Clavicle fractures (AO Surgery Reference)

Gathered by: Dr Zaky

Telegram: @Dr_Zaky_Ortho

Clinical and radiological examination

Medial clavicle

Extraarticular
Extra articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1A fractures.

Articular
Partial articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1B fractures.

Complete articular
Complete articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1C fractures.

Diaphyseal clavicle
Simple

Spiral
The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary...
Oblique
The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary...

Transverse
The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary...

Wedge

Intact spiral wedge

The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary...

Intact bending wedge

The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary...

Fragmentary wedge
The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary...

Multifragmentary
Fragmentary spiral
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental,...

Intact segmental
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental,...

Fragmentary segmental
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental,...

Lateral clavicle
Undisplaced, CC intact

Extraarticular
An impacted or undisplaced extra articular fracture with intact coraco-clavicular ligaments is classified as
AO/OTA 15.3A(a) fracture. The ligaments may be...

Articular
An impacted or undisplaced articular fracture with intact coraco-clavicular ligaments is either classified as
AO/OTA 15.3B(a) in case of a partial articular...

Displaced, CC intact
Extraarticular
Injuries that are characterized by a fracture line which starts medial to the coraco-clavicular ligaments and runs
superolaterally are classified as 15.3A(a). While...

Fragmentary
The fracture pattern in which the coracoclavicular ligaments avulse with a significant fragment of bone from
the clavicle is classified as an AO/OTA 15.3A(a)...

Displaced, CC disrupted

Extraarticular
A fracture which starts lateral to the CC ligaments and runs superiorly and does not affect the AC joint surface
is classified as an AO/OTA 15.3A(c) fracture.

Articular
A fracture which starts medial to the CC ligaments and runs superio laterally into the AC joint is classified as
an AO/OTA 15.3B(c) fracture.

Clinical and radiological examination

1/3 – General considerations
2/3 – Clinical examination
3/3 – Radiographic assessment

1. General considerations
Any signs and symptoms involving the shoulder region require an additional focused evaluation to assess distal
pulses, motor and sensation, as well as active and passive shoulder motion where possible. Any potential
associated injuries of the entire shoulder girdle and upper extremity should be considered followed by a
focused clinical examination of the clavicle and shoulder.

Fractures of the medial end of the clavicle

Recognition of significantly displaced fractures, especially in the posterior or retrosternal direction requires
urgent assessment and treatment due to potential injuries to the underlying neurovascular structures and airway.
Medial end fractures are often missed. These fractures are rare and may present as stress fractures from
repetitive strain/activity in pathologic or osteoporotic bone, or from high energy blunt/penetrating trauma with
multisystem injuries. These patients may have increased mortality due to the severity of their other life-
threatening injuries.

2. Clinical examination
Clinical assessment starts with inspection of the clavicle and shoulder. The skin is assessed for any tenting or
open wounds.

Shortening of the clavicle can be identified by comparison to the opposite intact side by comparing the distance
between two fixed bony landmarks such as the medial end of the clavicle (which is easily palpable) and the
acromioclavicular joint.

Asymmetric shoulder drooping may also be evident.

Anterior rotational deformity may be indicated by the presence of ptosis of the shoulder and/or scapular
winging.

3. Radiographic assessment
After the patient’s clinical status has been established and stabilized, x-ray examination of the injured shoulder
is mandatory. AP X-rays of the clavicle may underestimate the degree of injury or displacement.

To access radiographically the entire clavicle, specific views are required depending on the location of the
injury.

AP view

Medial
Shaft
Lateral
30° cephalad (Serendipity) view

Medial
Shaft

This illustration shows the typical sternoclavicular dislocation patterns seen in a serendipity projection.
For medial end clavicle injuries, CT imaging is often obtained to access better the fracture in the axial plane i.e.
posterior/retrosternal displacement which is difficult to access on plain radiographs.

Medial, extraarticular clavicle fracture

Extra articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1A fractures.

Definition: The medial end is the segment of the clavicle involving the costoclavicular ligament.

Medial, extraarticular clavicle fracture

An acute posterior sternoclavicular dislocation can be a life threatening situation and an immediate reduction in
the operating room should be undertaken as a potential life-saving procedure.
Nonoperative treatment

Main indications
Undisplaced fracture

Reduction of sternoclavicular dislocation

Main indications
Posterior or superior displaced fracture

Nonoperative treatment of clavicle fractures

Medial, extraarticular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.
Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand
Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Reduction of sternoclavicular dislocation

Medial, extraarticular clavicle fracture

1/2 – Introduction
2/2 – Aftercare

1. Introduction
Fractures of the medial clavicle are often a result of a high energy mechanism and associated with a
multisystem polytrauma.

Although various techniques for surgical fixation have been reported (eg, suture/wire loop, hook plate,
periarticular plate, conventional plate, spanning plate), there is currently no standardized operative procedure
for these very rare injuries, which are predominantly treated nonoperatively.

A detailed description of any of these techniques is outside the scope of the surgery reference.

Posterior sternoclavicular dislocation

An acute posterior sternoclavicular dislocation can be a life-threatening situation and an immediate closed
reduction in the operating room should be undertaken as a potential life-saving procedure.
This 3D CT shows posterior sternoclavicular dislocation.

If a thoracic surgeon is available, he or she should be present from the very beginning of the procedure. Under
general anaesthesia with the patient in a supine position, and a bolster between the shoulder blades, the arm is
abducted and extended to allow the medial clavicle to reduce.
If this is unsuccessful, a sharp towel clip may be placed percutaneously on the medial end of the clavicle and a
very careful reduction maneuver with an anteriorly directed force is attempted.

Once reduced, the sternoclavicular joint is usually stable.

Anterior, Superior, Inferior dislocations

Other dislocations of the medial sternoclavicular joint (eg, anterior, superior, inferior) are non-life-threatening.
Although closed reduction maneuvers can be attempted, maintaining stable reduction is usually not possible.
Thus, expectant management with reassurance is given with appropriate rehabilitation.
2. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Medial, articular clavicle fracture

Partial articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1B fractures.

Definition: The medial end is the segment of the clavicle involving the costoclavicular ligament.
Medial, articular clavicle fracture
An acute posterior sternoclavicular dislocation can be a life threatening situation and an immediate reduction in
the operating room should be undertaken as a potential life-saving procedure.

Nonoperative treatment

Main indications
Undisplaced fracture

Reduction of sternoclavicular dislocation

Main indications
Posterior or superior displaced fracture

Nonoperative treatment of clavicle fractures

Medial, articular clavicle fracture
 1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Reduction of sternoclavicular dislocation

Medial, articular clavicle fracture
 1/2 – Introduction
2/2 – Aftercare

1. Introduction
Fractures of the medial clavicle are often a result of a high energy mechanism and associated with a
multisystem polytrauma.

Although various techniques for surgical fixation have been reported (eg, suture/wire loop, hook plate,
periarticular plate, conventional plate, spanning plate), there is currently no standardized operative procedure
for these very rare injuries, which are predominantly treated nonoperatively.

A detailed description of any of these techniques is outside the scope of the surgery reference.

Posterior sternoclavicular dislocation

An acute posterior sternoclavicular dislocation can be a life-threatening situation and an immediate closed
reduction in the operating room should be undertaken as a potential life-saving procedure.

This 3D CT shows posterior sternoclavicular dislocation.

If a thoracic surgeon is available, he or she should be present from the very beginning of the procedure. Under
general anaesthesia with the patient in a supine position, and a bolster between the shoulder blades, the arm is
abducted and extended to allow the medial clavicle to reduce.

If this is unsuccessful, a sharp towel clip may be placed percutaneously on the medial end of the clavicle and a
very careful reduction maneuver with an anteriorly directed force is attempted.

Once reduced, the sternoclavicular joint is usually stable.

Anterior, Superior, Inferior dislocations
Other dislocations of the medial sternoclavicular joint (eg, anterior, superior, inferior) are non-life-threatening.
Although closed reduction maneuvers can be attempted, maintaining stable reduction is usually not possible.
Thus, expectant management with reassurance is given with appropriate rehabilitation.

2. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Medial, complete articular clavicle fracture
Complete articular fractures of the medial end of the clavicle are classified as AO/OTA 15.1C fractures.

Definition: The medial end is the segment of the clavicle involving the costoclavicular ligament.

Medial, complete articular clavicle fracture

An acute posterior sternoclavicular dislocation can be a life threatening situation and an immediate reduction in
the operating room should be undertaken as a potential life-saving procedure.

Nonoperative treatment

Main indications
Undisplaced fracture

Reduction of sternoclavicular dislocation

Main indications
Posterior or superior displaced fracture

Nonoperative treatment of clavicle fractures

Medial, complete articular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
 Telegram: @Dr_Zaky_Ortho

A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Reduction of sternoclavicular dislocation

Medial, complete articular clavicle fracture
 1/2 – Introduction
2/2 – Aftercare

1. Introduction
Fractures of the medial clavicle are often a result of a high energy mechanism and associated with a
multisystem polytrauma.

Although various techniques for surgical fixation have been reported (eg, suture/wire loop, hook plate,
periarticular plate, conventional plate, spanning plate), there is currently no standardized operative procedure
for these very rare injuries, which are predominantly treated nonoperatively.

A detailed description of any of these techniques is outside the scope of the surgery reference.

Posterior sternoclavicular dislocation

An acute posterior sternoclavicular dislocation can be a life-threatening situation and an immediate closed
reduction in the operating room should be undertaken as a potential life-saving procedure.

This 3D CT shows posterior sternoclavicular dislocation.

If a thoracic surgeon is available, he or she should be present from the very beginning of the procedure. Under
general anaesthesia with the patient in a supine position, and a bolster between the shoulder blades, the arm is
abducted and extended to allow the medial clavicle to reduce.

