractures into five main types [183]. Type I fractures occur lateral to the coracoclavicular ligaments and are usually stable [63]. Type IIA fractures are medial to the intact conoid and trapezoid ligaments [63]. Type IIB fractures are lateral to the torn conoid ligament but medial to the intact trapezoid ligament [63]. Type III fractures are intra-articular fractures through the acromioclavicular joint with intact coracoclavicular ligaments [63]. Type IV fractures involve disruption of the clavicular periosteal sleeve in pediatric patients [63]. Type V fractures involve a small, inferior cortical bone fragment remaining attached to the coracoclavicular ligaments [63]. The modified Neer classification remains the predominantly cited classification system for distal clavicle fractures [106]. However, the intra- and interobserver reliability of the modified Neer classification has been demonstrated to be inconsistent [106], with interrater agreement for lateral clavicle fractures rated as fair [124]. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice [124].

Craig: The Craig classification was introduced in 1996 to subclassify Type II (lateral third) clavicle fractures based on the integrity of the coracoclavicular ligaments and the relationship of the fracture line with the coracoclavicular ligaments and acromioclavicular joint [63]. In Craig Group II Type I fractures, the coracoclavicular ligaments remain intact to hold the fragments together and prevent rotation, tilting, or significant fracture displacement [83]. In Craig Group II Type IIA fractures, both the conoid and trapezoid ligaments are attached to the distal fragment [83]. In Craig Group II Type IIB fractures, the conoid ligament is ruptured while the trapezoid ligament remains attached to the distal segment [83]. Craig Group II Type III fractures involve the articular surface of the acromioclavicular joint alone [83]. Craig Group II Type IV fractures occur in children and involve ligaments intact to the periosteum with displacement of the proximal fragment [83]. Craig Group II Type V fractures are comminuted, with ligaments attached neither proximally nor distally, but to an inferior, comminuted fragment [83].

Robinson: The Robinson classification for distal clavicle fractures includes Type 3A for cortical alignment fractures and Type 3B for displaced fractures [64]. In the Robinson classification, Type 3A1 is extra-articular and Type 3A2 is intra-articular [64]. In the Robinson classification, Type 3B1 is extra-articular and Type 3B2 is intra-articular [64]. Neer type II fractures are equivalent to Robinson type 3B fractures [160].

Other Considerations: A new simple classification system for lateral clavicle fractures showed substantial inter- and intraobserver reliability [102]. A new classification system for distal clavicle fractures demonstrated moderate interobserver and substantial intraobserver reliability [108].

Pediatric Lateral Clavicle Injuries

Dameron and Rockwood: The Dameron and Rockwood classification is used for injuries involving the lateral end of the clavicle and acromioclavicular joint in children [53]. In pediatric Type I lateral clavicle injuries, there is mild strain of the acromioclavicular ligaments with no disruption of the periosteal tube [53]. In pediatric Type II lateral clavicle injuries, the acromioclavicular ligaments are completely disrupted with partial damage to the superolateral aspect of the periosteal sleeve [53]. In pediatric Type III lateral clavicle injuries, there is complete disruption of the acromioclavicular ligaments and greater disruption of the periosteal sleeve, resulting in gross instability [53]. In pediatric Type IV lateral clavicle injuries, the lateral clavicle displaces posteriorly and can pierce the trapezius muscle and/or fascia [53]. In pediatric Type V lateral clavicle injuries, the superior aspect of the periosteal sleeve is completely disrupted, resulting in displacement of the distal clavicle through the trapezial fascia into the subcutaneous tissues [53]. In pediatric Type VI lateral clavicle injuries, the distal clavicle displaces inferiorly, with the distal end displaced inferior to the coracoid process [53]. In children, displacement of the lateral clavicle occurs through the periosteal sleeve rather than through the coracoclavicular ligaments [53]. Most injuries to the lateral end of the clavicle in the immature skeleton are fractures involving the metaphyseal or physeal regions, specifically Salter-Harris type I or II fractures [53].

Medial (Proximal) Clavicle Fractures

Craig: Craig Group III fractures involve the proximal third of the clavicle [83]. Craig Group III Type I fractures involve minimal displacement [83]. Craig Group III Type II fractures are displaced with ligaments ruptured [83]. Craig Group III Type III fractures are intra-articular [83]. Craig Group III Type IV fractures involve epiphyseal separation in children and young adults [83]. Craig Group III Type V fractures are comminuted [83].

Clinical Presentation

Mechanism and Epidemiology

Clavicle fractures most commonly affect young, active, working individuals, with the majority occurring in males younger than 30 years [34]. These injuries typically result from a fall onto the shoulder or a direct blow to the shoulder, often in the setting of a fall [7, 34]. In the United States, the prevalence of clavicle fractures has remained relatively stable over the past decade, with football injuries representing the most common etiology [71]. Clavicular fractures account for 3.8% of all fractures and 35.0% to 45.0% of all shoulder girdle injuries [26]. Midshaft fractures constitute approximately 80% of all clavicle fractures, while distal third fractures account for approximately 15% and medial third fractures for 5% [26, 34]. In adolescent populations, clavicle fractures occur more commonly in males during sports, secondary to a direct blow to the shoulder, and on the nondominant side [125]. For adolescent lateral-end clavicle fractures, contact sport is the most common mechanism of injury, followed by cycling, falls, road traffic accidents, and direct blows [20]. Open clavicle fractures are rare injuries [22]. A small percentage of clavicular fractures are associated with more severe injuries, including scapulothoracic dissociation, scapular fractures, rib fractures, pneumothorax, and neurovascular compromise [26].

