Clavicle Fractures

Author: David Abbasi

Topic updated on 01/28/13 5:27am

Introduction

Clavicle fractures make up 5-10% of all fractures
Fracture mechanism
- direct blow to lateral aspect of shoulder
- fall on an outstretched arm or direct trauma
- often seen in young active patients
Pathoanatomy
- in displaced fractures SCM and trapezius muscles pull the medial fragment posterosuperiorly, while pectoralis major and weight of arm pull the lateral fragment inferomedially
- open fractures buttonhole through platysma
Associated injuries
- are rare but include
  - ipsilateral scapula fracture
  - scapulothoracic dissociation
    - should be considered with significantly displaced fractures
  - rib fracture
  - pneumothorax
  - neurovascular injury
Pediatric Clavicle fractures
- fracture patterns include
  - medial/middle/lateral fractures (listed below)
  - medial clavicle physeal injury
  - distal clavicle physeal injury
- pediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum.

Relevant Anatomy

Acromioclavicular Joint Anatomy
AC joint stability
- acromioclavicular ligament
  - provides anterior/posterior stability
  - has superior, inferior, anterior, and posterior components
  - superior ligament is strongest, followed by posterior
- coracoclavicular ligaments (trapezoid and conoid)
  - provides superior/inferior stability
  - trapezoid ligament inserts 3 cm from end of clavicle
  - conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
    - conoid ligament is strongest
- capsule, deltoid and trapezius act as additional stabilizers

Classification

Group I - Middle third (80-85%)
Nondisplaced	Less than 100% displacement	Nonoperative
Displaced	Greater than 100% displacement Nonunion rate of 4.5%	Operative
Group II - Neer Classification of Lateral third (10-15%)
Type I	Fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or interligamentous Usually minimally displaced Stable because conoid and trapezoid ligaments remain intact	Nonoperative
Type IIA	Fracture occurs medial to intact conoid and trapezoid ligament Medial clavicle unstable Up to 56% nonunion rate with nonoperative management	Operative
Type IIB	Fracture occurs either between ruptured conoid and intact trapezoid ligament or lateral to both ligaments torn Medial clavicle unstable Up to 30-45% nonunion rate with nonoperative management	Operative
Type III	Intraarticular fracture extending into AC joint Conoid and trapezoid intact therefore stable injury Patients may develop posttraumatic AC arthritis	Nonoperative	x
Type IV	A physeal fracture that occurs in the skeletally immature Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum Clavicle pulls out of periosteal sleeve Conoid and trapezoid ligaments remain attached to periosteum and overall the fracture pattern is stable	Nonoperative	x
Type V	Comminuted fracture Conoid and trapezoid ligaments remain attached to comminuted fragment Medial clavicle unstable	Operative	x
Group III - Medial third (5-8%)
Anterior displacement	Most often non-operative Rarely symptomatic	Nonoperative
Posterior displacement	Rare injury (2-3%) Often physeal fracture-dislocation (age < 25) Stability dependent on costoclavicular ligaments Must assess airway and great vessel compromise Serendipity radiographs and CT scan to evaluate Surgical management with thoracic surgeon on standby	Operative

Presentation

Symptoms
- shoulder pain
Physical exam
- deformity
- perform careful neurovascular exam
- examine skin

Imaging

Radiographs
- standard AP view
- 45° cephalic tilt determine superior/inferior displacement
- 45° caudal tilt determines AP displacement
CT
- may help evaluate displacement, shortening, comminution, articular extension, and nonunion
- useful for medial physeal fractures and sternoclavicular injuries

Treatment

Nonoperative
- sling immobilization with gentle ROM exercises at 2-4 weeks
  - indications
    - nondisplaced Group I (middle third)
    - stable Group II fractures (Type I, III, IV)
    - nondisplaced Group III (medial third)
    - pediatric distal clavicle fractures (skeletally immature)
  - outcomes
    - nonunion (1-5%)
      - risk factors for nonunion
        