If this is unsuccessful, a sharp towel clip may be placed percutaneously on the medial end of the clavicle and a
very careful reduction maneuver with an anteriorly directed force is attempted.

Once reduced, the sternoclavicular joint is usually stable.

Anterior, Superior, Inferior dislocations
Other dislocations of the medial sternoclavicular joint (eg, anterior, superior, inferior) are non-life-threatening.
Although closed reduction maneuvers can be attempted, maintaining stable reduction is usually not possible.
Thus, expectant management with reassurance is given with appropriate rehabilitation.

2. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal simple, spiral clavicle fracture
The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2A fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal simple, spiral clavicle fracture

Simple spiral fractures are common fractures of the clavicle. They are usually treated conservatively if there is
not a major displacement. Simple spiral fractures are not amenable to intramedullary fixation because of the
risk of telescoping effect.

Nonoperative treatment

Main indications
Shortening and displacement less than 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal simple, spiral clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Diaphyseal simple, oblique clavicle fracture

The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2A fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal simple, oblique clavicle fracture

Simple oblique fractures are common fractures of the clavicle. They can be treated conservatively or
operatively depending on the displacement and the functional demand of the patient. Plate or intramedullary
fixation is possible.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Lag screw with neutralization plate

Main indications
Shortening and displacement > 2 cm

ORIF - Compression plate with lag screw

Main indications
Shortening and displacement > 2 cm

Flexible intramedullary nail

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal simple, oblique clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.
Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.
The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Lag screw with neutralization plate

Diaphyseal simple, oblique clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Goal of treatment
The goal of treatment for a simple two part fracture of the shaft of the clavicle requires anatomical reduction
and absolute stability.

Note: This is the most common pattern. The deforming forces on the medial end is the pull of the muscles and
the deforming force on the lateral side is the weight of the upper extremity.

Beware of the major neurovascular bundle (subclavian artery, vein, and brachial plexus) running directly
beneath the midshaft of the clavicle.
 Telegram: @Dr_Zaky_Ortho

Other types of deformities may occur if the coracoclavicular ligaments are disrupted (eg, superior displacement
of the lateral fragment).

Lag Screw
The optimal inclination of the screw in relation to a simple fracture plane is 90°.
Neutralization plate
Lag screw fixation alone is typically insufficient to withstand the normal physiologic forces. A neutralization
plate is required for additional stability to distribute the forces and allow early mobilization.

Plate alternatives
We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built
into it.
However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.

Biomechanically, anterosuperior or anterior plates result in mechanically stronger fixation. The exact
placement of the plate will depend on the fracture pattern and the position of the fracture.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.
Approach
For this procedure an anterior approach is normally used.

3. Reduction and fixation

Reduction
Using the fracture interdigitations as a gauge for the reduction, obtain control over the proximal and distal
fragments using reduction clamps. Gentle traction using a lobster clamp on the lateral fragment or the free
draped arm, and a derotation force, typically to the lateral fragment will assist to anatomically reduce the
fracture.

Lag screw insertion(s)

Provisional stability is maintained with a pointed clamp followed by the insertion of one or more lag screws
(2.7 or 3.5).
 Basic technique: insertion of cortical lag screws

Plate application
The plate is secured with sufficient bicortical screws inserted in a neutral mode avoiding the previously
inserted lag screw.

Typically, a minimum of three bicortical screws in each segment is sufficient.

Note: Occasionally when the fracture location is more lateral or more medial, the bone quality near the
metaphysis may not offer sufficient screw purchase. In these instances, a plate offering additional screw
fixation may be required (eg, longer plate, periarticular plate, locking screws).
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

ORIF - Compression plate with lag screw

Diaphyseal simple, oblique clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Goal of treatment
The goal of treatment for a simple two-part fracture of the shaft of the clavicle is direct bone healing. This
requires anatomical reduction and absolute stability.

Note: This is the most common pattern. The deforming force on the medial end is the pull of the muscles and
the deforming force on the lateral side is the weight of the upper extremity.
Beware of the major neurovascular bundle (subclavian artery, vein, and brachial plexus) running directly
beneath the midshaft of the clavicle.

Other types of deformities may occur if the coracoclavicular ligaments are disrupted (eg, superior displacement
of the lateral fragment).

Plate and lag screw

Absolute stability can be optimally achieved by inserting a lag screw through the plate after primary axial
compression.
Plate alternatives
We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built
into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.

3. Reduction and fixation

Reduction
Using the fracture interdigitations as a gauge for the reduction, obtain control over the proximal and distal
fragments using reduction clamps. Apply gentle traction using a lobster clamp on the lateral fragment or the
free draped arm and a derotation force, typically to the lateral fragment, to anatomically reduce the fracture.
Maintaining provisional stability with an additional pointed clamp is helpful prior to the plate application. The
clamp is ideally placed away from any eventual screw and plate placement.

The use of K-wires to assist in reduction and temporary stability prior to plate application has been described.
However, this is not recommended as the surrounding vital neurovascular structures are in close proximity and
would be at risk for injury.

Plate application
The plate is then fixed with a single bicortical position screw medially or laterally depending on the fracture
pattern. The plate alignment and fracture reduction is confirmed.
A second eccentrically positioned screw is then applied on the opposite fragment in compression mode.

Lag screw insertion through the plate

If the fracture line is amenable to lag screw fixation through the plate, then further compression can be
achieved. Inserting the screw through the plate adds torsional stability.

Before fully tightening the lag screw, the axial compression has to be released slightly to allow additional
interfragmentary compression.
The loosened screw is then retightened.
Insertion of remaining screws
The remaining screws are then inserted in neutral position. Typically, a minimum of three bicortical screws in
each segment is sufficient.

Note: Occasionally when the fracture location is more lateral or more medial, the bone quality near the
metaphysis may not offer sufficient screw purchase. In these instances, a plate offering additional screw
fixation may be required (eg, longer plate, periarticular plate, locking screws).

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
 4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Flexible intramedullary nail

Diaphyseal simple, oblique clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Intramedullary nailing of the clavicle is reserved for young and highly active patients who are expected to
resume full active function soon after surgery.

It is also a procedure best reserved for bending- and fragmented-wedge fractures in the middle zone of the
clavicle

For technical reasons, other fracture patterns are not suitable for nailing.

This procedure is performed only under image intensifier guidance.

Intramedullary nailing
The goal of treatment for these types of fractures of the shaft of the clavicle is to achieve as anatomical
reduction as possible and then splint them with intramedullary fixation. The shape of the nail and the shape of
the bone maintain alignment and rotation. Shortening is prevented by bone contact.
Implant migration and damage to nearby neurovascular structures are potential complications that can be
encountered. However, it is a minimally invasive approach that requires less soft tissue dissection, preserves
blood supply and biology to improve healing.

Selection of pin
Stiff pins or thick K-wires should be avoided as the limited diameter of the intramedullary canal of the clavicle
and its curved anatomy presents inherent difficulties during insertion and stabilization of the fracture. Thus, the
procedure described will be with a flexible titanium intramedullary nail.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a nailing approach is used.

3. Reduction and fixation

For intramedullary nailing of clavicular fractures, the following reduction techniques are useful:

Shoulder manipulation with inline traction and an external rotation moment often helps to reduce the fracture.
(The shoulder should be draped free.)

Pointed reduction clamps can be used either percutaneously or through small stab incisions.
If a closed reduction cannot be achieved, a small incision directly over the fracture site to perform a limited
open reduction is helpful and often necessary.

Nail insertion
Using image intensifier, the entry point is obtained using a 2.5 mm drill bit in the anterior cortex of the medial
clavicle 1.5-2.0 cm lateral to the sternoclavicular joint.
The entry point is enlarged with a small awl in a lateral direction to allow for ease of insertion.

A 2.0 - 3.5 mm titanium elastic nail designed for intramedullary nailing, used for this or other applications, is
inserted then with the aid of the universal T-handle chuck. The nail is manually inserted with oscillating
movements under image intensifier control and advanced to the fracture site. If significant resistance is
encountered, reassess the position of the nail to redirect and complete the passage of the nail.
The tip of the nail has a slight curve, which will assist its passage into the lateral fragment.

The tip of the nail is advanced as far lateral as possible without perforating the cortex.
The medial end of the nail is then cut and buried subcutaneously or slightly proud depending on surgeon
preference.

A threaded end cap may be used and inserted over the medial end of the nail to prevent backing out of the nail.

Hardware removal is only indicated if the nail is prominent and threatening or irritating the overlaying soft
tissue at the entry point or perforating the far cortex.

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)
Full details on each phase can be found here.

Diaphyseal simple, transverse clavicle fracture

The AO/OTA classification does not further subdivide simple fractures of the diaphysis into subtypes (spiral,
oblique, or transverse), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2A fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal simple, transverse clavicle fracture

Simple transverse fractures of the clavicle are the most suitable fracture patterns for nailing. Transverse
fractures indicate a high-velocity trauma and careful examination for associated injuries should be performed.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Compression plate

Main indications
Shortening and displacement > 2 cm

Flexible intramedullary nail

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal simple, transverse clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Compression plate

Diaphyseal simple, transverse clavicle fracture

1/5 – Introduction
2/5 – Patient preparation and approach
3/5 – Reduction
4/5 – Fixation
5/5 – Aftercare

1. Introduction
Goal of treatment
The goal of treatment for a simple two-part fracture of the shaft of the clavicle requires anatomical restoration
of length, alignment and rotation.

In transverse and short oblique fractures of the diaphysis, placement of a lag screw is not always possible.
However, axial compression can be achieved using a compression plate.

Note: This is the most common pattern. The deforming force on the medial end is the pull of the muscles and
the deforming force on the lateral side is the weight of the upper extremity.

Beware of the major neurovascular bundle (subclavian artery, vein, and brachial plexus) running directly
beneath the midshaft of the clavicle.
Other types of deformities may occur if the coracoclavicular ligaments are disrupted (eg, superior displacement
of the lateral fragment).

