Fig. 1 A 17-year-old male high school soccer player who sustained a clavicle injury midseason and desired to return to soccer as quickly as possible: (A) injury radiographs; (B) three weeks postoperatively; (C) three months postoperatively
Courtesy of Nathan L. Grimm, MD, and Katherine J. Coyner, MD, FAAOS


Published 12/31/2019
Lisa K. Cannada, MD, FAAOS; Kyle J. Jeray, MD, FAAOS; Katherine J. Coyner, MD, FAAOS; Nathan L. Grimm, MD

Opinions on Operative Treatment of Clavicle Fractures from Sports and Trauma Experts

Over the years, treatment of midshaft clavicle fractures has evolved. A 2007 publication with level 1 evidence comparing operative versus nonoperative treatment of midshaft clavicle fractures affected clinical decision-making, as the trial observed improved functional outcome scores and decreased rates of malunion and nonunion with open reduction and internal fixation (ORIF). Interest and literature regarding the topic expanded. A recent PubMed search yielded 3,563 articles. Since 2010, more than 100 articles have been published per year. With any new level 1 evidence, some practitioners jump on the bandwagon. But the question remains: Is ORIF of midshaft clavicle fractures the better treatment option?

Here, trauma and sports medicine physicians comment on the recent meta-analysis by Guerra et al., which concluded that operative treatment was superior.

Lisa K. Cannada, MD, FAAOS, is an orthopaedic traumatologist, member of the AAOS Now Editorial Board, and member of the diversity content workgroup. She can be reached at

Management of midshaft clavicle fractures: a trauma surgeon’s perspective 

As the treatment for midshaft clavicle fractures remains controversial, Guerra et al., attempted to answer this clinical question by performing a meta-analysis of randomized, controlled trials (RCTs) comparing surgery to nonoperative treatment in “displaced” midshaft clavicle fractures.

After a lengthy literature search and comprehensive review, they found 14 articles that addressed this question with RCTs using PRISMA and GRADE guidelines. They concluded that “Surgery provided a better result compared to nonoperative treatment.” Only two articles examined the use of intramedullary devices, so no conclusion was reached with the use of those implants relative to plates. The authors went on to state that “long-term” outcomes were better, time to union was faster, and nonunion rates were lower with surgery (16.5 percent versus 1.4 percent). However, “long-term” outcomes (based on the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores) were defined as only greater than nine months, and, as the authors admitted, the small differences in outcome scores may have been statistically significant, but they did not approach clinical significance based on prior studies on the topic.

One can only wonder what the outcomes would be at two years or longer. Furthermore, the lower outcome scores at nine months may be biased by the high nonunion rate (110 patients with nonunion, of whom 78 patients elected to have additional surgery). Assuming the 78 patients who had additional surgery for nonunion had longer follow-up, they may have had improved outcome scores, as late reconstruction is a reliable and reproducible surgery with high satisfaction.

Only three papers addressed the time to return to previous activities/work. The authors found that earlier return to activities failed to reach a significant difference, thus questioning the value of earlier time to union. It also may be that the “earlier time to union” could be difficult to determine when radiographs are taken at four- to six-week intervals or more, considering the difference was noted to be only 5.1 weeks. Not surprisingly, when complications were assessed, and hardware removal was included, the surgical group had a higher complication rate (31.0 percent versus 20.5 percent) and a higher risk of additional surgery (17 percent versus 13 percent).

To the authors’ credit, they did acknowledge that the question still remains to be answered and that more data are needed. So, what is the correct treatment for the displaced midshaft clavicle?

In my opinion, the answer reflects more on the art of medicine and less on the science. Each patient should be evaluated, and, if possible, involved in treatment decision-making. The decision boils down to the risk-benefit ratio, which varies from one patient to another. Although good scientific data support a higher nonunion rate with closed treatment, the costs of operative care may be a big factor for a patient.

For example, consider two healthy college students with displaced midshaft clavicle fractures. One is a starting shortstop for the school’s softball team and has insurance, whereas the other is in the speech and debate club and has no insurance. The softball player wishes to get back on the field and understands that the likelihood of healing is much higher with surgery. For her, cost is not a factor, so she elects surgery. The other student is much more concerned about the cost and is willing to accept the higher risk of nonunion, understanding that it would not affect her position in the speech and debate club. If it does not heal, she then will face the decision again to consider surgery.

This is just one example; many other variables exist that are individual to each patient. In a multitrauma situation, the need for mobilization may be improved with fixation, and the shared decision may be to fix the fracture. Patients with significant comorbidities may elect to avoid the risks of surgery. A professional cyclist who desires to get back on a bike might elect surgery, whereas an accountant who plays chess may decide to accept the risks of nonoperative treatment.

Ultimately, without a clear “best” approach to treatment, a collective decision between the physician and patient may indeed be the best approach—at least today.