Physical Examination

When displacement occurs, the medial fragment typically displaces posterosuperiorly due to the pull of the sternocleidomastoid muscle, while the lateral fragment displaces inferomedially due to the pull of the pectoralis major and the weight of the arm [34]. This displacement pattern often results in a “Z” deformity [34]. A fall on the shoulder or the outstretched hand may fracture the clavicle; the lateral fragment is pulled down by the weight of the arm, while the medial fragment is held up by the sternomastoid muscle [11]. The fracture is often displaced, producing a lump along the ‘collar-bone’ [11]. Fractures of the outer third are easily mistaken for acromioclavicular injuries [11]. Vascular and neurological complications are rare [11]. A distal neurovascular examination is important because of the proximity of the brachial plexus and the subclavian vessels to the zone of injury [26]. Tenting of the skin should be evaluated carefully because it can be a sign of impending open fracture [26]. Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms [56]. Segmental fractures of the clavicle are easily missed [79]. The differential diagnosis of a fractured clavicle should be expanded to include idiopathic nontraumatic fractures [8].

Imaging

Upright and supine radiographs, including an AP view of the clavicle and a 15° cephalad tilt view, should be obtained to define displacement when the patient is upright [26]. A bilateral panoramic view of both shoulders should be obtained to measure clavicular shortening [26]. X-rays show that the fracture is usually in the middle third of the bone and the lateral fragment lies below the medial [11]. Outer-third injuries need special views to define any fracture [11]. Lateral clavicle fractures can be well visualized with AP radiographs using the Zanca view, which helps delineate the fracture by removing the overlap of the thoracic cage [170]. To accurately delineate the degree of lateral clavicle fracture displacement, radiographs should be taken with the patient standing and the arm unsupported by slings, braces, or the uninjured arm [178]. A stress view may be useful to determine the integrity of the coracoclavicular ligaments in lateral clavicle fractures [178]. CT scanning of lateral clavicle fractures is rarely required clinically but can be useful in selected cases to determine intra-articular extension or displacement [178]. For medial clavicle fractures, CT scanning is the procedure of choice [170]. Fractures of the medial clavicle, especially those involving the SC joint, are notoriously difficult to accurately assess with plain radiographs [178]. CT scanning is the radiographic procedure of choice when the anatomy of a medial clavicle fracture is unclear [178]. CT scanning can help distinguish between a medial epiphyseal fracture and true SC dislocations [178]. CT is the most accurate modality for determining fracture shortening and morphology but not typically obtained [26]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [16].

Complications and Sequelae

Although rare, limb or life-threatening neurovascular complications from clavicle surgery have potentially devastating implications for young, active patients who typically undergo surgical management of these fractures [15].

Investigations

Clinical Examination: Medial clavicle injuries in the pediatric population require evaluation both clinically and radiographically [210].

Plain radiography: Simple anteroposterior (AP) radiographs are usually sufficient to establish the diagnosis of a clavicle fracture [60]. In urgent trauma settings, the diagnosis may be made from a single AP chest radiograph, which may be the only available film [60]. This view allows evaluation of deformity relative to the normal side and identification of associated skeletal injuries, including rib, glenoid, and scapular fractures [60]. Length measurement comparing the injured to the uninjured side can be performed on the chest radiograph, where shortening of 2 cm or more represents a relative indication for primary fixation [60].

To determine whether operative intervention is warranted, a radiograph should be taken in the upright position to demonstrate maximal deformity [60]. Upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected [215]. An upright chest radiograph is specifically indicated to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management [222].

For optimal imaging technique, the radiographic beam for the AP radiograph of the clavicle should be angled 20 degrees superiorly to eliminate thoracic cage overlap and show the clavicle in profile [60]. If the torso is internally rotated a similar 20 degrees, the scapula and shoulder girdle are placed parallel to the cassette for a true AP film [60]. Alternatively, a PA 15° caudad radiograph is recommended for imaging fractures of the clavicle [224].

Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons [227]. Consequently, when clavicle shortening is considered in the decision to pursue operative management, the use of plain radiograph-based measurements is not recommended [225].

Computed Tomography: CT scanning of midshaft clavicular fractures is rarely performed in the clinical setting [60]. However, CT imaging can demonstrate the complex three-dimensional deformity affecting the shoulder girdle, including significant scapular angulation and protraction [60]. CT is useful for evaluating fractures of the medial third of the clavicle and the remainder of the shoulder girdle, such as the glenoid neck in cases of a “floating shoulder” [60].

Treatment

Non-Operative

Undisplaced middle-third clavicle fractures are managed conservatively, as accurate closed reduction is neither possible nor essential [11]. The standard of care involves supporting the arm in a simple sling until pain subsides, a process that typically takes 1–3 weeks [11]. While a figure-of-eight bandage is an alternative, comparative studies demonstrate no advantage over a simple sling for displaced midshaft fractures [43]. Patients report less discomfort and fewer complications with a simple sling, whereas the figure-of-eight bandage is associated with higher pain scores and no difference in clavicular shortening [43]. For nondisplaced fractures, treatment consists of a simple sling until healing is confirmed by radiographs and clinical assessment [138]. Active shoulder exercises should be encouraged once pain subsides, particularly in older patients [11]. Nonoperative care generally includes a standard arm sling for 6 weeks followed by physical therapy for strengthening once healing is evident [69].