Plate alternatives
We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built
into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.
Biomechanically, anterosuperior or anterior plates result in mechanically stronger fixation. The exact
placement of the plate will depend on the fracture pattern and the position of the fracture.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.

3. Reduction
Using the fracture interdigitations as a gauge for the reduction, obtain control over the proximal and distal
fragments using reduction clamps. Gentle traction and a derotation force, typically to the lateral fragment will
assist to anatomically reduce the fracture.

4. Fixation
The plate is applied to one of the main fragments with a single bicortical position screw. A reduction clamp is
placed on the opposite fragment.

A second screw is inserted eccentrically in the opposite fragment.

To increase axial compression, a second screw can be placed eccentrically.
When the second screw is tightened, the first screw needs to be loosened to allow further compression.

All other screws are inserted centrically and do not serve to increase compression.
5. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Flexible intramedullary nail

Diaphyseal simple, transverse clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Intramedullary nailing of the clavicle is reserved for young and highly active patients who are expected to
resume full active function soon after surgery.

It is also a procedure best reserved for bending- and fragmented-wedge fractures in the middle zone of the
clavicle

For technical reasons, other fracture patterns are not suitable for nailing.

This procedure is performed only under image intensifier guidance.

Intramedullary nailing
The goal of treatment for these types of fractures of the shaft of the clavicle is to achieve as anatomical
reduction as possible and then splint them with intramedullary fixation. The shape of the nail and the shape of
the bone maintain alignment and rotation. Shortening is prevented by bone contact.

Implant migration and damage to nearby neurovascular structures are potential complications that can be
encountered. However, it is a minimally invasive approach that requires less soft tissue dissection, preserves
blood supply and biology to improve healing.

Selection of pin
Stiff pins or thick K-wires should be avoided as the limited diameter of the intramedullary canal of the clavicle
and its curved anatomy presents inherent difficulties during insertion and stabilization of the fracture. Thus, the
procedure described will be with a flexible titanium intramedullary nail.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a nailing approach is used.

3. Reduction and fixation

For intramedullary nailing of clavicular fractures, the following reduction techniques are useful:

Shoulder manipulation with inline traction and an external rotation moment often helps to reduce the fracture.
(The shoulder should be draped free.)
Pointed reduction clamps can be used either percutaneously or through small stab incisions.

If a closed reduction cannot be achieved, a small incision directly over the fracture site to perform a limited
open reduction is helpful and often necessary.
Nail insertion
Using image intensifier, the entry point is obtained using a 2.5 mm drill bit in the anterior cortex of the medial
clavicle 1.5-2.0 cm lateral to the sternoclavicular joint.

The entry point is enlarged with a small awl in a lateral direction to allow for ease of insertion.
A 2.0 - 3.5 mm titanium elastic nail designed for intramedullary nailing, used for this or other applications, is
inserted then with the aid of the universal T-handle chuck. The nail is manually inserted with oscillating
movements under image intensifier control and advanced to the fracture site. If significant resistance is
encountered, reassess the position of the nail to redirect and complete the passage of the nail.

The tip of the nail has a slight curve, which will assist its passage into the lateral fragment.
The tip of the nail is advanced as far lateral as possible without perforating the cortex.

The medial end of the nail is then cut and buried subcutaneously or slightly proud depending on surgeon
preference.

A threaded end cap may be used and inserted over the medial end of the nail to prevent backing out of the nail.

Hardware removal is only indicated if the nail is prominent and threatening or irritating the overlaying soft
tissue at the entry point or perforating the far cortex.
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal wedge, intact spiral wedge clavicle

fracture
The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2B fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.
Diaphyseal wedge, intact spiral wedge clavicle
fracture
Intact spiral wedge fractures are not an indication for intramedullary nailing due to potential secondary
shortening.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Bridge plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal wedge, intact spiral wedge clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Bridge plate

Diaphyseal wedge, intact spiral wedge clavicle fracture
 1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Bridge plating
Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for
indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone
maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not
necessary.

Plate alternatives
A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is
significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which
has both a bend and a twist built into it.
However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).
Plate length
The goal when choosing the plate length is to reduce the concentration of bending forces. This typically
requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture
gaps.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.
3. Reduction and fixation
Reduction
Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction
by indirect means where possible.

The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be
acceptable in order to improve bone contact and avoid excessive gapping.

Plate application
The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well
tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned
anatomically with the lateral side of the plate.
The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.

A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is
unsuccessful.
Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal wedge, intact bending wedge clavicle
fracture
The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2B fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal wedge, intact bending wedge clavicle

fracture
This is the most common midshaft fracture and if significantly displaced, the best results are obtained by
means of an open reduction and open fixation.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

Flexible intramedullary nail

Main indications
Shortening and displacement > 2 cm

ORIF - Lag screw with neutralization plate

Main indications
Shortening and displacement > 2 cm

ORIF - Bridge plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal wedge, intact bending wedge clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time
Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Flexible intramedullary nail

Diaphyseal wedge, intact bending wedge clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Intramedullary nailing of the clavicle is reserved for young and highly active patients who are expected to
resume full active function soon after surgery.

It is also a procedure best reserved for bending- and fragmented-wedge fractures in the middle zone of the
clavicle

For technical reasons, other fracture patterns are not suitable for nailing.

This procedure is performed only under image intensifier guidance.

Intramedullary nailing
The goal of treatment for these types of fractures of the shaft of the clavicle is to achieve as anatomical
reduction as possible and then splint them with intramedullary fixation. The shape of the nail and the shape of
the bone maintain alignment and rotation. Shortening is prevented by bone contact.
Implant migration and damage to nearby neurovascular structures are potential complications that can be
encountered. However, it is a minimally invasive approach that requires less soft tissue dissection, preserves
blood supply and biology to improve healing.

Selection of pin
Stiff pins or thick K-wires should be avoided as the limited diameter of the intramedullary canal of the clavicle
and its curved anatomy presents inherent difficulties during insertion and stabilization of the fracture. Thus, the
procedure described will be with a flexible titanium intramedullary nail.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a nailing approach is used.

3. Reduction and fixation

For intramedullary nailing of clavicular fractures, the following reduction techniques are useful:

Shoulder manipulation with inline traction and an external rotation moment often helps to reduce the fracture.
(The shoulder should be draped free.)
Pointed reduction clamps can be used either percutaneously or through small stab incisions.

If a closed reduction cannot be achieved, a small incision directly over the fracture site to perform a limited
open reduction is helpful and often necessary.
Nail insertion
Using image intensifier, the entry point is obtained using a 2.5 mm drill bit in the anterior cortex of the medial
clavicle 1.5-2.0 cm lateral to the sternoclavicular joint.

The entry point is enlarged with a small awl in a lateral direction to allow for ease of insertion.
A 2.0 - 3.5 mm titanium elastic nail designed for intramedullary nailing, used for this or other applications, is
inserted then with the aid of the universal T-handle chuck. The nail is manually inserted with oscillating
movements under image intensifier control and advanced to the fracture site. If significant resistance is
encountered, reassess the position of the nail to redirect and complete the passage of the nail.

The tip of the nail has a slight curve, which will assist its passage into the lateral fragment.
The tip of the nail is advanced as far lateral as possible without perforating the cortex.

The medial end of the nail is then cut and buried subcutaneously or slightly proud depending on surgeon
preference.

A threaded end cap may be used and inserted over the medial end of the nail to prevent backing out of the nail.

Hardware removal is only indicated if the nail is prominent and threatening or irritating the overlaying soft
tissue at the entry point or perforating the far cortex.
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

ORIF - Lag screw with neutralization plate

Diaphyseal wedge, intact bending wedge clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
The goal of treatment for a wedge or multifragmentary fracture of the shaft of the clavicle requires restoration
of appropriate alignment and length of the clavicle. This may be achievable by absolute and/or relative
stability.

Note: This is the most common pattern. The deforming force on the medial end is the pull of the muscles and
the deforming force on the lateral side, by far the more important is the weight of the upper extremity.
Beware of the major neurovascular bundle (subclavian artery, vein, and brachial plexus) running directly
beneath the midshaft of the clavicle.

Other types of deformities may occur if the coracoclavicular ligaments are disrupted (eg, superior displacement
of the lateral fragment).

Lag screws
The optimal inclination of the screw in relation to a simple fracture plane is 90°.

If amenable, one lag screw should also be inserted through the plate, which will add torsional stability.
Neutralization plate
Lag screw fixation alone is typically insufficient to withstand the normal physiologic forces. A neutralization
plate is required for additional stability to distribute the forces and allow early mobilization.

Plate alternatives
We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built
into it. Its shape offers advantages.
However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anterosuperiorly. A reconstruction plate which is easier to contour
may be used in smaller patients where the forces working on the plate are not as great. It is too weak for larger
patients.

Biomechanically, anterosuperior or anterior plates result in mechanically stronger fixation. The exact
placement of the plate will depend on the fracture pattern and the position of the fracture.

Plate length
Plate length is determined by the fracture pattern and location. If possible 3 holes proximal and 3 holes distal to
the fracture region should be used.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.

3. Reduction and fixation

Plate application
The plate is fixed with a single bicortical position screw medially or laterally depending on the fracture pattern.
Lag screw insertion
If the fracture line of the wedge is amenable to lag screw fixation through the plate, optimal compression is
achieved. Inserting the screw through the plate adds torsional stability.

If the wedge cannot be fixed as above, then it should be reduced and fixed to each of the main fragments in
succession with smaller cortical screws used as lag screws.
The heads should be recessed as much as possible if they come to lie under the plate.
Another combination would be that the wedge is lagged to one of the main fragments and the other fracture
plane is placed under axial compression as described in the beginning of this section. The wedge depicted in
this illustration has subclavius attached to it and depends on the muscle for its viability. Thus, when fixing this
wedge with lag screws, outmost care must be taken not to devitalize the wedge.

