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Objective To investigate the efficacy of Endobutton plate combined with high-strength suture Nice knot fixation in the treatment of distal clavicular fractures with coracoclavicular ligament injuries. Methods A retrospective analysis was performed on 43 patients who sustained distal clavicular fractures along with injuries to the coracoclavicular ligament. These patients were treated between January 2017 and December 2023. The fractures were classified according to the fixation method: high-strength Nice knot suture fixation (experimental group, n  = 23) and acromioclavicular Kirschner wire fixation (control group, n  = 20). The basic information of the two groups of patients, including age, gender, cause of injury, fracture classification, hospitalization duration, fracture healing time and complications, was collected and analyzed. The increase rate of coracoclavicular space on the affected side was collected and analyzed. The pain level of the affected shoulder was assessed using the visual analog scale (VAS). The shoulder joint function was assessed using the American Shoulder and Elbow Surgeons (ASES) scores and Constant-Murley scores before and after surgery. Results No significant differences were observed in the general demographic data, including age, gender, injury etiology, Craig classification, and hospitalization duration between the two groups ( p  > 0.05). Both groups were followed for a period ranging from 12 to 33 months, with an average follow-up of 20.53 ± 5.16 months. The bone healing time in the experimental group was significantly shorter than in the control group (12.82 ± 1.12 weeks vs. 17.25 ± 1.71 weeks, p  < 0.05). At the final follow-up, The increase rate of coracoclavicular space was (9.25 ± 2.53) % in the experimental group and (8.10 ± 2.53) % in the control group, which was not significantly different ( p  > 0.05). Both groups demonstrated significant improvements in VAS scores, Constant-Murley scores, and ASES scores post-operatively compared to pre-operative values ( p  < 0.05 ). One month after surgery, the Constant-Murley and ASES scores were significantly superior in the experimental group compared to the control group ( p  < 0.05). However, no statistical difference was observed three months post-surgery or during the final follow-up ( p  > 0.05). The control group reported one case of infection related to the Kirschner wire and one case of Kirschner wire displacement postoperatively. Conversely, no significant complications were reported in the experimental group. Conclusion In the management of distal clavicle fractures accompanied by coracoclavicular ligament injuries, particularly oblique fractures or those with butterfly-shaped fragments, the application of a high-strength Nice knot suture in conjunction with Endobutton plate fixation can effectively stabilize the fracture site. This approach not only mitigates complications associated with Kirschner wire fixation but also enhances fracture healing, leading to favorable postoperative outcomes.

Purpose This study aimed to introduce a minimally invasive plate osteosynthesis technique along Langer’s lines for treating comminuted midshaft clavicular fractures and to evaluate its clinical and radiological outcomes. Methods From February 2020 to January 2023, 66 patients with midclavicular comminution fractures were randomized to either a conventional surgery group or a minimally invasive surgery (MIPO) group. In the MIPO group, three minimal incisions were made along Langer’s lines at the distal and proximal fracture ends and at the fracture site, and an anatomical locking plate was used for fixation. The operative duration, the total length of surgical incisions and the number of C-arm fluoroscopy during the procedures were recorded, respectively. All patients underwent follow-up, with clavicle X-rays to assess fracture union. Postoperative scar condition was assessed using the Vancouver Scar Scale (VSS), shoulder joint function with the Constant-Murley score, and overall upper limb function with the DASH score. Results No statistically significant differences were observed in mean operative duration (60.52 ± 8.92 vs. 58.21 ± 7.85, P  = 0.27) or the average number of intraoperative C-arm fluoroscopies (4.23 ± 0.91 vs. 3.89 ± 0.88, P  = 0.13) between the MIPO and traditional groups. A statistically significant difference was found in incision length (6.52 ± 0.76 cm vs. 10.45 ± 0.93 cm, P  < 0.05). The MIPO group demonstrated significantly shorter times to bone union (14.21 ± 2.62 weeks vs. 16.82 ± 3.24 weeks, P  < 0.05) and return to normal activities (14.84 ± 3.12 weeks vs. 17.68 ± 3.56 weeks, P  < 0.05) compared to the traditional group. The VSS scores vs. 4.23 ± 0.86 and 7.56 ± 0.98 ( P  < 0.05) for the MIPO and traditional groups, respectively. At one year postoperatively, the Constant-Murley scores were 94.6 ± 4.12 vs. 92.3 ± 4.86 ( P  < 0.05), and the DASH scores were 4.56 ± 0.96 vs. 6.45 ± 0.92 ( P  < 0.05) for the MIPO and traditional groups, respectively. Conclusion This MIPO technique achieves effective reduction and stabilization of the comminuted clavicular midshaft fractures without prolonging the surgical duration, while also taking into account the aesthetic quality of the incision and yielding favorable clinical outcomes.