Nondisplaced distal clavicle fractures (Neer types I, III, and IV) are treated nonoperatively with a sling [81, 90]. The earliest return to sports activity is generally around 2 months post-injury, though early return carries a risk of refracture or displacement [90]. These fractures involving the acromioclavicular joint carry an increased likelihood of chronic pain and posttraumatic arthrosis [90]. Medial third clavicle fractures are usually managed nonsurgically with an arm sling for comfort and shoulder immobilization for 2 to 6 weeks [190]. Shoulder range of motion begins as soon as pain subsides or becomes tolerable [190]. Contact sports should be avoided for at least 2 to 3 months to allow complete healing and rehabilitation [190]. If patients survive the initial trauma, good clinical and functional outcomes are expected regardless of management choice [1].

In adolescents, nonoperative management is the preferred approach for the majority of clavicular fractures [36]. Teenage patients with completely displaced fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively [23]. Significant radiographic remodeling occurs in teenagers, with improvements of 70% in shortening, 73% in superior displacement, and 83% in angulation [6]. Long-term follow-up confirms excellent functional outcomes for adolescent mid-shaft fractures treated nonoperatively [29]. Shortened midshaft fractures in adolescents also yield excellent outcomes after nonoperative treatment [72]. Comparably excellent outcomes for severe clavicular fractures in adolescent athletes are achievable with nonoperative care [109, 112]. Nonsurgical treatment of complete displaced clavicle fractures in adolescents achieves a good prognosis [142]. More than 90% of Pediatric Orthopaedic Society of North America members favor nonoperative treatment for nondisplaced and angulated midshaft fractures in the 12–19-year-old population [146]. Common nonoperative options include 2 to 4 weeks of shoulder immobilization with a simple sling [146].

Nonunion rates for nonoperative treatment of midshaft clavicle fractures in adolescents are low, reported as 0.1% to 0.4% [146]. Malunion may be observed radiographically without significant functional impairment in these patients [146]. For adults, the rate of nonunion for completely displaced mid-shaft fractures treated non-operatively is 15.1% according to a meta-analysis of 2144 fractures [133]. In a multicenter, prospective, randomized clinical trial, the non-union rate was 14% in the non-operative group for completely displaced middle third clavicle fractures [69]. Radiographic malunion was universal in this non-operative group [69]. Complications, including non-union and symptomatic malunion, were more frequent in the non-operative group [69]. A direct relationship exists between increased displacement and worse DASH scores in the non-operative group [69]. Nonoperative treatment of displaced midshaft clavicular fractures may result in higher nonunion rates [146].

Proportional shortening of 8% in nonoperatively treated clavicle fractures is not associated with impaired function or patient dissatisfaction [43]. This shortening did not significantly correlate with the DASH score, Constant score, or SF-12 score at any time during follow-up [43]. There was no correlation between proportional shortening of 8% and patient satisfaction [43]. Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and the risk of complications and delayed surgery is low [25]. Functional results after a distal clavicle fracture are excellent whether treated conservatively or surgically [73]. Nonsurgical treatment should be considered as an option to surgery for fully displaced lateral fractures of the clavicle more often [147].

Risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures are multifactorial [156]. A targeted approach is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union [132]. Specific treatment should not be broadly applied but individualized based on fracture characteristics and patient expectations [18]. Treatment must be tailored to each patient, considering the type of fracture, amount of displacement and comminution, age, level of activity, and aesthetic appearance of the shoulder [44]. Considerable disagreement between surgeons exists regarding the recommendation for surgery for midshaft clavicle fractures [198].

Operative

Indications: There is a growing trend towards internal fixation of acute clavicular fractures associated with severe displacement, fragmentation, or shortening [11]. Current evidence-based indications for surgical fixation of midshaft clavicular fractures include radiographic shortening of greater than or equal to 2 cm [164]. Indications also include displacement in a caudal/cephalad plane by equal to or greater than 100% or one bone width [164], and significant comminution [164]. Additional indications include open fractures [164], fractures with underlying neurovascular injury [164], and fractures that result in significant scapular malposition or winging [164]. Fracture-specific indications for operative treatment include displacement >2 cm [24], shortening >2 cm [24], increasing comminution (>3 fragments) [24], and segmental fractures [24]. Other fracture-specific indications are open fractures [24], impending open fractures with soft tissue compromise [24], obvious clinical deformity [24], and scapular malposition and winging on initial examination [24]. Associated injury indications include vascular injury requiring repair [24], progressive neurologic deficit [24], ipsilateral upper extremity injuries/fractures [24], multiple ipsilateral upper rib fractures [24], “floating shoulder” [24], and bilateral clavicle fractures [24]. Patient factor indications include polytrauma with requirement for early upper extremity weight-bearing/arm use [24] and patient motivation for rapid return of function, such as elite sports or self-employed professionals [24]. Operative repair should be reserved for medically well, physically active patients who stand to benefit the most from a rapid restoration of normal anatomy and stable fixation [24]. For healthy, active adults, midshaft clavicular fractures should undergo consideration for surgical stabilization if significantly displaced (2 cm of shortening, 100% displacement or significant comminution) [68]. Most mid-shaft clavicle fractures can be treated effectively by non-operative means, but a select group of patients with completely displaced fractures, shortening of 2 cm or more, or specific indications benefit from surgical fixation [75].