Compression plating of remaining simple fracture

The fracture pattern is now reduced to a simple fracture.
A screw is inserted in the lateral segment in compression mode.

Further screws can then be inserted in the lateral segment in neutral mode.

Note: Occasionally when the fracture location is more lateral or more medial, the bone quality near the
metaphysis may not offer sufficient screw purchase. In these instances, a plate offering additional screw
fixation may be required (eg, longer plate, periarticular plate, locking screws).

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)
Full details on each phase can be found here.

ORIF - Bridge plate

Diaphyseal wedge, intact bending wedge clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Bridge plating
Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for
indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone
maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not
necessary.

Plate alternatives
A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is
significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which
has both a bend and a twist built into it.
However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).
Plate length
The goal when choosing the plate length is to reduce the concentration of bending forces. This typically
requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture
gaps.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.
3. Reduction and fixation
Reduction
Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction
by indirect means where possible.

The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be
acceptable in order to improve bone contact and avoid excessive gapping.

Plate application
The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well
tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned
anatomically with the lateral side of the plate.
The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.

A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is
unsuccessful.
Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal wedge, fragmentary wedge clavicle
fracture
The AO/OTA classification does not further subdivide wedge fractures of the diaphysis into subtypes (spiral,
bending or fragmented), but the treatment may vary depending of the fracture configuration.

They are all classified as AO/OTA 15.2B fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal wedge, fragmentary wedge clavicle

fracture
The wedge fragments are most often two small to address by a separate lag screw. In this case a bridging plate
is most often used.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Bridge plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal wedge, fragmentary wedge clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Bridge plate

Diaphyseal wedge, fragmentary wedge clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Bridge plating
Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for
indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone
maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not
necessary.
Plate alternatives
A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is
significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which
has both a bend and a twist built into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.
When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).

Plate length
The goal when choosing the plate length is to reduce the concentration of bending forces. This typically
requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture
gaps.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.

3. Reduction and fixation

Reduction
Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction
by indirect means where possible.
The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be
acceptable in order to improve bone contact and avoid excessive gapping.

Plate application
The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well
tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned
anatomically with the lateral side of the plate.

The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.
A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is
unsuccessful.

Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal multifragmentary, fragmentary spiral

clavicle fracture
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental, fragmented segmental), but the treatment may vary depending of
the fracture configuration.

They are all classified as AO/OTA 15.2C fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.
Diaphyseal multifragmentary, fragmentary spiral
clavicle fracture
The main goal treating these fractures is to restore length and rotation. Bridge plating is the most commonly
used technique. Nailing will not be a suitable option due to potential telescoping effect (shortening).

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Bridge plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal multifragmentary, fragmentary spiral clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Bridge plate

Diaphyseal multifragmentary, fragmentary spiral clavicle fracture
 1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Bridge plating
Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for
indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone
maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not
necessary.

Plate alternatives
A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is
significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which
has both a bend and a twist built into it.
However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).
Plate length
The goal when choosing the plate length is to reduce the concentration of bending forces. This typically
requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture
gaps.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.
3. Reduction and fixation
Reduction
Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction
by indirect means where possible.

The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be
acceptable in order to improve bone contact and avoid excessive gapping.

Plate application
The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well
tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned
anatomically with the lateral side of the plate.
The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.

A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is
unsuccessful.
Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.

4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal multifragmentary, intact segmental
clavicle fracture
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental, fragmented segmental), but the treatment may vary depending of
the fracture configuration.

They are all classified as AO/OTA 15.2C fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal multifragmentary, intact segmental

clavicle fracture
These complex injuries are often found in polytrauma patients. Full arm and shoulder use may be necessary for
essential mobilization of other injured areas (eg. to walk on crutches).

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Compression plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal multifragmentary, intact segmental clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
 Telegram: @Dr_Zaky_Ortho

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Compression plate

Diaphyseal multifragmentary, intact segmental clavicle fracture

1/2 – Introduction
2/2 – Aftercare

1. Introduction
In a segmental fracture, treat each with the fixation dictated by the fracture pattern.

2. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Diaphyseal multifragmentary, fragmentary segmental

clavicle fracture
The AO/OTA classification does not further subdivide multifragmentary fractures of the diaphysis into
subtypes (fragmented spiral, intact segmental, fragmented segmental), but the treatment may vary depending of
the fracture configuration.

They are all classified as AO/OTA 15.2C fractures.

Definition: The diaphysis of the clavicle extends from the attachment of the coracoclavicular ligament laterally
to the costoclavicular ligament medially.

Diaphyseal multifragmentary, fragmentary segmental

clavicle fracture
These fractures often results from high energy injury and a careful examination for associated injuries should
be performed. The main choice of treatment is between nonoperative treatment and bridging plate.

Nonoperative treatment

Main indications
Shortening and displacement < 2 cm

ORIF - Bridge plate

Main indications
Shortening and displacement > 2 cm

MIO - Bridge plate

Main indications
Shortening and displacement > 2 cm

Nonoperative treatment of clavicle fractures

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Bridge plate

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Bridge plating
Bridge plating (or biological plating) is a technique to achieve relative stability by splinting. This allows for
indirect healing with preservation of blood supply and soft tissue attachments while bridging the fracture zone
maintaining the correct length, rotation and alignment. Anatomical reduction of each fracture fragment is not
necessary.
Plate alternatives
A precontoured plate is useful in situations when normal anatomical landmarks are distorted or there is
significant bone fragmentation. We will here show the procedure with a precontoured clavicular plate which
has both a bend and a twist built into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to
be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being
applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may
be used in smaller patients where the forces working on the plate are not as great.
When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).

Plate length
The goal when choosing the plate length is to reduce the concentration of bending forces. This typically
requires a longer plate. Care must be taken not to insert a screw in each hole of the plate or rigidly fix fracture
gaps.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure an anterior approach is normally used.

3. Reduction and fixation

Reduction
Fracture fragments should not be devitalized or stripped from their soft tissue attachments. Achieve reduction
by indirect means where possible.
The aim is to restore normal alignment and rotation as well as length. At times some sacrifice of length may be
acceptable in order to improve bone contact and avoid excessive gapping.

Plate application
The plate can often assist as a reduction tool to restore the length and rotation.

A properly contoured plate is usually fixed first to the medial side as medial side malalignment is less well
tolerated. The lateral fragment is then reduced by manipulation involving traction and rotation and is aligned
anatomically with the lateral side of the plate.

The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.
A push-pull device is often helpful in obtaining the appropriate clavicular length when manual distraction is
unsuccessful.

Once the fracture alignment, length, and rotation are satisfactory, the remaining screws can be inserted.
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

MIO - Bridge plate

Diaphyseal multifragmentary, fragmentary segmental clavicle fracture

1/4 – Introduction
2/4 – Patient preparation and approach
3/4 – Reduction and fixation
4/4 – Aftercare

1. Introduction
Caution!
This procedure is extremely difficult and should not be performed except by very expert upper extremity
surgeons.

The goal of treatment

The goal of treatment for a multifragmentary fracture of the shaft of the clavicle requires restoration of the
appropriate alignment length and rotation.
This may be achieved with a minimally invasive plate osteosynthesis technique (MIPO). It requires less soft
tissue dissection, preserves blood supply and biology to improve healing.

Plate selection
We will here show the procedure with a precontoured clavicular plate.

Note: Even a precontoured plate may also require some additional contouring.

The use of the image intensifier is also required to verify the correct application of the plate when using a
MIPO technique.

When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer
sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg,
longer plate, periarticular plate, locking head screws).
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a MIO anterior approach is used.

3. Reduction and fixation

In MIPO of clavicular fractures, the following reduction techniques are useful:

Shoulder manipulation with inline traction and an external rotation movement often helps to reduce the
fracture. (The shoulder should be draped free.)
Pointed reduction clamps can be used either percutaneously or through small stab incisions.

If the fracture zone is extensive and normal anatomic landmarks cannot be restored, one uses a pre-contoured
plate which is then fixed to the medial side first, as this side cannot tolerate malalignment. The lateral end of
the clavicle is then reduced to the plate by manipulation. Once reduced, the reduction is maintained with a
percutaneous applied clamp, and the lateral end of the plate is fixed to the clavicle with one screw. C-arm
control of the reduction is then carried out. If deemed satisfactory, fixation of the plate on the medial and
lateral end of the plate is completed.
The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior
flat surface of the lateral segment will often restore the correct rotation.

Plate application
The precontoured plate is inserted through the skin incision medially or laterally into a subcutaneous tunnel
over the clavicle. Two positions are possible, superiorly or anteriorly.
Cortex screws are inserted first, one on each end of the plate, to bring the plate close to bone.

Fracture reduction and plate position is checked. If satisfactory, additional cortical and/or locking screws are
inserted to complete the fixation.

If the fracture reduction and plate position are not satisfactory, the screws may be loosened and reduction
procedure repeated.
4. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Lateral, undisplaced fracture with CC intact,

extraarticular clavicle fracture
An impacted or undisplaced extra articular fracture with intact coraco-clavicular ligaments is classified as
AO/OTA 15.3A(a) fracture. The ligaments may be minimally stretched.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

These fractures typically occur from a direct blow to the point of the shoulder such as from a fall in which the
patient lands directly on the shoulder.

Epidemiology of these fractures is bimodal with young active patients sustaining injuries from sporting events,
bicycling accidents, and motor vehicle collisions. Older patients typically sustain these injuries in falls from a
standing height.