Kyle J. Jeray, MD, FAAOS, is chairman of the Orthopedic Department at Prisma Health in Greenville, S.C. He practices orthopaedic trauma and is a member of the Orthopaedic Trauma Association and AAOS, where he has been involved with the Leadership Fellows Program as a participant and mentor.

Fig. 1 A 17-year-old male high school soccer player who sustained a clavicle injury midseason and desired to return to soccer as quickly as possible: (A) injury radiographs; (B) three weeks postoperatively; (C) three months postoperatively
Courtesy of Nathan L. Grimm, MD, and Katherine J. Coyner, MD, FAAOS
Fig. 1 A 17-year-old male high school soccer player who sustained a clavicle injury midseason and desired to return to soccer as quickly as possible: (A) injury radiographs; (B) three weeks postoperatively; (C) three months postoperatively
Courtesy of Nathan L. Grimm, MD, and Katherine J. Coyner, MD, FAAOS
Fig. 1 A 17-year-old male high school soccer player who sustained a clavicle injury midseason and desired to return to soccer as quickly as possible: (A) injury radiographs; (B) three weeks postoperatively; (C) three months postoperatively
Courtesy of Nathan L. Grimm, MD, and Katherine J. Coyner, Md, FAAOS
Kyle J. Jeray, MD, FAAOS
Nathan L. Grimm, MD
Katherine J. Coyner, MD, FAAOS

Management of midshaft clavicle fractures: the sports medicine perspective

As Guerra et al., pointed out in their meta-analysis on treatment of midshaft clavicle fractures, there is a paucity of high-quality studies evaluating operative versus nonoperative treatment. Only 2.4 percent of the articles screened met the inclusion criteria for the meta-analysis. Many of the available studies are plagued by methodological shortcomings that challenge the interpretation of the results. As a result, extrapolation of these data into objective information applicable to a particular athlete with unique demands remains difficult. This lack of sport-specific data adds complexity to the shared decision-making process for surgical versus nonsurgical treatment.

All fractures are not created equally and, therefore, are not treated equally. From a sports medicine perspective, one of the concerning issues in the literature is cohort heterogeneity within the studies. The studies may have contained both athletes and nonathletes, as well as patients with varying levels of activity. This poses a problem for clinicians counseling athletes, as the appropriateness of extrapolating nonathlete data is unclear.

Paraphrasing Sir William Osler, it is much more important to know what sort of patient has an injury than what sort of injury a patient has. For sports medicine surgeons, it is important to give full consideration to the injury in the context of the athlete and the demands that individual will put on the involved bone, joint, tendon, etc. For example, when evaluating an in-season athlete who uses extremes of shoulder motion (e.g., swimmers), a loss of only a few degrees of motion can significantly impact his or her power, cadence, and overall performance. These elite athletes may perform more than 2,500 shoulder revolutions per day, which is a demand that the average person would not put on the shoulder. A malunion resulting in a subtle change in biomechanics or range of motion can be devastating for such a patient.

Similarly, the timing of return to sport may be more important for the Olympian who has sustained a clavicle fracture than the “weekend warrior” whose leisure activities are perhaps less important to him or her.

Certainly, in traditional surgical management of fractures, we respect the four principles set forth by the AO Foundation for guiding appropriate fracture management. We also consider the indications for management of clavicle fractures that have broadly been agreed upon: shortening > 2 cm, tenting of the skin, more than 100 percent displacement, open fracture, etc.

However, our treatment algorithm pays close attention to the details of the individual demands of the athlete, the timing of return to sport, and the desired level of return to sport. The current study lends credence to the opinion that a more aggressive surgical approach for a high-demand athlete may be the right answer.

That is, Guerra et al., offered several key findings that may support a more aggressive surgical approach in athletes. First, the rate of nonunion was 1.4 percent for the surgical group versus 16.5 percent for those undergoing nonoperative treatment. Furthermore, the time to union in the operative group was 5.1 weeks shorter. This is advantageous for the athlete who is seeking the quickest return to sport or “previous level of activity,” as it was defined within the study. Understanding that complications can pose setbacks, when Guerra et al., removed planned hardware removal from the operative group, there were significantly more reoperations in the nonoperative group. This provides great evidence for discussing treatment options with patients and athletes.

Currently, our algorithm for managing midshaft clavicle fractures in athletes takes into consideration the characteristics of the fracture, level of sport, upper extremity demand of sport, timing of the injury, and the athletic goals of the patient. For example, Fig. 1 illustrates a 17-year-old high school soccer player who sustained an in-season displaced clavicle fracture but desired to finish the season in the hopes of playing collegiate-level soccer. The patient underwent open reduction and internal fixation of the clavicle, finished the season, and was recruited to play soccer at the collegiate level.

Nathan L. Grimm, MD, and Katherine J. Coyner, MD, FAAOS, are from the Department of Orthopaedic Surgery in the Division of Sports Medicine at the University of Connecticut Musculoskeletal Institute.


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