Surgical Approach / Technique: Specific contoured locking plates are available for the treatment of displaced middle-third clavicle fractures [11]. The use of a pre-contoured plate facilitates surgical care, reducing hardware prominence and secondary surgical procedures [68]. Dual plating may be used as an adjuvant in highly comminuted clavicle fracture cases [68]. Dual plating with 2.4- or 2.7-mm plates may additionally have a benefit of decreased hardware prominence [68]. Outer-third clavicle fractures are quite troublesome and may need open reduction and internal fixation [11]. Parameters for the management of distal and medial clavicle fractures remain unclear and should be assessed on a case-by-case basis [68]. Fracture displacement and the development of nonunion may not, in isolation, affect outcome especially in the elderly for distal and medial clavicle fractures [68]. Floating shoulder injuries should be carefully assessed on the basis of component injuries individually because surgical management has not been shown to result in improved clinical outcomes [68].

Implant Selection: Surgical management of medial third clavicle fractures is usually reserved for fractures associated with injury to the mediastinal structures secondary to fracture displacement [190]. Fractures associated with injury to the mediastinal structures should be reduced fairly emergently, with an attempt at closed reduction [190]. Open reduction and internal fixation (ORIF) is sometimes necessary to maintain reduction of an unstable medial clavicle fracture [190]. Several techniques have been used for ORIF of displaced medial third clavicle fractures including wire fixation, plate-and-screw constructs, or interosseous sutures [190]. A recent study reported 100% union rate and excellent DASH functional outcome scores following surgical management of medial third clavicle fractures in 27 patients [190]. Surgical treatment consisted of transosseous sutures in 8 cases, and plate and screws fixation in 19 cases in this study [190]. The plate is very effective and safe for the management of medial clavicle fractures [114].

Other Considerations: An advantage of internal fixation for displaced middle-third clavicle fractures is that the patient can mobilize the arm and return to work and independence more quickly [11]. Surgical fixation for midshaft clavicle fractures has been shown to result in improved outcomes compared with non-operative measures in a select group of patients [75]. In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment [127]. Plate fixation significantly reduced nonunion, although not having a significant effect on final functional outcomes for displaced midshaft clavicle fractures [17]. Secondary surgical procedures were performed less often in the surgically treated group when excluding planned hardware removals [17]. When plate removal was included, revision surgeries were not different between surgical and nonoperative groups [17]. A systematic review of 22 randomized controlled trials showed decreased nonunion in surgically treated patients with a number needed to treat of 10 [17]. Risk of revision surgery across all treatment arms when including plate removal was the same for surgical and nonoperative management [17]. Surgical management outperformed nonsurgical management in both Disabilities of the Arm, Shoulder and Hand and Constant scores, although averages do not reach minimally clinically important difference at a minimum of 1-year posttreatment follow-up [17]. A number of prospective and/or randomized trials demonstrate some advantages to primary fixation, including a decreased delayed- and nonunion rate, a lower symptomatic malunion rate, and earlier return to function [39]. There is consistent evidence that the rates of malunion and nonunion are less with primary surgery [43]. There is essentially no evidence that primary surgical treatment improves final patient function [43]. Tamaoki et al. reported no difference in the DASH scores at 6 weeks, 6 months, and 1 year between operative and nonoperative groups [43]. Tamaoki et al. also reported no difference in pain levels, time to return to previous activities, and dissatisfaction with the cosmetic result [43]. Analysis of the DASH score favored operative management in a review of published evidence by Smeeing et al. [43]. The Canadian Orthopaedic Trauma Society found that outcome scores were significantly improved in the operatively managed group at all time points [43]. The Canadian Orthopaedic Trauma Society found a reduced union time and prevalence of nonunion in the operatively managed fractures [43]. The Canadian Orthopaedic Trauma Society advocated plate fixation of completely displaced midshaft clavicle fractures in active adult patients [43]. In a multicenter, prospective, randomized clinical trial, the operative group had significantly better Constant and DASH scores at all time points for completely displaced middle third clavicle fractures [69]. In this trial, the operative group was significantly more likely to be satisfied with their shoulder [69]. There was no significant difference between groups for range of motion [69]. Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome [28].

Most modern prospective studies examining the potential benefits of primary clavicle fracture fixation have been in adult patients, with 16 years of age the typical (arbitrary) lowest age of inclusion [24]. Adolescent patients can develop symptomatic malunion following nonoperative treatment of displaced midshaft fractures of the clavicle [24]. Nonunion remains rare in adolescent patients with displaced midshaft clavicle fractures [24]. In a retrospective study of 43 adolescent patients with displaced midshaft clavicle fractures, complications in the plate group were minor [24]. In this study, a more rapid return to function with a shorter time to union resulted in the plate group [24]. Five patients in the nonoperative group developed a symptomatic malunion [24]. Four patients in the nonoperative group chose corrective osteotomy [24]. The consensus is that operative intervention for adolescent clavicle fractures should be reserved for older, larger adolescents with severely displaced fractures [24].

Complications

General and Non-Operative

Malunion: Malunion is inevitable in displaced clavicle fractures [11]. In children, the bone is soon remodelled following malunion [11]. In adults, slight deformity from malunion has to be accepted unless there is a very unsightly bump with skin irritation [11]. Treating displaced middle-third fractures with shortening of more than 2 cm by simple splintage incurs a risk of symptomatic malunion, mainly pain and lack of power during shoulder movements [11]. Radiographic malunion was universal in the non-operative group for completely displaced middle third fractures in a randomized clinical trial [69]. In a retrospective study of 43 adolescent patients, 5 patients in the nonoperative group developed a symptomatic malunion [24]. Four of the five adolescents with symptomatic malunion chose corrective osteotomy [24].