The history should include the age, activity level, comorbidities, and mechanism of injury as these will be used
in the decision making regarding surgery. A thorough examination of the involved limb (and patient, if there is
a high energy mechanism present) is mandantory prior to embarking on treatment.
Radiographic evaluation of a distal clavicle fracture includes an anterior posterior radiograph centered on the
distal clavicle and a "upshot" or Zanca view which is angled 20 degrees cephalad: this allows the profile of the
fracture to be seen clearly free of the scapula and rib cage. CT imaging is often obtained to assess better the
fracture in the axial plane.

Lateral, undisplaced fracture with CC intact,

extraarticular clavicle fracture
All isolated extraarticular nondisplaced fractures of the lateral clavicle with intact CC are treated
nonoperatively.

Nonoperative treatment

Main indications
All undisplaced extraarticular fractures of the lateral clavicle

Nonoperative treatment of clavicle fractures

Lateral, undisplaced fracture with CC intact, extraarticular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
 3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Lateral, undisplaced fracture with CC intact,

articular clavicle fracture
An impacted or undisplaced articular fracture with intact coraco-clavicular ligaments is either classified as
AO/OTA 15.3B(a) in case of a partial articular fracture, and AO/OTA 15.3C(a) in case of a complete articular
fracture. The ligaments may be minimally stretched. These fractures are rare and typically stable.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

These fractures typically occur from a direct blow to the point of the shoulder such as from a fall in which the
patient lands directly on the shoulder.

Epidemiology of these fractures is bimodal with young active patients sustaining injuries from sporting events,
bicycling accidents, and motor vehicle collisions. Older patients typically sustain these injuries in falls from a
standing height.

The history should include the age, activity level, comorbidities, and mechanism of injury as these will be used
in the decision making regarding surgery. A thorough examination of the involved limb (and patient, if there is
a high energy mechanism present) is mandantory prior to embarking on treatment.

Radiographic evaluation of a distal clavicle fracture includes an anterior posterior radiograph centered on the
distal clavicle and a "upshot" or Zanca view which is angled 20 degrees cephalad: this allows the profile of the
fracture to be seen clearly free of the scapula and rib cage. CT imaging is often obtained to assess better the
fracture in the axial plane.

Lateral, undisplaced fracture with CC intact,

articular clavicle fracture
All isolated articular nondisplaced fractures of the lateral clavicle with intact CC are treated nonoperatively.

Nonoperative treatment
Main indications
All undisplaced articular fractures of the lateral clavicle

Nonoperative treatment of clavicle fractures

Lateral, undisplaced fracture with CC intact, articular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
 Telegram: @Dr_Zaky_Ortho

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

Lateral, displaced fracture with CC intact,

extraarticular clavicle fracture
Injuries that are characterized by a fracture line which starts medial to the coraco-clavicular ligaments and runs
superolaterally are classified as 15.3A(a). While the main segment of the clavicle is displaced superiorly the
smaller distal segment is held in place by the intact CC ligaments.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

These fractures typically occur from a direct blow to the point of the shoulder such as from a fall in which the
patient lands directly on the shoulder.

Epidemiology of these fractures is bimodal with young active patients sustaining injuries from sporting events,
bicycling accidents, and motor vehicle collisions. Older patients typically sustain these injuries in falls from a
standing height.

The history should include the age, activity level, comorbidities, and mechanism of injury as these will be used
in the decision making regarding surgery. A thorough examination of the involved limb (and patient, if there is
a high energy mechanism present) is mandantory prior to embarking on treatment.

Radiographic evaluation of a distal clavicle fracture includes an anterior posterior radiograph centered on the
distal clavicle and a "upshot" or Zanca view which is angled 20 degrees cephalad: this allows the profile of the
fracture to be seen clearly free of the scapula and rib cage. CT imaging is often obtained to assess better the
fracture in the axial plane.
Lateral, displaced fracture with CC intact,
extraarticular clavicle fracture
Nonoperative treatment

Main indications
Shortening or displacement < 2 cm

ORIF - Pre-contoured distal plate

Main indications
Shortening or displacement > 2 cm

Nonoperative treatment of clavicle fractures

Lateral, displaced fracture with CC intact, extraarticular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
 2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.
Mobilization of the upper extremity for general indications
It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side
Straightening and bending of the elbow

Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck
Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-
scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.
Activities of daily living
At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.
A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.
2. Phase 2: Beginning of week 4 to end of week 6 after injury (early
repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)
Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.
Mobilization for general indications
Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.
Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.
Activities of daily living
All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Pre-contoured distal plate

Lateral, displaced fracture with CC intact, extraarticular clavicle fracture
 1/6 – Introduction
2/6 – Patient preparation and approach
3/6 – Reduction
4/6 – Fixation
5/6 – Check of osteosynthesis
6/6 – Aftercare

1. Introduction
Most distal clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial
management typically requires temporary immobilization for comfort followed by gradual increase in activity.

Operative fixation is indicated for selected cases of displaced distal clavicle fractures in high demand patients.
Plate fixation is a preferred technique if distal clavicular bone purchase is adequate.

Precontoured anatomic plates with locking capabilities facilitate and optimize fixation in the distal fragment.

While hook plate fixation is an option for those fractures with inadequate distal screw purchase, the high rate
of plate irritation and subsequent need of removal of hook plates makes anatomic plate fixation preferred if
technically feasible.

Pitfall: The typical mode of failure of distal clavicle fixation is pullout of the distal fixation with redisplacement
of the shaft. It is mandatory for the operating surgeon to obtain sufficient distal fixation consistent with the
expected compliance and healing potential of the patient such that union will occur prior to potential hardware
failure. If, in the opinion of the operating surgeon, this is not obtainable with conventional plate fixation,
convert to hook plate fixation.

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.
Approach
For this procedure a superior approach is normally used.

3. Reduction
Fracture assessment
Following reflection of the deltoid, the distal clavicle fracture site is identified and cleared of any hematoma or
debris.

Pitfall: it is important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to
stability of the small distal clavicular fragment.

A sterile 18 gauge needle is used to identify the acromioclavicular joint. This allows the surgeon to determine
accurately the size and integrity of the distal clavicular fragment. Assessment is then performed to determine
whether conventional plate fixation is possible, or if hook plate fixation is required.
Reduction can be performed using fracture clamps on the proximal and distal fragments, with downward and
anterior pressure on the proximal fragment and superiorly directed force on the shoulder girdle and attached
distal fragment.

Alternatively, a ball spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction, temporary fixation with a K-wire directed from anterior to posterior can be
performed.

Alternatively (and preferentially) if fracture configuration permits, a lag screw can be placed at this point.
4. Fixation
Plate selection
An anatomical precontoured plate for the distal clavicle is chosen for fixation. Advantages of these plates
include the insertion of multiple (locked or unlocked) screws in the distal fragment to maximize fixation. Use
the guide jigs to help you determine the predetermined pattern of locking screws which may also increase
fixation strength.

While fixation is typically weakest in the distal fragment, it is important to assure proximal fixation with at
least 3 bicortical screws in the shaft fragment.

Placement and temporary securement of the plate

The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through
preset holes in the plate or with a reduction clamp.
Pitfall: It is important to avoid screw penetration into the acromioclavicular joint. If there is any doubt an
intraoperative radiograph can confirm plate position.

Alternative 1: Application in compression mode

If fracture pattern is amenable to compression, the plate can be applied in compression mode. To do this,
screws are placed in the distal fragment to secure the plate to the distal fragment. Typically, cancellous screws
are used in the distal fragment.

If desired threaded drill sleeves can be used to insert locking screws in a preset pattern in the distal fragment.
Then, a compression screw is inserted in the shaft of the plate to compress the fracture site.

Alternative 2: Application in neutralization mode with lag screw through plate

Alternatively, if fracture configuration permits, a lag screw can be inserted across the fracture site through the
plate. Following this step, remaining screws in the plate may be inserted.
Pearl: Additional stability
Redisplacement of the shaft fragment can be further prevented by the insertion of a coracoclavicular screw
inserted through the plate and then into the coracoid. One must aim for the posterior base portion of the
coracoid. Due to the intrinsic motion between the clavicle and the coracoid this screw will eventually loosen or
break, but will provide 6-8 weeks of added fixation before failure. The placement of this screw is at the
surgeon's discretion when added stability is deemed necessary.

5. Check of osteosynthesis
At the conclusion of fixation, the fracture site, plate and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, an intraoperative radiograph should be taken for confirmation.

6. Aftercare
The aftercare can be divided into 4 phases:
 1. Inflammatory phase (week 1–3)
2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Lateral, displaced fracture with CC intact,

fragmentary clavicle fracture
The fracture pattern in which the coracoclavicular ligaments avulse with a significant fragment of bone from
the clavicle is classified as an AO/OTA 15.3A(a) (extra articular) or AO/OTA 15.3B(a) (partial articular)
fracture.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

These fractures typically occur from a direct blow to the point of the shoulder such as from a fall in which the
patient lands directly on the shoulder.

Epidemiology of these fractures is bimodal with young active patients sustaining injuries from sporting events,
bicycling accidents, and motor vehicle collisions. Older patients typically sustain these injuries in falls from a
standing height.

The history should include the age, activity level, comorbidities, and mechanism of injury as these will be used
in the decision making regarding surgery. A thorough examination of the involved limb (and patient, if there is
a high energy mechanism present) is mandantory prior to embarking on treatment.