Introduction The purpose of this prospective study was to report the outcomes of two different methods in CC and AC reconstruction for the treatment of AC separation using a tendon graft and knot-hiding titanium clavicular implant. Materials and methods Twenty-seven patients with Rockwood grade III and V acromioclavicular (AC) separations were randomized into two groups. The primary outcome was whether taking the tendon graft through the coracoid risked a fracture. The following were secondary outcomes: follow-up of clavicular wound healing and Nottingham Clavicle score, Constant score, and Simple Shoulder Test results obtained preoperatively and 24 months postoperatively. The anteroposterior radiographic change between the clavicular and coracoid cortexes and the clavicular tunnel diameter was measured postoperatively and 24 months postoperatively. General patient satisfaction with the outcome (poor, fair, good, or excellent) was assessed 2 years postoperatively. Results No coracoid fractures were detected. No issues in clavicular wound healing were detected. The mean Nottingham Clavicle score increased from a preoperative mean of 42.42 ± 13.42 to 95.31 ± 14.20 ( P  < 0.00). The Constant score increased from a preoperative mean of 50.81 ± 17.77 to 96.42 ± 11.51 ( P  < 0.001). The Simple Shoulder Test score increased from a preoperative mean of 7.50 ± 2.45 to 11.77 ± 1.18 ( P  < 0.001). The changes were significant. The coracoclavicular distance increased from 11.88 ± 4.00 to 14.19 ± 4.71 mm ( P  = 0.001), which was significant. The clavicular drill hole diameter increased from 5.5 to a mean of 8.00 ± 0.75 mm. General patient satisfaction was excellent. Conclusions There were no significant differences between the two groups. There were no implant related complications in the clavicular wound healing. The results support the notion that good results are achieved by reconstructing both the CC and AC ligaments with a tendon graft. Study registration This clinical trial was registered on Clinicaltrials.gov.

To compare the clinical efficacy of vertical double-plate fixation (combining a distal clavicle locking plate and a radial lateral plate) versus clavicular hook plate fixation for unstable distal clavicle fractures. A retrospective analysis was conducted on 37 patients with unstable distal clavicle fractures (Neer II/V) treated at our institution from May 2015 to May 2023. Twenty-one patients underwent open reduction and internal fixation with clavicular hook plates (16 Neer II, 5 Neer V), while 16 patients received vertical double-plate fixation (12 Neer II, 4 Neer V). Postoperative evaluations included: 1) radiographic assessment of fracture healing at 1, 2, 3, and 6 months; 2) Visual Analogue Scale (VAS) pain scores during passive shoulder mobilization at 1, 2, and 4 weeks; and 3) Constant-Murley shoulder function scores and complication rates (incision infection, nonunion, acromial osteolysis, impingement syndrome) at 3, 6 and 12 months. The clavicular hook plate group (mean age 47.96±17.01 years) and vertical double-plate group (mean age 49.47±15.33 years) showed comparable demographics. All patients achieved fracture union within 3–6 months, with no implant displacement. The vertical double-plate group demonstrated significantly lower VAS scores during early rehabilitation (4.6±1.09, 4.05±0.88, 2.8±1.0 vs. 7.25±1.16, 5.9±1.12, 4.75±0.71; P<0.05). At 3, 6 and 12 months, Constant-Murley scores were markedly higher in the vertical double-plate group (84.41±4.48, 92.25±2.47, 94.55 vs. 75.35±5.92, 83.4±3.87, 88.10±2.10; P<0.05). The clavicular hook plate group exhibited higher complication rates: 4 cases of impingement syndrome, 3 of acromial osteolysis, and 5 with limited shoulder mobility—all improving after implant removal. Both techniques effectively achieve fracture union for unstable distal clavicle fractures. However, vertical double-plate fixation offers superior pain control, facilitates earlier functional rehabilitation, improves shoulder functional recovery, and reduces postoperative complications, demonstrating enhanced clinical efficacy compared to hook plate fixation.

