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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.

Background Bipolar clavicle injury is a rare injury involving any combination of dislocation and/or fracture at both ends of the clavicle. Most reports of bipolar clavicle injury have been based on a single case, and treatment of this injury remains controversial. The present study was performed to evaluate the efficacy of surgical management with internal plating for bipolar clavicle injuries. Methods We performed internal plating to treat seven consecutive bipolar clavicle injuries with different injury patterns from May 2013 to June 2021. A clavicle hook plate was used for five sternoclavicular joint injuries (including a revision surgery) and three acromioclavicular joint dislocations, a T plate was used for one sternoclavicular joint injury, and an anatomic plate was used for one distal clavicle fracture. At follow-up, radiographs were assessed for bone alignment, joint congruity, fracture union or malunion, and implant failure or migration. Clinical evaluation included determination of the Disability of the Arm, Shoulder, and Hand (DASH) score; Constant–Murley score; visual analog scale (VAS) score; and complications. Results The patients were regularly followed up after the operation, and functional parameters were assessed over time. At a mean follow-up of 28.1 ± 22.0 months, each fracture had solid bone union, and each dislocation showed no sign of recurrent instability. The mean shoulder forward flexion was 159.3° ± 7.9°, and the mean DASH score was 8.8 ± 5.1. The mean Constant–Murley score was 88.9 ± 7.9, with six cases assessed as excellent and one case assessed as good. The mean VAS score was 1.0 ± 1.5, and the mean patient satisfaction score was 9.3 ± 0.8. No complications occurred, and each patient was able to resume their preinjury daily activity and was highly satisfied with their treatment. Conclusions In the present study, internal plating for bipolar clavicle injury allowed early mobilization and resulted in good joint function. We recommend fixation of the more severely affected side first because the other side may be passively reduced and acquire stability once the more severely affected side has been fixed. Internal fixation of the other end may therefore be unnecessary unless residual instability exists.

Aim: We aimed to evaluate clinical and functional outcomes of indirect fracture reduction performed by coracoclavicular fixation with minimal invasive double button lift-up system in Neer type IIa unstable fractures of distal clavicle. Material and methods: 22 patients with Neer type 2 distal clavicle fracture were enrolled in that prospective study. All patients underwent indirect reduction and osteosynthesis performed by coracoclavicular fixation with minimal invasive double button lift-up system. Postoperative follow-up was carried out clinically and radiologically with plain X-rays and utilization of Constant and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) shoulder scores. Mean follow-up time was 15 months. A standard sling was applied for 2 weeks, postoperatively. Rehabilitation program was started on postoperative day 1. Results: Mean age was 39 (range: 21–60), 18 of the patients were male. Right dominant extremity was affected in 14 patients. Mean duration of the surgical intervention was 40 min (range: 30–55 min). Mean union time was found to be 14 weeks (range: 7–21 weeks). Mean postoperative ASES and Constant scores were 79.9 (66.9–88.3) and 82.2 (71–100), respectively. The duration of return to normal daily activities were found to be 4.5 months. Any loss of reduction, AC joint arthrosis, and clavicular shortening were not detected in X-rays. Conclusion: This study has demonstrated that indirect osteosynthesis performed by coracoclavicular fixation with double button lift-up system in the treatment of unstable Neer type IIa fractures of the distal clavicle had successful clinical, radiological, and functional outcomes.

Background Large multi-centre studies of clavicle fractures have so far been missing. The aim of this observational study was to describe the epidemiology, classification and treatment of clavicle fractures in the The Swedish Fracture Register (SFR) that collects national prospective data from large fracture populations. Methods Data were retrieved from the SFR on all clavicle fractures sustained by patients ≥ 15 years of age in 2013–2014 ( n  = 2 422) with regards to date of injury, cause of injury, fracture classification and treatment. Results Sixty-eight per cent of the clavicle fractures occurred in males. The largest subgroup was males aged 15–24 years, representing 21% of clavicle fractures. At the ages of 65 years and above, females sustained more clavicle fractures than males. Same-level falls and bicycle accidents were the most common injury mechanisms. Displaced midshaft fractures constituted 43% of all fractures and were the most frequently operated fractures. Seventeen per cent of the patients underwent operative treatment within 30 days of the injury, where plate fixation was the choice of treatment in 94% of fractures. Conclusion The largest patient group was young males. Displaced midshaft fractures were the most common type of clavicle fracture as well as the most frequently operated type of fracture.

Background This study aims to systematically evaluate and compare the intraoperative outcomes, postoperative efficacy, and clinical prognosis of Nice knot versus lag screw in augmenting locking plate fixation for comminuted clavicular fractures. Through comprehensive assessment of different therapeutic approaches, we endeavor to provide more scientific and effective therapeutic options for patients with comminuted clavicular fractures. Methods From January 2020 to December 2022, 123 patients with unilateral midshaft comminuted clavicular fractures were enrolled, including 58 cases in the Nice knot (NK) group and 65 cases in the lag screw (LS) group. The general information, intraoperative conditions, postoperative clinical outcomes, and imaging results of patients in both groups were recorded and compared. The Visual Analog Scale (VAS) score, Constant-Murley score, Disabilities of the Arm, Shoulder and Hand (DASH) score and incidence of complications were assessed between the two groups. Results There were no significant differences in general information between the two groups. The NK group demonstrated significantly shorter operation time and less intraoperative blood loss compared to the LS group ( P  < 0.01). Both groups had one case of implant failure, while two cases of nonunion were observed in the LS group ( P  > 0.05). Follow-up results revealed no significant differences in VAS score, QuickDASH score, or Constant-Murley score between the two groups ( P  > 0.05). Conclusion This study demonstrated that both the Nice knot and lag screw achieved favorable clinical outcomes in augmenting locking plate fixation for Robinson IIB clavicle fractures. However, the NK group exhibited advantages of decreased intraoperative blood loss and shorter operation time, which makes it a valuable, effective, and safe surgical approach for managing Robinson IIB clavicle fractures, worthy of clinical promotion.

