14 - Fractures of the clavicle

Abstract

The treatment of clavicle fractures remains controversial. While most clavicle fractures can and should be treated nonoperatively with a sling, a subgroup of patients with displaced fractures clearly benefit from primary fracture fixation. There have been high-quality, randomized clinical trials describing the benefits of surgical fixation in this group, including faster time to union, more rapid return of function, lower nonunion rates, lower symptomatic malunion rates, and improved overall functional outcomes, although the magnitude and duration of functional improvement are debatable. Thus, the incidence of surgical fixation of clavicle fractures is increasing, especially in the active, younger, athletic population; the increase is justified by a faster return to previous activity level and decreased time to recovery. While both plates and intramedullary devices are utilized for fixation, at the present time the most popular choice of implant for the treatment of clavicle fractures, nonunions, and symptomatic malunions is a precontoured plate. Precontoured clavicle plates are more anatomic than straight plates, decrease the requirement for intraoperative contouring, decrease soft tissue irritation, and reduce rates of reoperation for hardware removal, while maintaining biomechanical strength similar to compression plates. Neurovascular complications during fixation are very rare and may be avoided through knowledge of the anatomy of the clavicle and the surrounding structures, and careful surgical technique. Current controversies include the specific indications for primary surgical intervention, the treatment of adolescent clavicle fractures, the position of plate application, and the role of intramedullary fixation. Further prospective studies should help elucidate the answers to these questions.