Background Thoracic outlet syndrome can develop following the malunion of a clavicle midshaft fracture. To date, thoracic outlet syndrome complicated by clavicle malunion is typically treated with either first rib resection or corrective clavicle osteotomy; however, there have been no reports of these two procedures being performed simultaneously using the same approach. We present the first documented case of thoracic outlet syndrome caused by clavicle malunion treated by simultaneous first rib resection and corrective clavicle osteotomy through a single infraclavicular approach. Case presentation A 46-year-old woman presented with numbness and muscle weakness in the left upper limb, which worsened with 90º abduction external rotation of the shoulder joint. She had a history of conservative treatment for a left clavicle midshaft fracture 21 years earlier. Magnetic resonance imaging taken with upper extremity elevation revealed stenosis of the left subclavian artery at the costoclavicular space. Three-dimensional clavicle symmetry plane demonstrated that the distal fragment of the left clavicle displaced inferiorly and malunited, and left scapular depressed and retracted. The distance between the left clavicle and the first rib was up to 7 mm shorter than that on the right side. She was diagnosed with left arterial thoracic outlet syndrome caused by clavicle malunion. Using an infraclavicular approach, we performed the first rib resection and clavicle osteotomy. We inserted the first rib bone graft into the osteotomy site and performed the plate fixation. Her symptoms had resolved by two years postoperatively. Conclusions The present case provides new information on the surgical procedure of thoracic outlet syndrome due to clavicle malunion. In our patient, the inferior displacement of malunited clavicle and the associated scapular malposition may cause narrowing of the costoclavicular space, resulting in the development of thoracic outlet syndrome. The present case demonstrates that the infraclavicular approach enables the simultaneous first rib resection and corrective clavicle osteotomy and provides reliable decompression of the costoclavicular space. Clinical trial number Not applicable.

Background Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. Questions/purposes We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? Methods Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30–51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient’s wish, or surgeon’s preference. Results Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, −0.7; 95% CI, −2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82–1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24–2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. Conclusions After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. Level of Evidence Level II, therapeutic study.

Background Evidence regarding the treatment of displaced, extraarticular lateral clavicle fractures is scarce. No study has shown clinically significant differences between surgical and nonsurgical treatment, but the sample sizes have been small, as it has been difficult to include enough patients with this relatively uncommon fracture type. Purpose This study aims to compare outcomes after surgical and nonsurgical treatment for displaced lateral clavicle fractures. Methods This is a pragmatic, noninferiority, preference-tolerant, randomized controlled trial (RCT). A total of 100 patients between the ages of 18 and 65 with displaced lateral clavicle fractures will be randomly allocated on a 1:1 ratio to surgical or nonsurgical treatment with the option of early crossover after 6 weeks. An observational cohort will comprise patients not willing to be randomized. This is a multicenter Scandinavian RCT including hospitals in Sweden, Norway, Denmark, and Finland. The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year. Follow-up points will be 6 weeks, 3 months, 6 months, and 1 year. The secondary outcomes are the DASH score, the EQ-5D-5L score, the University of California, Los Angeles (UCLA) activity score, the Nottingham Clavicle Score (NCS), a visual analog scale (VAS) for pain, and anchor questions in the form of the Patient Global Impression of Change (PGIC) collected at all timepoints during the study. All complications, radiographic healing, and return to work will be reported. Discussion The optimal treatment for displaced Neer type II and V lateral clavicle fractures remains a topic of debate. This RCT may provide a better understanding of the differences in outcomes of nonsurgical and surgical treatment while reflecting real-world clinical practice and guiding the development of a treatment algorithm for the orthopedic community. Trial registration ClinicalTrials.gov NCT06981065. Registered on 19 May 2025. https://clinicaltrials.gov/study/NCT06981065?term=Scandilac&rank=1