Non-Union: Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates [25]. In a prospective study, non-union developed in 5% of cases, evenly distributed between the middle part and the acromial part of the clavicle [87]. The non-union rate was 14% in the non-operative group for completely displaced middle third fractures in a randomized clinical trial [69]. Factors predisposing to nonunion include inadequate initial immobilization after closed or open reduction [42], severity of fracture displacement [42], and primary open reduction of the fracture [42]. Inadequate immobilization of clavicular fractures favors the development of nonunions [42]. In a study of 16 patients with midshaft clavicular nonunions, 8 were noncompliant with the initial immobilization of 21 days [42]. Children rarely present with posttraumatic clavicular nonunions [42]. Shortening of greater than 2 cm has been reported as a risk factor for nonunion and malunion [167]. Final shortening of greater than 2 cm was associated with a nonunion rate of 15% and subsequent poor outcomes [167]. A nonunion rate of 21% was noted for fractures with greater than 2 cm of shortening [167].

Symptoms and Sequelae: In a prospective study of 222 patients, sequelae from clavicular fractures were common [5]. Treating displaced middle-third fractures with shortening of more than 2 cm by simple splintage incurs an increased incidence of non-union [11]. The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively [93]. In a study of 208 patients with 9–10 year follow-up, 46% of patients had residual symptoms, especially those with no bony contact and those with comminuted fractures [167]. In a study of 252 clavicle fractures, 31% of patients with completely displaced midshaft fractures had residual symptoms [167]. Complications, including non-union and symptomatic malunion, were more frequent in the non-operative group compared to the operative group in a randomized clinical trial of displaced midshaft fractures [69]. There was a direct relationship in the non-operative group between increased displacement and worse DASH score [69]. Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates compared to operative treatment [12]. The authors recommend a more prolonged surveillance period in children with recurrent fractures of the clavicle [40].

Operative

General Complications: The overall 30-day complication rate following ORIF for clavicle fractures was 1.9% [101]. Surgical treatment of midshaft clavicle fractures is associated with a slightly higher incidence of complications compared with the nonoperative approach [74]. Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures [118]. Although rare, limb or life-threatening neurovascular complications from clavicle surgery have potentially devastating implications for young, active patients [15].

Implant-Related Issues: In a randomized study of 56 patients with plate and 62 patients with intramedullary nails, the percentage of patients reporting implant irritation was 70% for plates and 66% for intramedullary nails [17]. Intramedullary fixation was associated with a higher likelihood of implant removal (82%) compared to plate fixation (50%) [17]. In a study comparing operative and nonoperative care, 11 of 62 operative patients reported hardware irritation or prominence [39]. In a study comparing operative and nonoperative care, 18 of 62 operative patients reported incisional numbness [39]. In a study comparing operative and nonoperative care, 9 of 62 operative patients reported a sensitive or painful fracture site [39]. In a study comparing operative and nonoperative care, 3 of 62 operative patients reported a scar complaint [39].

Specific Techniques and Populations: In a retrospective study of 43 adolescent patients, complications in the plate group were minor [24]. Plate fixation does not predispose to nonunion and is not associated with any significant complications [180]. A limited incision approach for plating of acute midshaft clavicle fractures achieved a low complication rate comparable to the reported rate for standard incision techniques [62]. The technique of clavicle pinning resulted in minimal complications [129]. Operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected adolescent cases [36]. In a study of 16 patients with midshaft clavicular nonunions treated with plate fixation and autologous bone grafting, there was only one failure [42]. In a study of 16 patients with midshaft clavicular nonunions treated with plate fixation and autologous bone grafting, two patients were dissatisfied with the final cosmetic outcome [42].

Associated Injuries and Specific Pathologies

High-Energy Trauma: Associated injuries are increasingly common in patients with fractures of the clavicle compared to older traditional studies [45]. Patients with clavicle fractures from high-energy vehicular trauma are more likely to have associated injuries to the thoracic cage, including ipsilateral rib fractures, scapular and/or glenoid fractures, proximal humeral fractures, and hemo/pneumothoraces [45]. Studies from Level 1 trauma centers have noted a high mortality rate (20% to 34%) from associated chest and head traumas in polytrauma patients with clavicle fractures [45]. Multiple ipsilateral rib fractures may be associated with higher rates of poor outcome in the associated clavicle fracture [45].

Penetrating Trauma: The clavicle can be injured from penetrating trauma including projectiles, blasts, and sword or machete blows [45]. In a case of a high-velocity bullet injury, the bullet fractured the humerus, shattered the clavicle, lacerated the subclavian vein and artery causing life-threatening hemorrhage, and came to rest in the soft tissues of the neck [45].

Iatrogenic and Post-Operative Fractures: Ipsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall [189]. Women reported higher rates of distal clavicle fracture in the postoperative period following acromioclavicular joint reconstruction [141]. The high fracture rate in the female cohort (90 days, 19.6%) following acromioclavicular joint reconstruction highlights a potentially under-recognized clinical consideration [141]. Clavicle and coracoid fractures occurred in 1.9 out of 100 cases of operative acromioclavicular joint separations [78].