        Group II (up to 56%)
        
        comminution
        
        fracture displacement & shortening (>2 cm)
        
        advanced age and female gender
    - decreased shoulder strength and endurance
      - seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
Operative
- open reduction internal fixation
  - indications
    - absolute
      - unstable Group II fractures (Type IIA, Type IIB, Type V)
      - open fxs
      - displaced fracture with skin tenting
      - subclavian artery or vein injury
      - floating shoulder (clavicle and scapula neck fx)
      - symptomatic nonunion
      - posteriorly displaced Group III fxs
      - displaced Group I (middle third) with >2cm shortening
    - relative and controversial indications
      - brachial plexus injury (questionable b/c 66% have spontaneous return)
      - closed head injury
      - seizure disorder
      - polytrauma patient
  - outcomes
    - improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement
    - Outcome measures included
      - improved functional outcome / less pain with overhead activity
      - faster time to union
      - decreased symptomatic malunion rate
      - improved cosmetic satisfaction
      - improved overall shoulder satisfaction
- coracoclavicular ligament repair vs reconstruction
  - indication
    - indicated in group IIb and group III fractures with ligamentous injury

Techniques

Sling Immobilization
- technique
  - sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces)
  - after 2-4 weeks begin gentle range of motion exercises
  - no attempt at reduction should be made
- complications of nonoperative treatment
  - nonunion (1-5%)
    - treatment of nonunion
      - if asymptomatic, no treatment necessary
      - if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Open Reduction Internal Fixation
- surgical technique
  - plate and screw fixation
    - superior vs anterior plating
      - superior plating biomechanically higher load to failure and bending
      - superior plating better for inferior bony comminution
      - superior plating has higher risk of neurovascular injury during drilling
    - limited contact dynamic compression plate
      - 3.5mm reconstruction plate
      - locking plates
      - precontoured anatomic plates
        
        lower profile needing less chance for removal surgery
  - intramedullary screw or nail fixation
    - higher complication rate including hardware migration
  - hook plate
    - AC joint spanning fixation
- postoperative rehabilitation
  - sling for 7-10 days followed by active motion
  - strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
  - full activity including sports at ~ 3 months
- complications (~10% to 30%)
  - hardware complications
    - ~30% of patient request plate removal
    - superior plates associated with increased irritation
  - neurovascular injury (3%)
    - superior plates associated with increased risk of subclavian artery or vein penetration
  - adhesive capsulitis
    - 4% in surgical group develop adhesive capsulitis requiring surgical intervention nonunion (1-5%)
    - infection (~4.8%)
    - mechanical failure (~1.4%)
Coracoclavicular ligament repair vs reconstruction
- technique
  - primary repair can be done
  - most add supplementary suture (mersilene tape, fiberwire, ethibond) tied around coracoid and either into or around clavicle

Please Rate Educational Value!

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Qbank (9 Questions)

TAG

(OBQ11.118) A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true? Topic

Review Topic

FIGURES: A

1. No difference in shoulder function
2. Higher risk of nonunion with operative management
3. Higher risk of symptomatic malunion with nonoperative management
4. Earlier return to sport with nonoperative management
5. No difference in union rates

PREFERRED RESPONSE ▶

DISCUSSION: Historically, displaced midshaft clavicle fractures, as seen in Figure A, were managed nonoperatively. Recent literature has demonsrated improved outcomes with operative management of these fractures.

Khan et al review current concepts in the management of clavicle fractures. For displaced midshaft clavice fractures, operative treatment seems to result in improved patient and surgeon-based outcomes, decreased rates of malunion and nonunion, and shorter time to union.

Kim and McKee review recent evidence regarding the management of clavicle fractures. For midshaft clavicle fractures, the incidence of nonunion and symptomatic malunion with nonoperative management is higher than previously believed. They state that risk factors include 100% displacement, comminution, increasing age and female gender.