Background and aim Isolated midshaft clavicle fractures (MCF) and acromioclavicular joint (ACJ) injuries are common, but simultaneous cases are rare and often receive insufficient clinical attention, resulting in missed diagnoses. Moreover, there is no consensus on the injury mechanism, classification, and treatment, and the prognosis remains poorly summarized. This review aims to provide an overview of MCFs with ipsilateral ACJ injuries, focusing on injury mechanism, classification, treatment, and prognosis. Methods We searched the literature published between 1962 and 2024 on PubMed, Web of Science, and EMBASE using the search terms “clavicle fracture [Title/Abstract]) AND (acromioclavicular [Title/Abstract])”. Studies reporting clinical outcomes in patients with MCF and ipsilateral ACJ injuries were included. 37 studies were included after screening. The study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Data on study design, patient demographics, treatment approaches, and outcomes were extracted for qualitative analysis. We then summarized key findings and presented our insights. Results MCFs with ipsilateral ACJ injuries are often associated with comorbidities such as rib fractures, hemopneumothorax, scapula fractures, neurovascular injuries, and atypical MCF displacement patterns. These cases should raise suspicion for combined injuries. Due to the \"floating\" nature of the lateral clavicle, the \"Piano Key Sign\" is typically negative and not reliable for diagnosis. Initial ACJ evaluation may be inconclusive, so reevaluation after MCF fixation is recommended. Type IV ACJ injuries can be underestimated on anteroposterior radiographs, and additional axillary radiographs and CT scans may better visualize posterior clavicle displacement. Most researchers believe ACJ capsule and ligament damage occurs first, but is insufficient to cause significant dislocation, suggesting that isolated MCF may involve combined ACJ injury with intact coracoclavicular ligaments. Notably, most patients reported favorable outcomes without major complications within two years, regardless of treatment approach. Conclusions MCFs with ipsilateral ACJ injuries are rare and often missed when ACJ injuries are mild. The injury mechanism is unclear, and no classification system exists to indicate severity. These injuries are typically treated separately without a unified protocol. Despite promising outcomes, further studies are needed to address these issues and improve understanding of long-term results.

Finite element analysis has become indispensable for biomechanical research on clavicle fractures. This review summarized evidence regarding configurations and applications of finite element analysis in clavicle fracture fixation. Seventeen articles involving 22 clavicles were synthesized from CINAHL, Embase, IEEE Xplore, PubMed, Scopus, and Web of Science databases. Most studies investigated midshaft transverse closed fractures by reconstructing intact models from CT scans and simulating fractures through gap creation. Common loading schemes included axial compression, distal torsion, and inferior bending. The primary objective was comparing different implant designs/placements on construct stiffness, von Mises stress, and fracture site micro-motion. Our review suggested a preference for plate fixation, particularly with anterior placement, for midshaft transverse fractures. However, limited fracture types studied constrain comprehensive recommendations. Additionally, the review highlighted discrepancies between finite element and clinical studies, emphasizing the need for improved modeling of physiological conditions. Future research should focus on developing a comprehensive database of finite element models to test various implant options and placements under common loading schemes, bridging the gap between biomechanical simulations and clinical outcomes. Graphical Abstract