Other Considerations: The results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome following clavicle fracture [10].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: Surgical treatment of midshaft clavicle fractures leads to better shoulder functional scores at short- and long-term follow-up despite a slightly higher incidence of complications [74]. The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup [153]. Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment [50]. Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures [144]. A limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to the reported rate for standard incision techniques [62]. The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern [57].

Other Considerations: Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among patients who survive the trauma [31]. A high proportion of patients with medial clavicle fractures will die within 3 years of the injury [31]. Sixty-eight patients with medial clavicle fractures identified over a 5-year period demonstrated excellent functional results following conservative management [41]. The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after trauma when midshaft clavicle fractures were treated conservatively [93]. Clavicle fractures do not increase the occurrence of later subacromial pain syndrome, and results do not suggest protraction of the scapula as a major risk factor for the development of subacromial pain syndrome [10]. Segmental resection of the clavicle appears justified due to the absence of functional consequences observed at the longest follow-up [151].

Significant remodeling was observed in teenagers treated nonoperatively for completely displaced midshaft clavicular fractures, with improvements of 70% in shortening, 73% in superior displacement, and 83% in angulation [6]. Shortened midshaft clavicular fractures had excellent outcomes after nonoperative treatments [72]. The functional results after a distal clavicle fracture will be excellent after conservative treatment [73]. Ninety-five percent of clavicle fractures healed uneventfully, while non-union developed in 5% of cases [87]. Follow-up radiographs at 10 months demonstrated a healed clavicle fracture with improvement in the degree of angulation and minimal distal clavicle osteolysis in a patient with Type VI acromioclavicular separation and middle-third clavicle fracture [4]. Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management [98].

Surgical treatment of midshaft clavicle fractures significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach [74]. Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks [232]. Carefully indicated adolescent patients undergoing ORIF of clavicle fractures can return to play more quickly than previously thought [96]. The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union [205].

An observed association with a tendency toward scapular protraction may provide insight into glenohumeral internal rotation deficit after operative treatment of mid-shaft clavicle fractures [21]. Risk factors for nonunions of lateral clavicle fractures include early mechanical stress, a lateral clavicular fragment larger than 3 cm, and time delay to surgery [228]. A fracture involving the upper one-third of the ribs significantly increases the rate of the clavicle fracture being > 100% displaced on early follow-up [214].