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.

Point-of-care ultrasound (PoCUS) can be used as a non-invasive and radiation free adjunct in the triage of patients with clavicle injuries. However, the diagnostic accuracy of PoCUS performed by non-radiologists for this purpose is not yet sufficiently established. A multicentre, prospective cohort study was conducted in 8 emergency departments (EDs) to establish the diagnostic accuracy of PoCUS of the clavicle in patients ≥4 years of age who presented with a clavicle injury. PoCUS was performed by trained emergency physicians, and results were compared with X-ray outcomes (gold standard). A total of 167 patients were included, of which 127 (76 %) patients had a fracture on X-ray, and 121 (72 %) on PoCUS. PoCUS of the clavicle had a sensitivity of 93 % (95 %CI 87–97 %), a specificity of 93 % (95 %CI 80–98 %), a negative likelihood ratio of 0.09 (95 %CI 0.04–0.14), and a positive likelihood ratio of 12.39 (95 %CI 4.17–36.82) for the presence of a clavicle fracture. Stratified based on age, specificity of PoCUS was lower in children compared to adults, whereas sensitivity was not affected. The agreement between X-ray and PoCUS for fracture displacement was substantial (κ = 0.771). PoCUS of the clavicle is a useful adjunct in the triage of patients with clavicle injuries and can help to distinguish which patients need further diagnostic workup. Netherlands Trial Register, registration code: NL9236. •After only limited training PoCUS of the clavicle can be performed reliably.•PoCUS has high diagnostic accuracy for exclusion or detection of clavicle fractures.•PoCUS as a diagnostic adjunct can help decide which patients need diagnostic workup.

To investigate the three-dimensional displacement of midshaft clavicular fractures after closed reduction and fixation with titanium elastic intramedullary nails. From January 2019 to January 2023, 74 patients with midshaft clavicle fractures (classified according to the AO/OTA system as groups A, B, and C) underwent closed reduction and titanium elastic nail fixation. Preoperative bilateral clavicular CT data and postoperative CT data of the affected clavicle were recorded and processed using Mimics software. Clavicle length, clavicle shortening, separation, and rotational displacement along the X/Y/Z axes were measured and recorded. Within-group comparisons showed a significant reduction in clavicle shortening and separation displacements, with a notable restoration of clavicle length postoperatively ( p  < 0.05). Except for Z-axis rotational displacement in Group A, no significant differences were observed in clavicle rotational displacement along the X/Y/Z axes between preoperative and postoperative measurements ( p  > 0.05). Between-group comparisons showed that preoperative separation displacement was significantly associated with AO/OTA classification (H = 6.427, p  = 0.040), while no significant differences were observed in other displacements between preoperative and postoperative measurements across groups. Titanium elastic intramedullary nails effectively restore clavicular length and correct shortening and separation displacement in midshaft fractures, but do not significantly improve rotational displacement along the X/Y/Z axes.

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.

Background This study aims to evaluate the efficacy and clinical outcomes of Nice knot-assisted fixation in the management of comminuted and displaced clavicle fractures. Methods A systematic search was conducted across multiple electronic databases, including PubMed, Embase, Cochrane Library, China Biology Medicine (CBM) database, CNKI, Wanfang, and VIP database, to identify studies comparing Nice knot-assisted fixation with traditional surgical treatment for displaced midshaft clavicle fractures. The primary outcomes assessed included fracture healing times, hospitalization days, complications, and functional outcomes. Secondary outcomes such as intraoperative blood loss, operative time, incision length, and fluoroscopy time were also evaluated. Data were analyzed using random-effects models, and summary statistics including Mean Difference (MD), risk ratios (RRs) and theirs’ 95% confidence intervals (CIs) were calculated. Results Screening of the literature yielded a total of 11 studies meeting the inclusion criteria, involving 754 patients. Meta-analysis of the pooled data demonstrated a significant advantage of Nice knot-assisted fixation over traditional surgical treatment in terms of operative time (MD = -11.53, 95% CI: -18.16 to -4.91, p  = 0.0006) and blood loss (MD = -14.19, 95% CI: -20.93 to -7.45, p  = 0.00001). Additionally, Nice knot-assisted fixation was associated with reduced fracture healing time (MD = -0.63, 95% CI: -1.12 to -0.14, p  = 0.01) rather than hospitalization days (MD = -0.47, 95% CI: -1.14 to 0.21, p  = 0.18) and complications (RR = 0.48, 95% CI: 0.23 to 1.01, p  = 0.05) compared to traditional surgical treatment. Moreover, nice knot-assisted fixation was associated with increased constant-murley score and Neer score, and reduced visual analogue scale (VAS) score compared to traditional surgical treatment. Conclusion This study highlights that Nice knot assistance offers advantages in reducing intraoperative blood loss, shortening operation time, and achieving favorable postoperative outcomes.