Radiographic evaluation of a distal clavicle fracture includes an anterior posterior radiograph centered on the
distal clavicle and a "upshot" or Zanca view which is angled 20 degrees cephalad: this allows the profile of the
fracture to be seen clearly free of the scapula and rib cage. CT imaging is often obtained to assess better the
fracture in the axial plane.
Lateral, displaced fracture with CC intact,
fragmentary clavicle fracture
Nonoperative treatment

Main indications
Shortening or displacement less than 2 cm. Low demand (typically elderly) patients

ORIF - Hook plate

Main indications
Severely displaced fracture

ORIF - Pre-contoured distal plate

Main indications
Severely displaced fracture

Nonoperative treatment of clavicle fractures

Lateral, displaced fracture with CC intact, fragmentary clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Telegram: @Dr_Zaky_Ortho

Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
 Telegram: @Dr_Zaky_Ortho

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Hook plate

Lateral, displaced fracture with CC intact, fragmentary clavicle fracture

1/7 – Introduction
2/7 – Patient preparation and approach
3/7 – Verification of necessity of hook plate use
4/7 – Direct reduction and fixation
5/7 – Indirect reduction and fixation
6/7 – Check of osteosynthesis
7/7 – Aftercare

1. Introduction
Clavicle hook plate fixation is indicated when there is insufficient bone in the distal clavicular fragment for
adequate fixation with a conventional or distal clavicle plate.

The decision to proceed with hook plate fixation can be made preoperatively or intraoperatively if
unanticipated inadequate fixation is obtained in the distal fragment.

This makes hook plate fixation an attractive alternative when unexpected difficulties are encountered with
fixation of the distal clavicular fragment.

One drawback of hook plate fixation is that, following solid healing of the fracture, plate removal is generally
required to optimize shoulder range of motion and eliminate residual discomfort from the hardware.

The avulsed fragment should be included in the plate screw fixation whenever possible.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a superior approach is normally used.

3. Verification of necessity of hook plate use

Following reflection of the deltoid the distal clavicle fracture site is identified and cleared of any hematoma or
debris.

Pitfall: it important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to
stability of the small distal clavicular fragment.
A sterile 18-gauge needle is used to identify the acromioclavicular joint (this allows the surgeon a clear
determination of the size and integrity of the distal clavicular fragment). Assessment is then performed whether
conventional plate fixation is possible, or if hook plate use is required.

4. Direct reduction and fixation

Reduction
Reduction can be performed with several different methods, depending on fracture configuration and surgeon’s
preference. Generally, reduction will be easier if the shoulder girdle is supported and prevented from sagging
downwards.

Conventional direct reduction can be performed using fracture clamps on the proximal and distal fragments,
with downward and anterior pressure on the proximal fragment and superior force on the distal fragment and
attached shoulder girdle.

Alternatively a ball spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction, temporary fixation of the small lateral fragment to the main medial fragment is
performed with a K-wire directed from lateral to medial, trans fixating the AC joint.

Incision for hook placement

A small incision is made at the posterior aspect of the acromioclavicular joint to allow sub-acromial placement
of the hook.
Plate selection
The trial hook plates are used to select the correct length of plate (to allow a minimum of 3 screws in the
proximal fragment) and to determine the correct depth of the hook.

Plate positioning
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward and medial translation of the arm through its tip position under
the acromion.
Plate application
The fixation of the hook plate is completed with insertion of the cortical screws in the shaft fragment and
cancellous screws in the distal fragment to augment fixation.

Locking screws may be used if bone quality is poor.

The K-wire is removed.

5. Indirect reduction and fixation

The hook plate is a powerful tool that can be used to provide an indirect reduction of a distal clavicle fracture.

This indirect reduction technique is useful for comminuted fractures or fractures with very small distal
fragments in which conventional reduction and fixation is difficult.
Incision for hook placement
A small incision is made on the posterior aspect of the acromioclavicular joint to allow subacromial hook
placement.

Plate selection
With the hook portion of the trial hook plate in the subacromial space, the shaft portion of the hook plate is
used to lever the shaft fragment in to place.
At this point a trial and error method with the three different trail hook plate depths is used to determine the
optimal hook depth for accurate fracture reduction.

Pitfalls and pearls

Pitfall: It is important not to over-reduce the clavicle. This is the most common technical error and occurs
when the hook depth chosen is too small which leads to inferior displacement of the shaft fragment. This
results in an excessive pressure exerted on the acromion by the hook portion of the plate: acromial erosion or
fracture can occur.
Avoidance of over-reduction
There are a number of intraoperative maneuvers that will help avoid over-reduction. These include:

1. Selecting a hook depth that is appropriate for the individual case

2. It may be necessary to contour the shaft or hook portion of the plate with the hand held bending irons to
optimize plate placement, as anatomy in this area may be quite variable. Care should be taken not to bend
he plate or hook repeatedly as this might lead to material failure
3. Excessive downward pressure on the clavicle should be avoided as this often results in over-reduction
4. A superior bony prominence of the distal clavicle may be resected to provide a flat superior surface for
plate placement: this will prevent over-reduction of the clavicle
5. In cases where reduction is uncertain, intraoperative imaging with a trial in place will clarify the degree
of clavicular reduction and can aid in correction of any over-reduction

Pitfall: A too great hook depth will result in under-reduction, or residual superior displacement of the shaft
fragment.
Pearl: It may be necessary to contour the shaft or hook portion of the plate with the hand held bending irons to
optimize plate placement, as individual anatomy in this area may be quite variable. Care should be taken not
to repeatedly bend the plate or hook as this might lead to material failure.

Hook placement
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward displacement of the arm through its position under the
acromion.
Reduction and plate application
To avoid excessive stress on any screw insert first the screw closest to the fracture and tighten until appropriate
resistance is felt. This may leave the plate proud but...

...sequential insertion of the following screws should approximate it to the shaft fragment and result in accurate
fracture reduction. Note this can be done only if regular screws are used. Locking screws are contraindicated
for such a maneuver.
If feasible, a lag screw is now inserted to secure the avulsed segment to the rest of the clavicle.

6. Check of osteosynthesis
At the conclusion of fixation the fracture site, plate and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, an intraoperative radiograph should be taken for confirmation.

7. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)
Full details on each phase can be found here.

ORIF - Pre-contoured distal plate

Lateral, displaced fracture with CC intact, fragmentary clavicle fracture

1/6 – Introduction
2/6 – Patient preparation and approach
3/6 – Reduction
4/6 – Fixation
5/6 – Check of osteosynthesis
6/6 – Aftercare

1. Introduction
Most distal clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial
management typically requires temporary immobilization for comfort followed by gradual increase in activity.

Operative fixation is indicated for selected cases of displaced distal clavicle fractures in high demand patients.
Plate fixation is a preferred technique if distal clavicular bone purchase is adequate.

Precontoured anatomic plates with locking capabilities facilitate and optimize fixation in the distal fragment.

The avulsed fragment should be included in the plate screw fixation whenever possible. Most often it is too
small to accommodate a screw, in this case the dislocation forces are neutralized using an additional suture
anchor, or a hook plate.

While hook plate fixation is an option for those fractures with inadequate distal screw purchase, the high rate
of plate irritation and subsequent need of removal of hook plates makes anatomic plate fixation preferred if
technically feasible.

Pitfall: The typical mode of failure of distal clavicle fixation is pullout of the distal fixation with redisplacement
of the shaft. It is mandatory for the operating surgeon to obtain sufficient distal fixation consistent with the
expected compliance and healing potential of the patient such that union will occur prior to potential hardware
failure. If, in the opinion of the operating surgeon, this is not obtainable with conventional plate fixation,
convert to hook plate fixation.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a superior approach is normally used.

3. Reduction
Fracture assessment
Following reflection of the deltoid, the distal clavicle fracture site is identified and cleared of any hematoma or
debris.
Pitfall: it is important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to
stability of the small distal clavicular fragment.

A sterile 18 gauge needle is used to identify the acromioclavicular joint. This allows the surgeon to determine
accurately the size and integrity of the distal clavicular fragment. Assessment is then performed to determine
whether conventional plate fixation is possible, or if hook plate fixation is required.

Reduction can be performed using fracture clamps on the proximal and distal fragments, with downward and
anterior pressure on the proximal fragment and superiorly directed force on the shoulder girdle and attached
distal fragment.

Alternatively, a ball spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction, temporary fixation with a K-wire directed from lateral to medial, trans fixating
the AC joint, the small lateral fragment to the main medial fragment.

4. Fixation
Plate selection
An anatomical precontoured plate for the distal clavicle is chosen for fixation. Advantages of these plates
include the insertion of multiple (locked or unlocked) screws in the distal fragment to maximize fixation. Use
the guide jigs to help you determine the predetermined pattern of locking screws which may also increase
fixation strength.

While fixation is typically weakest in the distal fragment, it is important to assure proximal fixation with at
least 3 bicortical screws in the shaft fragment.
If desired threaded drill sleeves can be used to insert locking screws in a preset pattern in the distal fragment.

Placement and temporary securement of the plate

The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through
preset holes in the plate or with a reduction clamp.

Pitfall: It is important to avoid screw penetration into the acromioclavicular joint. If there is any doubt an
intraoperative radiograph can confirm plate position.
Application in neutralization mode with lag screw through plate
Alternatively if fracture configuration permits, a lag screw can be inserted across the fracture site through the
plate. Following this step, remaining screws in the plate may be inserted. It is important that the inferior
fragment with its attached CC ligaments is included in the fixation.

K-wire is removed.
Pearl: Additional stability
Superior displacement of the shaft fragment can be resisted through the placement of a suture anchor inserted
into the coracoid base. The fibre wire is then used to prevent superior displacement of the clavicle.

If a suture anchor is not available, clavicle can also be secured to the coracoid using a cerclage fiber passed
under the coracoid. If necessary one can use a tendon (auto or allograft).

Alternative techniques for ligament repair can be found here:

Ligament repair
5. Check of osteosynthesis
At the conclusion of fixation the fracture site, plate and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, an intraoperative radiograph should be taken for confirmation.

6. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Lateral, displaced fracture with CC disrupted,

extraarticular clavicle fracture
A fracture which starts lateral to the CC ligaments and runs superiorly and does not affect the AC joint surface
is classified as an AO/OTA 15.3A(c) fracture.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

Displaced fractures demonstrate swelling, bruising, and a deformity with apparent superior migration of the
shaft fragment as the shoulder sags downwards and medially.
Lateral, displaced fracture with CC disrupted,
extraarticular clavicle fracture
In the injuries in which the AC ligament is disrupted and the injury involves the joint or the lateral 1/3 of the
clavicle medial to the AC ligaments there is no bony or ligamentous connection between the medial 2/3 of the
clavicle which is fixed to the sternum and the scapula and the arm. As a result the weight of the arm displaces
the arm downwards and forwards as the scapula is directed forwards by the shape of the rib cage. There are
several operative techniques described for these injuries, however, there is no single standard technique
yielding excellent result as a rule.

Nonoperative treatment

Main indications
Minimally displaced fractures or low demand (typically elderly) patients

ORIF - Hook plate

Main indications
Severely displaced fracture
ORIF - Pre-contoured distal plate

Main indications
Severely displaced fracture

Nonoperative treatment of clavicle fractures

Lateral, displaced fracture with CC disrupted, extraarticular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.
Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion.
Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
 Telegram: @Dr_Zaky_Ortho

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Hook plate

Lateral, displaced fracture with CC disrupted, extraarticular clavicle fracture

1/7 – Introduction
2/7 – Patient preparation and approach
3/7 – Verification of necessity of hook plate use
4/7 – Direct reduction and fixation
5/7 – Indirect reduction and fixation
6/7 – Check of osteosynthesis
7/7 – Aftercare

1. Introduction
Clavicle hook plate fixation is indicated when there is insufficient bone in the distal clavicular fragment for
adequate fixation with a conventional or distal clavicle plate.

The decision to proceed with hook plate fixation can be made preoperatively or intraoperatively if
unanticipated inadequate fixation is obtained in the distal fragment.

This makes hook plate fixation an attractive alternative when unexpected difficulties are encountered with
fixation of the distal clavicular fragment.

One drawback of hook plate fixation is that, following solid healing of the fracture, plate removal is generally
required to optimize shoulder range of motion and eliminate residual discomfort from the hardware.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a superior approach is normally used.

3. Verification of necessity of hook plate use

Following reflection of the deltoid the distal clavicle fracture site is identified and cleared of any hematoma or
debris.

Pitfall: it important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to
stability of the small distal clavicular fragment.
A sterile 18-gauge needle is used to identify the acromioclavicular joint (this allows the surgeon a clear
determination of the size and integrity of the distal clavicular fragment). Assessment is then performed whether
conventional plate fixation is possible, or if hook plate use is required.

4. Direct reduction and fixation

Reduction
Reduction can be performed with several different methods, depending on fracture configuration and surgeon’s
preference. Generally, reduction will be easier if the shoulder girdle is supported and prevented from sagging
downwards.

Conventional direct reduction can be performed using fracture clamps on the proximal and distal fragments,
with downward and anterior pressure on the proximal fragment and superior force on the distal fragment and
attached shoulder girdle.

Alternatively, a ball-spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction, temporary fixation with a K-wire directed from anterior to posterior can be
performed.

Alternatively (and preferentially), if fracture configuration permits, a lag screw can be placed at this point.

Incision for hook placement

A small incision is made at the posterior aspect of the acromioclavicular joint to allow sub-acromial placement
of the hook.
Plate selection
The trial hook plates are used to select the correct length of plate (to allow a minimum of 3 screws in the
proximal fragment) and to determine the correct depth of the hook.

Plate positioning
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward and medial translation of the arm through its tip position under
the acromion.
Plate application
The fixation of the hook plate is completed with insertion of the cortical screws in the shaft fragment and
cancellous screws in the distal fragment to augment fixation.

Locking screws may be used if bone quality is poor.

The K-wire is removed.

5. Indirect reduction and fixation

The hook plate is a powerful tool that can be used to provide an indirect reduction of a distal clavicle fracture.

This indirect reduction technique is useful for comminuted fractures or fractures with very small distal
fragments in which conventional reduction and fixation is difficult.
Incision for hook placement
A small incision is made on the posterior aspect of the acromioclavicular joint to allow subacromial hook
placement.

Plate selection
With the hook portion of the trial hook plate in the subacromial space, the shaft portion of the hook plate is
used to lever the shaft fragment in to place.
At this point a trial and error method with the three different trial hook plates depths is used to determine the
optimal hook depth for accurate fracture reduction.

Pitfalls and pearls

Pitfall: It is important not to over-reduce the clavicle. This is the most common technical error and occurs
when the hook depth chosen is too small which leads to inferior displacement of the shaft fragment. This
results in an excessive pressure exerted on the acromion by the hook portion of the plate: acromial erosion or
fracture can occur.
There are a number of intraoperative maneuvers that will help avoid over-reduction. These include:

1. Selecting a hook depth that is appropriate for the individual case

2. It may be necessary to contour the shaft or hook portion of the plate with the hand held bending irons to
optimize plate placement, as anatomy in this area may be quite variable. Care should be taken not to bend
he plate or hook repeatedly as this might lead to material failure
3. Excessive downward pressure on the clavicle should be avoided as this often results in over-reduction
4. A superior bony prominence of the distal clavicle may be resected to provide a flat superior surface for
plate placement: this will prevent over-reduction of the clavicle
5. In cases where reduction is uncertain, intraoperative imaging with a trial in place will clarify the degree
of clavicular reduction and can aid in correction of any over-reduction

Pitfall: A too great hook depth will result in under-reduction, or residual superior displacement of the shaft
fragment.
Pearl: It may be necessary to contour the shaft or hook portion of the plate with the hand held bending irons to
optimize plate placement, as anatomy in this area may be quite variable. Care should be taken not to bend the
plate or hook repeatedly as this might lead to material failure.

Hook placement
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward displacement of the arm through its position under the
acromion.
Reduction and plate application
To avoid excessive stress on any screw, insert first the screw closest to the fracture and tighten until appropriate
resistance is felt. This may leave the plate proud but...

…sequential insertion of the following screws should approximate it to the shaft fragment and result in
accurate fracture reduction. Note this can be done only if regular screws are used. Locking screws are
contraindicated for such a maneuver.
If feasible, the coracoclavicular ligaments should be repaired with sutures.

Alternative techniques for ligament repair can be found here:

Ligament repair

6. Check of osteosynthesis
At the conclusion of fixation, the fracture site, plate and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, an intraoperative radiograph should be taken for confirmation.

7. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

 2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

ORIF - Pre-contoured distal plate

Lateral, displaced fracture with CC disrupted, extraarticular clavicle fracture

1/6 – Introduction
2/6 – Patient preparation and approach
3/6 – Reduction
4/6 – Fixation
5/6 – Check of osteosynthesis
6/6 – Aftercare

1. Introduction
Most distal clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial
management typically requires temporary immobilization for comfort followed by gradual increase in activity.

Operative fixation is indicated for selected cases of displaced distal clavicle fractures in high demand patients.
Plate fixation is a preferred technique if distal clavicular bone purchase is adequate.

Precontoured anatomic plates with locking capabilities facilitate and optimize fixation in the distal fragment.

While hook plate fixation is an option for those fractures with inadequate distal screw purchase, the high rate
of plate irritation and subsequent need of removal of hook plates makes anatomic plate fixation preferred if
technically feasible.

Pitfall: The typical mode of failure of distal clavicle fixation is pullout of the distal fixation with redisplacement
of the shaft. It is mandatory for the operating surgeon to obtain sufficient distal fixation consistent with the
expected compliance and healing potential of the patient such that union will occur prior to potential hardware
failure. If, in the opinion of the operating surgeon, this is not obtainable with conventional plate fixation,
convert to hook plate fixation.
2. Patient preparation and approach
Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a superior approach is normally used.

3. Reduction
Fracture assessment
Following reflection of the deltoid the distal clavicle fracture site is identified and cleared of any hematoma or
debris.
Pitfall: it important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to
stability of the small distal clavicular fragment.

A sterile 18 gauge needle is used to identify the acromioclavicular joint. This allows the surgeon to determine
accurately the size and integrity of the distal clavicular fragment. Assessment is then performed to determine
whether conventional plate fixation is possible, or if hook plate fixation is required.

Reduction can be performed using fracture clamps on the proximal and distal fragments, with downward and
anterior pressure on the proximal fragment and superiorly directed force on the shoulder girdle and attached
distal fragment.

Alternatively, a ball spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction temporary fixation with a K-wire directed from anterior to posterior can be
performed.
Alternatively (and preferentially), if fracture configuration permits, a lag screw can be placed at this point.

4. Fixation
Plate selection
A precontoured distal clavicle plate is then chosen and applied with as many screws as possible in the distal
fragment.

While fixation is typically weakest in the distal fragment, it is important to assure proximal fixation with at
least 3 bicortical screws in the shaft fragment.
In a limited resource environment, a 3.5 mm pelvic reconstruction plate can be used in this setting. The plate
alone would fail, and therefore its stability has to be supplemented by inserting a screw through the plate into
the base of the coracoid. This has to be kept in mind when choosing the optimal placement of the plate.

Placement and temporary securement of the plate

The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through
holes in the plate or with a reduction clamp.

Pitfall: It is important to avoid screw penetration into the acromioclavicular joint. If there is any doubt an
intraoperative radiograph can confirm plate position.
Alternative 1: Application in compression mode
If fracture pattern is amenable to compression, the plate can be applied in compression mode. To do this,
screws are placed in the distal fragment to secure the plate to the distal fragment. Typically, cancellous screws
are used in the distal fragment.

Then, a compression screw is inserted in the shaft of the plate to compress the fracture site.
Alternative 2: Application in neutralization mode with lag screw through plate
Alternatively, if fracture configuration permits, a lag screw can be inserted across the fracture site through the
plate. Following this step, remaining screws in the plate may be inserted.