Key Evidence

• [L5] If patients with medial clavicle fractures can survive the initial trauma, there is every reason to expect good clinical and functional outcomes, regardless of whether surgical or nonsurgical management is chosen. [1] (10.1097/corr.0000000000001916)
• [L3] Initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. [2] (10.5435/jaaos-d-16-00130)
• [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. [3] (10.1016/j.jse.2018.01.004)
• [L5] Follow-up radiographs at 10 months demonstrated a healed clavicle fracture with improvement in the degree of angulation and minimal distal clavicle osteolysis. [4] (10.1097/00042752-200209000-00011)
• [L2] The risk for persistent symptoms following nonoperative treatment of clavicular fractures was far higher than expected. [5] (10.1080/17453670510041475)
• [L4] Significant remodeling was observed across all measurements, with improvements of 70% in shortening, 73% in superior displacement, and 83% in angulation. [6] (10.1177/03635465241228818)
• [L5] The authors suggest the differential diagnosis of a fractured clavicle should be expanded to include idiopathic nontraumatic fractures. [8] (10.1097/01.blo.0000203465.12690.db)
• [L3] Most patients with clavicle fractures have an excellent outcome using conservative management. [9] (10.1016/j.jse.2019.06.022)
• [L4] The results do not suggest protraction of the scapula as a major risk factor for the development of SAPS. [10] (10.1016/j.xrrt.2024.01.008)
• [L2] Nonoperative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes compared to operative treatment. [12] (10.1177/2325967119s00428)
• [L4] [14] (10.3109/17453674.2010.480939)
• [L5] Although rare, limb or life-threatening neurovascular complications from clavicle surgery have potentially devastating implications for young, active patients who typically undergo surgical management of these fractures. [15] (10.1097/bte.0000000000000097)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. [16] (10.5435/jaaos-d-17-00598)
• [L5] Specific treatment of clavicle fractures should not be broadly applied but rather should be individualized based on fracture characteristics and patient expectations. [18] (10.1016/j.jse.2011.08.053)
• [L4] [20] (10.1177/17585732221131922)
• [L4] The observed association with a tendency toward scapular protraction may provide insight into this phenomenon. [21] (10.1186/s13018-026-06856-7)
• [L4] Open clavicle fractures are rare injuries. [22] (10.1097/bot.0b013e31821c0b7f)
• [L2] Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. [23] (10.1177/2325967123s00041)
• [L4] Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. [25] (10.1016/j.jse.2023.12.006)
• [L4] Operative treatment of displaced medial clavicle fractures provides an excellent long-term functional outcome. [28] (10.1007/s00068-018-1024-6)
• [L3] Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. [29] (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
• [L4] Clavicle fixation is a safe and effective procedure in the pediatric population with a lack of serious complications. [30] (10.1177/2325967119s00056)
• [L4] Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. [31] (10.1097/corr.0000000000001839)
• [L1] This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two standardised treatment options for dislocated midshaft clavicular fractures. [33] (10.1186/1471-2474-12-196)
• [L1] [34] (10.5435/jaaos-d-23-00472)
• [L4] Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively, although operative treatment with plate and screw application has consistently good outcomes with a low complication rate in selected cases. [36] (10.2106/jbjs.22.01036)
• [L5] The authors recommend a more prolonged surveillance period in children with recurrent fractures of the clavicle. [40] (10.1097/bpb.0000000000000231)
• [Paper] Sixty eight patients with medial clavicle fractures were identified over a 5 year period, with excellent functional results seen following conservative management. [41] (10.1016/j.injury.2016.06.011)
• [L4] [42] (10.1016/s1058-2746(95)80017-4)
• [L3] Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. [50] (10.1016/j.otsr.2017.03.021)
• [L3] Complication rates following surgical clavicle fracture care averaged 8.1%. [52] (10.1186/s12891-022-05075-5)
• [L4] These findings do not support routine operative reduction and fixation of shortened midshaft clavicular fractures based on the argument of functional outcome. [54] (10.3109/17453674.2015.1040982)
• [L4] Clinicians must carefully examine patients with isolated clavicle fractures for concomitant injuries to the ipsilateral shoulder girdle, particularly in the context of compression mechanisms. [56] (10.1177/03635465000280062301)
• [L4] The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. [57] (10.1016/j.jse.2020.10.006)
• [L5] In this large cohort with long-term follow-up, a limited incision approach for plating of acute midshaft clavicle fractures achieved good functional and radiographic outcomes with a low complication rate comparable to the reported rate for standard incision techniques. [62] (10.1016/j.jse.2025.06.002)
• [L4] [64] (10.5435/00124635-201107000-00002)
• [L3] Displaced midshaft clavicular fractures with the intent of achieving 'good' outcome must be managed non-operatively. [67] (10.1016/j.injury.2020.10.019)
• [L3] The prevalence of clavicle fractures in the United States population has been relatively stable over the past 10 years, with football injuries being the most common etiology. [71] (10.1016/j.xrrt.2025.05.023)
• [L3] Shortened midshaft clavicular fractures had excellent outcomes after both operative and nonoperative treatments. [72] (10.1097/bpo.0000000000000627)
• [L4] The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment. [73] (10.1016/j.injury.2010.09.036)
• [L1] Surgical treatment of midshaft clavicle fractures significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. [74] (10.1177/0363546519826961)
• [L3] This review demonstrated an incidence of 1.35 complications per 100 person-years, with clavicle and coracoid fractures occurring in 1.9 out of 100 cases. [78] (10.1177/2325967121s00330)
• [Case_report] The case highlights that segmental fractures of the clavicle are easily missed. [79] (10.1177/1758573214564496)
• [Paper] Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). [81] (10.2106/jbjs.rvw.25.00260)
• [L4] The clavicle is essential for positioning the scapula during arm movement and transmitting forces of attached muscles. [82] (10.1016/s1058-2746(99)90161-1)
• [L4] No difference in reoperation rates between plate types or location could be detected, and excellent functional outcomes continue to be observed several years after clavicle fracture fixation. [85] (10.1016/j.injury.2014.04.032)
• [Paper] [86] (10.1067/mse.2003.2)
• [L3] Ninety-five percent of fractures healed uneventfully, while non-union developed in 5% of cases, evenly distributed between the middle part and the acromial part of the clavicle. [87] (10.1016/s0020-1383(99)00312-5)
• [L5] The optimal management of type II distal clavicle fractures remains controversial, with many authors advocating surgical intervention due to a nonunion rate that has generally averaged 30%. [88] (10.1016/s0278-5919(02)00108-4)
• [L4] In our unit there is no clearly favoured method of internal fixation of lateral clavicle fractures. [89] (10.1007/s00590-021-03173-z)
• [Case_report] Although ORIF of displaced midshaft clavicle fractures remains controversial in the adolescent population, there may be additional circumstances beyond absolute indications for surgical intervention that warrant ORIF at initial presentation. [91] (10.1016/j.xrrt.2023.03.004)
• [L4] The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. [93] (10.1186/s13018-023-04450-9)