[LANGUAGE= \"English\"] BACKGROUND: Although non-surgical management is a commonly used treatment for pediatric clavicle fractures, there is limited data in the literature regarding the most effective method. This study aims to compare the radiological outcomes of the figure-of-eight bandage versus the arm sling in the treatment of mid-shaft clavicle fractures in school-age children.METHODS: Patients were divided into two groups based on the preferred conservative management method: Group 1 (arm sling) and Group 2 (figure-of-eight bandage). The degree of angulation and shortening was measured at initial admission and during follow-up. Demographic characteristics and radiological data were compared between the two groups.RESULTS: Group 1 included 10 girls and 10 boys, while Group 2 included 12 girls and 17 boys (p=0.761). The mean shortening at initial presentation was 7.28±6.06 mm in Group 1 and 6.65±5.58 mm in Group 2 (p=0.625). At follow-up, the mean shortening was 6.24±5.59 mm in Group 1 and 5.59±4.91 mm in Group 2 (p=0.569). The mean angulation at initial presentation was 21.28±10.05° in Group 1 and 20.41±12.23° in Group 2 (p=0.752). At follow-up, the mean angulation was 14.45±9.41° in Group 1 and 11.82±10.27° in Group 2 (p=0.189). In intra-group comparisons, no significant difference was found between the initial shortening and follow-up shortening in either group (Group 1: p=0.062; Group 2: p=0.190). A significant reduction in angulation was observed in both groups during follow-up (p=0.001 for Group 1; p=0.001 for Group 2).CONCLUSION: The radiological outcomes of the figure-of-eight bandage and the arm sling in the treatment of mid-shaft clavicle fractures in school-age children are similar.[LANGUAGE= \"Turkish\"] AMAÇ: Cerrahi dışı tedavi, pediatrik klavikula kırıklarında için sıklıkla kullanılması, hangi yöntemle yapılacağına dair literatürde sınırlı veri bulunmaktadır. Çalışmanın amacı, okul çağı çocuklarındaki klavikula orta diafiz kırıklarında sekiz bandajı ve kol askısının radyolojik sonuçlarını karşılaştırmaktır. GEREÇ VE YÖNTEM: Hastalar tercih edilen konservatif tedavi yöntemine göre iki gruba ayrıldı. (Grup 1: kol askısı, Grup 2: sekiz bandajı). İlk başvuruda ve takipte açılanma ve kısalma miktarı ölçüldü. Genel özellikler ve radyolojik veriler iki grup arasında karşılaştırıldı.BULGULAR: Grup 1'de 10 kız ve 10 erkek, Grup 2'de ise 12 kız ve 17 erkek vardı (p=0.761). Grup 1'de ilk başvurudaki ortalama kısalma 7.28±6.06 mm ve Grup 2'de 6.65±5.58 mm idi (p=0.625). Takipteki ortalama kısalma Grup 1'de 6.24±5.59 mm ve Grup 2'de 5.59±4.91 mm idi (p=0.569). Başlangıç başvurusundaki ortalama açılanma Grup 1'de 21.28±10.05° ve Grup 2'de 20.41±12.23° idi (p=0.752). Takipteki ortalama açılanma Grup 1'de 14.45±9.41° idi; Grup 2'de 11.82±10.27° (p=0.189). Grup içi karşılaştırmalarda, her iki grupta da başlangıç kısalma miktarı ile takipteki kısalma miktarı arasında anlamlı bir fark bulunmadı [p=0.062 (grup 1); p=0.190 (grup 2)]. Açısal değerler incelendiğinde, iki grupta da takipler sırasında açılanma miktarının istatistiksel olarak anlamlı şekilde azaldığı görüldü [p=0.001 (grup 1); p=0.001 (grup 2)].SONUÇ: Okul çağı çocuklarındaki klavikula orta diafiz kırıklarında sekiz bandajı ve kol askısının radyolojik sonuçları benzerdir.