Pearl: Additional stability

Redisplacement of the shaft fragment can be further prevented by the insertion of a coracoclavicular screw
inserted through the plate and then into the coracoid. One must aim for the posterior base portion of the
coracoid. Due to the intrinsic motion between the clavicle and the coracoid this screw will eventually loosen or
break, but will provide 6-8 weeks of added fixation before failure. The placement of this screw is at the
surgeon's discretion when added stability is deemed necessary.
Alternatively, a sling of autograft/allograft tendon or heavy suture may be passed around the clavicle and under
or through the base of the coracoid as further reinforcement of the plate construct to prevent superior migration
of the clavicular shaft.

Alternative techniques for ligament repair can be found here:

Ligament repair

5. Check of osteosynthesis
At the conclusion of fixation, the fracture site, plate and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, an intraoperative radiograph should be taken for confirmation.

6. Aftercare
The aftercare can be divided into 4 phases:
 1. Inflammatory phase (week 1–3)
2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Lateral, displaced fracture with CC disrupted,

articular clavicle fracture
A fracture which starts medial to the CC ligaments and runs superio laterally into the AC joint is classified as
an AO/OTA 15.3B(c) fracture.

Definition: Distal fractures of the clavicle involve the clavicle lateral to a perpendicular line to the medial
cortex of the coracoid base.

Displaced fractures demonstrate swelling, bruising, and a deformity with apparent superior migration of the
shaft fragment as the shoulder sags downwards and medially.

Lateral, displaced fracture with CC disrupted,

articular clavicle fracture
In the injuries in which the AC ligament is disrupted and the injury involves the joint or the lateral 1/3 of the
clavicle medial to the AC ligaments there is no bony or ligamentous connection between the medial 2/3 of the
clavicle which is fixed to the sternum and the scapula and the arm. As a result the weight of the arm displaces
the arm downwards and forwards as the scapula is directed forwards by the shape of the rib cage. There are
several operative techniques described for these injuries, however, there is no single standard technique
yielding excellent result as a rule.

Nonoperative treatment

Main indications
Minimally displaced fractures

ORIF - Hook plate

Main indications
Severely displaced fracture or AC joint dislocation in young active patients

Nonoperative treatment of clavicle fractures

Lateral, displaced fracture with CC disrupted, articular clavicle fracture

1/4 – Phase 1: injury to the end of week 3 after injury (inflammatory phase)
2/4 – Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)
3/4 – Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling
phase)
4/4 – Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

1. Phase 1: injury to the end of week 3 after injury (inflammatory

phase)
Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support - full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest.
Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm's
weight. The simplest sling is a triangular bandage tied behind the neck.
Additional support is provided by a swath that wraps around the humerus and the chest to restrict further
shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of
a swath.

Abduction brace
In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension
by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or
an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging
venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation
of the proprioception and therefore promotes optimal joint motion.
The following exercises are recommended.

Opening and closure of the hand

Squeezing of a soft ball

Bending of the wrist forward, backwards and in a circular motion.

Movement of an open hand from side to side

Straightening and bending of the elbow

 Squeezing the shoulder blades together while the shoulders remain relaxed
Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-

scapula
Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not
progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

External rotation at waist level

Internal rotation at waist level
Forward flexion without scapular protraction with the forearm supported by the table (illustrated)
 Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and
toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not
be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).
Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and
shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.
Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient's side while
showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to
wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early

repair phase)
Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue
repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support - full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors
and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of
the clavicle and scapula.
Activities of daily living
All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food
preparation)

Radiographic control
Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent
reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late

repair and early tissue remodeling phase)
Phase 3 principle: reestablishment of proprioception in the limb.
Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary
injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-

scapula
All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the
clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.
A "shoulder therapy set" might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to
provide full passive forward flexion of the injured right shoulder.
As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully
consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To
increase muscle strength, one must increase the resistance against which the muscles work. Endurance training
follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic
patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and
abduction of the injured limb as comfort permits.

Radiographic control
Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without
adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits
progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and

reintegration phase)
Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal
endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is
encouraged.

ORIF - Hook plate

Lateral, displaced fracture with CC disrupted, articular clavicle fracture

1/7 – Introduction
2/7 – Patient preparation and approach
3/7 – Verification of necessity of hook plate use
4/7 – Direct reduction and fixation
5/7 – Indirect reduction and fixation
6/7 – Check of osteosynthesis
7/7 – Aftercare

1. Introduction
Hook plate fixation is indicated when there is insufficient bone in the distal clavicular fragment for adequate
fixation with a conventional or distal clavicle plate.

This is typically the case with an intra-articular fracture. Hook plate fixation is an attractive alternative when
dealing with fixation of small intra-articular fracture fragments.

One drawback of hook plate fixation is that, following solid healing of the fracture, plate removal is generally
required to optimize shoulder range of motion and eliminate residual discomfort from the hardware.
 Telegram: @Dr_Zaky_Ortho

2. Patient preparation and approach

Patient preparation
This procedure is normally performed with the patient either in a beach chair or a supine position.

Approach
For this procedure a superior approach is normally used.

3. Verification of necessity of hook plate use

Following reflection of the deltoid the distal clavicle fracture site is identified and cleared of any hematoma or
debris.

Typically, a displaced intra-articular fracture will result in disruption of part of or the entire acromioclavicular
joint capsule and therefore the joint is usually readily apparent.
4. Direct reduction and fixation
Reduction
Reduction can be performed with several different methods, depending on fracture configuration and surgeon’s
preference.
Make certain that downward displacement of the arm is corrected.

Conventional direct reduction can be performed using fracture clamps while applying downward and anterior
pressure on the shaft and a lifting and superior force on the distal fragment and attached shoulder girdle.

Alternatively, a ball spiked pusher may be utilized to align the fragments.

Temporary fixation
Following accurate reduction temporary fixation with a K-wire directed from anterior to posterior can be
performed.
Alternatively (and preferentially) if fracture configuration permits, a lag screw can be placed at this point.

Incision for hook placement

A small incision is made at the posterior aspect of the acromioclavicular joint to allow sub-acromial placement
of the hook.
Plate selection
The trial hook plates are used to select the correct length of plate (to allow a minimum of 3 screws in the shaft)
and to determine the correct depth of the hook.

Plate application
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward and medial translation of the arm through its tip position under
the acromion.
The hook plate is secured to the shaft fragment with cortical and cancellous screws (if possible) in the articular
fragment to augment fixation.

Locking screws may be used if bone quality is poor.

K-wire is then removed.

5. Indirect reduction and fixation

The hook plate is a powerful tool that can be used to provide an indirect reduction of a distal clavicle fracture.

This indirect reduction technique is useful for comminuted fractures or fractures with very small distal
fragments in which conventional reduction and fixation is difficult.
Plate selection
A small incision is made at the posterior aspect of the acromioclavicular joint to allow sub-acromial placement
of the hook. The hook portion of the trial hook plate trial is placed in the subacromial space at the posterior
aspect of the joint, and the shaft portion of the trial hook plate is then used to lever the clavicle into place.

At this point a trial and error method with the three different trial hook plate depths is used to determine the
optimal hook depth for accurate reduction. Typically, the short four-hole hook plate will be adequate for most
acromioclavicular joint dislocations.
Pitfall: A too great hook depth will result in under-reduction, or residual superior displacement of the shaft
fragment.

Pitfall: It is important not to over-reduce the clavicle. This is the most common technical error and occurs
when the hook depth chosen is too small which leads to inferior displacement of the shaft fragment. This
results in an excessive pressure exerted on the acromion by the hook portion of the plate: acromial erosion or
fracture can occur.
Case: Over reduction
This is an example of an intra-articular distal clavicle fracture with significant displacement.

Note the increased coracoclavicular distance.

Following hook plate fixation, over reduction of the clavicle is demonstrated with a decrease of the
coracoclavicular distance compared to the normal side. This puts severe pressure on the acromion from the tip
of the hook plate as can be seen in this postoperative radiograph.
Subsequent erosion of the hook through the acromion can occur as demonstrated in this illustration: acromial
fracture can also occur. When hook plate mechanical failure occurs, over reduction is the most common
contributing mechanism.

Avoidance of over-reduction
There are a number of intraoperative maneuvers that will help avoid over-reduction. These include:

1. Selecting a hook depth that is appropriate for the individual case

2. It may be necessary to contour the shaft or hook portion of the plate with the hand held bending irons to
optimize plate placement, as anatomy in this area may be quite variable. Care should be taken not to bend
he plate or hook repeatedly as this might lead to material failure
3. Excessive downward pressure on the clavicle should be avoided as this often results in over-reduction
4. A superior bony prominence of the distal clavicle may be resected to provide a flat superior surface for
plate placement: this will prevent over-reduction of the clavicle
 5. In cases where reduction is uncertain, intraoperative imaging with a trial in place will clarify the degree
of clavicular reduction and can aid in correction of any over-reduction

Hook placement
At this point, the definitive hook plate is applied to the fracture.

Correct placement of the hook portion posteriorly under the acromion aids in reduction and avoids rotator cuff
impingement.

The hook portion of the plate resists downward displacement of the arm through its position under the
acromion.

Reduction and plate application

To avoid excessive stress on any screw, insert first the screw closest to the fracture and tighten until appropriate
resistance is felt. This may leave the plate proud but...
…sequential insertion of the following screws should approximate it to the shaft fragment and result in
accurate fracture reduction. Note this can be done only if regular screws are used. Locking screws are
contraindicated for such a maneuver.

If feasible, the coracoclavicular ligaments can be repaired with sutures.

Alternative techniques for ligament repair can be found here:

Ligament repair
6. Check of osteosynthesis
At the conclusion of fixation, the fracture site, plate, and screws are carefully checked to ascertain accurate
reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains
regarding these findings, and intraoperative radiograph should be taken for confirmation.

7. Aftercare
The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)

2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

Telegram: @Dr_Zaky_Ortho