• [L4] [94] (10.1007/s00068-019-01122-4)
• [L3] These data suggest that carefully indicated adolescent patients undergoing ORIF of clavicle fractures can RTP more quickly than previously thought. [96] (10.1177/23259671251374299)
• [L1] Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. [98] (10.2106/jbjs.19.00955)
• [L4] The overall 30-day complication rate following ORIF for clavicle fractures was 1.9 %, with 128 patients experiencing adverse events out of a cohort of 6753 patients. [101] (10.1016/j.injury.2024.111883)
• [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. [102] (10.1016/j.jse.2025.04.021)
• [L5] The modified Neer classification remains the predominantly cited classification system for distal clavicle fractures, yet its intra- and interobserver reliability has been demonstrated to be inconsistent, which can lead to incorrect treatment choices and misclassifications in research. [106] (10.1097/corr.0000000000001456)
• [L3] The study demonstrated moderate interobserver and substantial intraobserver reliability of the new classification system and the associated treatment choice for distal clavicle fractures. [108] (10.1016/j.otsr.2018.05.015)
• [L2] Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment. [109] (10.1177/03635465231219248)
• [L2] Comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment. [112] (10.1177/2325967121s00214)
• [L5] We conclude that the plate is very effective and safe for the management of medial clavicle fractures. [114] (10.1097/bte.0000000000000006)
• [L3] Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. [118] (10.1016/j.jse.2016.01.028)
• [L4] [123] (10.1016/j.ocl.2009.12.005)
• [L3] The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair, and additional 3D CT did not improve the overall level of interrater or intrarater agreement of the classification system or associated treatment choice. [124] (10.1177/0363546515593949)
• [L4] Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. [125] (10.1177/2325967120921344)
• [L2] In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. [127] (10.1016/j.jse.2013.06.025)
• [L4] The technique of clavicle pinning resulted in minimal complications, short hospital stay and excellent functional outcomes. [129] (10.4103/0973-6042.57895)
• [L5] A targeted approach to the management of mid-shaft clavicle fractures is needed, with simple fractures treated nonoperatively and complex displaced fractures considered for surgery to prevent non-union. [132] (10.1016/j.injury.2020.11.066)
• [L1] [133] (10.1302/0301-620x.97b11.35588)
• [L4] Nondisplaced clavicle fractures continue to be treated conservatively with a simple sling until the fracture is healed according to radiographs and clinical assessment. [138] (10.3810/psm.2011.09.1930)
• [L3] Women reported higher rates of distal clavicle fracture in the postoperative period, and the high fracture rate in the female cohort (90 days, 19.6%) highlights a potentially under-recognized clinical consideration. [141] (10.1002/ars2.70063)
• [L4] Nonsurgical treatment of complete displaced clavicle fractures in adolescents can achieve a good prognosis. [142] (10.1177/03635465241275671)
• [L3] Patients reported a good quality of life and functional outcome after plating for midshaft clavicular fractures. [144] (10.1016/j.injury.2017.10.032)
• [L5] [146] (10.5397/cise.2025.00500)
• [L3] Nonsurgical treatment should be considered as an option to surgery for fully displaced lateral fractures of the clavicle more often. [147] (10.1016/j.injury.2024.111422)
• [L5] Segmental resection of the clavicle allows avoiding recurrences and appears justified due to the absence of functional consequences observed at the longest follow-up. [151] (10.1016/j.main.2006.08.004)
• [L1] The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup. [153] (10.1007/s11999-011-1915-x)
• [L3] The risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures are multifactorial. [156] (10.1016/j.otsr.2014.11.018)
• [L4] Midshaft clavicular fractures should be classified according to the Robinson classification on two-plane radiography to optimize treatment decisions. [157] (10.1016/j.clinimag.2014.07.012)
• [L4] [160] (10.1302/0301-620x.95b7.31316)
• [Paper] [167] (10.1097/01.bte.0000187285.99726.0e)
• [L5] There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents due to concerns about symptomatic malunion and poor functional outcomes with nonsurgical management, though definitive indications for fixation in this population remain unclear. [175] (10.5435/00124635-201301000-00002)
• [L4] In our experience plate fixation does not predispose to nonunion, restores the length of the clavicle, and is not associated with any significant complications. [180] (10.1016/1058-2746(93)90077-t)
• [L1] This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. [181] (10.1177/1758573218777996)
• [L5] [183] (10.1007/s10140-018-1586-y)
• [L3] Both procedures can be used to treat distal clavicle fractures because they have a minimal risk of complications and present similar, high union rates. [186] (10.1016/j.jseint.2021.05.007)
• [L3] Ipsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall. [189] (10.1016/j.injury.2016.12.021)
• [L3] While most distal clavicle fracture fixation methods can achieve stable union, there is a highly variable complication profile associated with each fixation method. [191] (10.1016/j.otsr.2019.03.012)
• [L4] Considerable disagreement between surgeons exists regarding recommendation for surgery for midshaft clavicle fractures. [198] (10.1016/j.jse.2025.06.023)
• [L4] The prognosis for obtaining bony union after infected clavicle fractures is poor, with only two of six patients achieving union. [205] (10.1097/01.blo.0000183088.60639.05)
• [L5] Medial clavicle injuries in the pediatric population must be evaluated both clinically and radiographically using chest, clavicle, and serendipity views as well as CT scan. [210] (10.1097/bot.0b013e3181aa7d3d)
• [L2] In addition, a fracture involving the upper one-third of the ribs significantly increases the rate of the clavicle fracture being > 100% displaced on early follow-up. [214] (10.1097/bot.0000000000000758)
• [L4] This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected. [215] (10.1097/bot.0000000000000129)
• [L4] An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management. [222] (10.1097/bot.0000000000000727)
• [L4] We recommend the PA 15° caudad radiograph for imaging fractures of the clavicle. [224] (10.1067/mse.2003.25)
• [L4] When clavicle shortening is considered in the decision to pursue operative management, the use of plain radiograph-based measurements is not recommended. [225] (10.4055/cios.2016.8.4.367)
• [L3] Standard plain unilateral radiographs of the clavicle are insufficient to reliably determine the degree of shortening of clavicle fractures and the need for surgery among shoulder/sports medicine fellowship–trained orthopaedic surgeons. [227] (10.1177/0363546514523926)
• [L4] Risk factors for nonunions include early mechanical stress, a lateral clavicular fragment larger than 3 cm, and time delay to surgery. [228] (10.1007/s00402-018-3075-x)
• [L4] Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. [232] (10.1177/0363546510372795)

See Also

• Fractures
• Clavicle Fracture Fixation
• Soft Tissue Structures
• Internal Fixation
• Distal Clavicle Osteolysis

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[228] Which lateral clavicle fractures can be treated by an arthroscopic-assisted endobutton procedure? An analysis of risk factors. Archives of Orthopaedic and Trauma Surgery. 2018. DOI: 10.1007/s00402-018-3075-x

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