Incorrect Answers
Answer 1. Recent randomized prospective trials have shown improved short term shoulder function with operative management of displaced midshaft clavicle fractures.
Answer 2. Nonunion rates of 7-15% have been shown with nonoperative management versus 2% with operative fixation
Answer 4. Earlier return to activities has been reported with operative management
Answer 5. As with answer 2, there is a significantly higher rate of nonunion with nonoperative management

REFERENCES:

1. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. Review. PMID:19181992 (Link to Abstract)

2. Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin North Am. 2008 Oct;39(4):491-505, vii. Review. PMID:18803979 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Patrick McCulloch MD, Jan Szatkowski MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ10.94) What is the preferred treatment of displaced distal clavicle fractures in children less than eight years old? Topic

Review Topic

1. Closed reduction and pinning of the fracture
2. Open reduction and plating
3. Sling immobilization
4. Coracoclavicular ligament reconstruction
5. Open reduction and suture fixation

PREFERRED RESPONSE ▶

DISCUSSION: Pediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum. The coracoclavicular ligaments remain attached to the periosteum and new bone fills any remaining bony gaps within the periosteal sleeve. Recent articles by Nenopoulos et al recommend sling immobilization for the majority of fractures (84%) and only attempt surgical fixation for children >8 years old with severely displaced fractures (>2 cortical diameters). They found excellent function with conservative treatment and union in all fractures. Surgical care resulted in improved cosmetic appearance.

REFERENCES:

1. eaty JH, Kasser JR, eds. Rockwood & Wilkins' Fractures in Children, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:757-765.

2. Herring JA, ed. Tachdjian's Pediatric Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders; 2008:2423-2429.

3. Nenopoulos SP, Gigis IP, Chytas AA, Beslikas TA, Nenopoulos AS, Christoforidis JE. Outcome of distal clavicular fracture separations and dislocations in immature skeleton. Injury. 2010 Nov 3. Epub ahead of print PMID:21055749 (Link to Abstract)

Question Authors:

Charles Jobin MD,

Please Rate Educational Value!

4.0

Average 4.0 of 12 Ratings

TAG

(OBQ10.101) A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion? Topic

Review Topic

FIGURES: A

1. Open reduction and internal fixation with plating
2. Open reduction and percutaneous pinning
3. Closed reduction and percutaneous pinning
4. Closed reduction and external fixation
5. Nonoperative treatment with a sling and early range of motion

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a left clavicle fracture with significant shortening. Open reduction and internal fixation with plate and screw constructs of displaced, shortened clavicle fractures has been shown to lead to the best patient reported functional outcomes as well as have the least incidence of nonunion and symptomatic malunion. Factors associated with poor functional outcome as well as nonunion in these injuries include fracture displacement >2cm, fracture comminution, fracture displacement > 100%, female gender, and advancing age.

The referenced article by Khan et al is an excellent review of the indications, treatment methods and outcomes of clavicle fractures.

REFERENCES:

1. Ring D, Jupiter JB. Injuries to the shoulder girdle, in Browner BD, Jupiter JB, Levine AM, Trafton P, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia, PA: WB Saunders; 2003:1625-1654.

2. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. PMID:19181992 (Link to Abstract)

Question Authors:

Ben Taylor MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ08.54) Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively? Topic

Review Topic

1. Sling immobilization
2. Displacement and comminution
3. Age less than 40 years old
4. Immediate motion exercises
5. Male

PREFERRED RESPONSE ▶

DISCUSSION: Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.

The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2 vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks, p=0.001). However, 15% had hardware and wound complications. At one year, the operative group was more likely to be satisfied with the shoulder in general (p=0.002) and the appearance of the shoulder in particular (p=0.001) in comparison to the nonoperative group.

Prior studies have shown that greater than 2cm of shortening treated non-operatively results in increased fatigueability and poor outcome, but not necessarily nonunion. The Lazarides article concluded that “Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result.”

Studies have shown no difference in outcome when treated with a Figure-of-8 harness compared to a simple sling.

REFERENCES:

1. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10. PMID:17200303 (Link to Abstract)

2. Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elbow Surg. 2006 Mar-Apr;15(2):191-4. PMID: 16517363 PMID:16517363 (Link to Abstract)

3. Robinson, Court-Brown, MCQueen. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. JBJS 2004; 86A: 7: 1359. PMID:15252081 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 4 Ratings

TAG

(OBQ08.168) A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. What is the most appropriate management of the clavicular injury? Topic

Review Topic

FIGURES: A

1. Closed reduction and figure of 8 splinting
2. Open reduction and plate fixation
3. Open reduction and percutaneous pinning
4. Simple sling to involved side
5. Sling with abduction pillow to involved side

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph shows a comminuted clavicle fracture with significant displacement. Indications for surgical fixation of clavicle fractures include: open fractures, underlying neurovascular injury, or impending open fracture from internal bony pressure causing skin compromise. Relative indications for fixation include: greater than 15 mm of shortening, greater than 100% displacement (no bony contact), highly comminuted fractures, and polytrauma patients.

Jeray et al review the evaluation and treatment of midshaft clavicle fractures. They state "when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions."

REFERENCES:

1. Ring D, Jupiter JB: Injuries to the shoulder girdle, in Browner BD, Jupiter, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp1625-1654

2. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007 Apr;15(4):239-48. PMID:17426295 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Patrick McCulloch MD, Mark Miller MD,

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

TAG

(OBQ08.219) A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. After nine months of conservative treatment, he continues to complain of pain. A current radiograph is shown in Figure A. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Addition of a bone stimulator
2. Figure of eight brace
3. Closed reduction and percutaneous pinning
4. Open reduction and internal fixation
5. Open reduction and internal fixation with bone grafting

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a clavicular nonunion. Observation is the wrong answer because the patient is symptomatic (if the patient is asymptomatic an atrophic nonunion of the clavicle can be observed unless neurovascular symptoms are present). Intramedullary fixation is difficult because the pin has to pass through thin atrophic ends of bone close to neurovascular structures. Percutaneous pinning may cause distraction and migration of K-wires is common.

In the referenced study by Boyer et al, the authors note success in treating atrophic nonunions of the clavicle with compression and lag-screw fixation (absolute stability), in conjunction with cancellous autograft.

The referenced study by Bradbury et al reports on 32 clavicle nonunion procedures. They note 31 of 32 went on to union with use of a 3.5mm recon plate or small fragment DCP plate, also in conjunction with cancellous autograft.

REFERENCES:

1. Boyer MI, Axelrod TS. Atrophic nonunion of the clavicle: treatment by compression plate, lag-screw fixation and bone graft. J Bone Joint Surg Br. 1997 Mar;79(2):301-3. PMID:9119861 (Link to Abstract)

2. Bradbury N, Hutchinson J, Hahn D, Colton CL. Clavicular nonunion. 31/32 healed after plate fixation and bone grafting. Acta Orthop Scand. 1996 Aug;67(4):367-70. PMID:8792741 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 13 Ratings

TAG

(OBQ07.1) A 45-year-old male falls onto his left shoulder while biking. An injury radiograph is shown in Figure A. He elects for nonoperative treatment. What is the most likely clinical outcome? Topic

Review Topic

FIGURES: A

1. Symmetric cosmesis of shoulders
2. Reduced shoulder motion
3. Symptomatic nonunion
4. Shoulder instability
5. Decreased shoulder strength and endurance

PREFERRED RESPONSE ▶

DISCUSSION: Patients who have nonoperative treatment of displaced midshaft clavicle fractures have significant decreases in both strength and endurance to approximately 80% of the contralateral side as described by the McKee article. There was a trend correlating shortening >2cm with poor outcome (p=0.06). Motion was found to be preserved. In the Canadian Orthopaedic Trauma Society's landmark randomized control trial of operative versus nonoperative treatment for displaced clavicle fractures, patients treated non-operatively had lower subjective outcomes scores, slower rates to union, more nonunions, more symptomatic malunions, and were less satisfied with the appearance of their shoulder. There were more hardware related complications in the operatively treated group. The second McKee article describes improvements in subjective outcome scores after midshaft clavicle malunion corrective osteotomy.

REFERENCES:

1. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM,Potter J. Deficits following nonoperative treatment of displaced midshaftclavicular fractures. J Bone Joint Surg Am. 2006 Jan;88(1):35-40. PMID:16391247 (Link to Abstract)

2. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J BoneJoint Surg Am. 2003 May;85-A(5):790-7. PMID:12728026 (Link to Abstract)

3. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10. PMID:17200303 (Link to Abstract)

Question Authors:

Charles Jobin MD,

Please Rate Educational Value!

3.0

Average 3.0 of 9 Ratings

TAG

(OBQ07.25) A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace? Topic

Review Topic

FIGURES: A

1. Decreased sleep disturbance
2. Decreased personal care and hygiene impairment
3. Decreased rates of malunion
4. Improved long-term clinical outcomes
5. No advantage, equivalent result between a simple sling and figure-of-eight brace

PREFERRED RESPONSE ▶

DISCUSSION: Figure of eight braces have been shown to have no differences as compared to simple slings in regard to healing times, healing rates, and alignment at final follow-up.

The referenced study by Andersen et al is a Level 1 randomized controlled study showing equivalent cosmetic and clinical outcomes with sling versus figure of eight bracing despite increased sleep disturbances and increased rate of personal care impairment.

The second referenced study by Nordqvist et al is a Level 4 case series designed to analyze the long-term outcome of mid-clavicle fractures in adults and to evaluate the clinical importance of displacement and fracture comminution. They found a 39/225 rate of moderate shoulder pain with figure of eight bracing. Overall they concluded that few patients with fractures of the mid-part of the clavicle require operative treatment.

REFERENCES:

1. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987 Feb;58(1):71-4. PMID:3554886 (Link to Abstract)

2. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma. 1998 Nov-Dec;12(8):572-6. PMID:9840792 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

Please Rate Educational Value!

2.0

Average 2.0 of 15 Ratings

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10. PMID:17200303 (Link to Abstract)
Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987 Feb;58(1):71-4. PMID:3554886 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM,Potter J. Deficits following nonoperative treatment of displaced midshaftclavicular fractures. J Bone Joint Surg Am. 2006 Jan;88(1):35-40. PMID:16391247 (Link to Abstract)

Level of Evidence 4 (Case Series)

McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J BoneJoint Surg Am. 2003 May;85-A(5):790-7. PMID:12728026 (Link to Abstract)
Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma. 1998 Nov-Dec;12(8):572-6. PMID:9840792 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. Review. PMID:19181992 (Link to Abstract)
Kim W, McKee MD. Management of acute clavicle fractures. Orthop Clin North Am. 2008 Oct;39(4):491-505, vii. Review. PMID:18803979 (Link to Abstract)
Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. PMID:19181992 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Ring D, Jupiter JB. Injuries to the shoulder girdle, in Browner BD, Jupiter JB, Levine AM, Trafton P, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia, PA: WB Saunders; 2003:1625-1654.

Undefined

eaty JH, Kasser JR, eds. Rockwood & Wilkins' Fractures in Children, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:757-765.
Herring JA, ed. Tachdjian's Pediatric Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders; 2008:2423-2429.
Nenopoulos SP, Gigis IP, Chytas AA, Beslikas TA, Nenopoulos AS, Christoforidis JE. Outcome of distal clavicular fracture separations and dislocations in immature skeleton. Injury. 2010 Nov 3. Epub ahead of print PMID:21055749 (Link to Abstract)
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10. PMID:17200303 (Link to Abstract)
Lazarides S, Zafiropoulos G. Conservative treatment of fractures at the middle third of the clavicle: the relevance of shortening and clinical outcome. J Shoulder Elbow Surg. 2006 Mar-Apr;15(2):191-4. PMID: 16517363 PMID:16517363 (Link to Abstract)
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Clavicle Fractures

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