Injuries of the Clavicle,

Acromioclavicular Joint and

Sternoclavicular Joint

Andrew H. Schmidt, M.D.

Revised October 2010

Andrew H. Schmidt, MD & T. J. McElroy, MD;

Created March 2004; Revised January 2007 & October 2010
 Goals

1) Review anatomy of clavicle, AC joint, and

sternoclavicular joint
2) Review imaging of these areas.
3) Clavicle Fractures
Nonoperative RX
Surgical Repair
Nonunions and Malunions
4) AC Joint Injuries
5) Sternoclavicular joint injuries
 Clavicle

“S”-shaped bone
Medial - sternoclavicular joint
Lateral - acromioclavicular joint and
coracoclavicular ligaments
Muscle attachments:
– Medial: sternocleidomastoid
– Lateral: Trapezius, pectoralis major
 AC Joint

Diarthrodial joint between medial facet of acromion and the

lateral (distal) clavicle.
Contains intra-articular disk of variable size.
Thin capsule stabilized by ligaments on all sides:
– AC ligaments control horizontal (anteroposterior ) displacement
– Superior AC ligament most important
 Distal Clavicle

Coracoclavicular ligaments
– “Suspensory ligaments of the upper
extremity”
– Two components:
• Trapezoid
• Conoid
– Stronger than AC ligaments
– Provide vertical stability to AC joint
 Mechanism of Injury

Direct impact to the anterior - superior

shoulder of moderate – high force.
1. Fall from height
2. Motor vehicle accident
3. Sports injury
4. Blow to the point of the shoulder
5. Rarely, a direct injury to the clavicle
 Physical Examination
Inspection
– Evaluate deformity and/or
displacement
– Beware of rare inferior or
posterior displacement of
distal or medial ends of
clavicle
– Compare to opposite side.
Physical Examination

Palpation
Evaluate pain
Look for instability with stress
 Physical Examination

Neurovascular examination
– Must be done thoroughly and documented!
Evaluate upper extremity motor and sensation
Measure shoulder range-of-motion
 Radiographic Evaluation
of the Clavicle

Anteroposterior View

30-degree Cephalic Tilt

View
Radiographic Evaluation of the
Clavicle

Quesana View
– 45-degree angle superiorly and a 45-degree
angle inferiorly
– Provide better assessment of the extent of
displacement
Radiographic Evaluation of the AC
Joint

Zanca View
– AP view centered at AC joint with 10
degree cephalic tilt
– Less voltage than used for AP shoulder
 Stress Views of the Distal
Clavicle & AC Joint

Rationale: demonstrate instability and differentiate grade III AC

separations from partial Grade I-II injuries.
Performed by having patient hold 10# weight with injured arm.
Rarely used today, since most Grade I-III AC joint injuries are
treated the same anyway, and management of distal clavicle
fractures depends on initial displacement and location of
fracture.
 Radiographic Evaluation of the
Medial One Third
X-ray: Cephalic tilt view of
40 to 45 degrees
CT scan usually indicated
to best assess degree and
direction of
displacement

S=sternum
C= medial clavicle
E= esophagus
Clavicle Fractures
Classification of Clavicle
Fractures

Group I : Middle third

– Most common (80% of clavicle fractures)
Group II: Distal third
– 10-15% of clavicle injuries
Group III: Medial third
– Least common (approx. 5%)
Treatment Options
Nonoperative
– Sling
– Brace
Surgical
– Plate Fixation
– Screw or Pin Fixation
– Titanium elastic nails (usually
inserted medial to lateral)
 Nonoperative Treatment
“Standard of Care” for most clavicle fractures.
Unclear about the need to wear a specialized brace.
Simple Sling vs. Figure-of-8 Bandage

Prospective randomized trial of 61 patients

Simple sling
– Less discomfort
Functional and cosmetic results identical
Alignment of healed fractures unchanged
from the initial displacement in both groups

Andersen et al., Acta Orthop Scand 58: 71-4, 1987.

 Nonoperative Treatment
It is difficult to reduce clavicle fractures by
closed means.
Most clavicle fractures unite rapidly despite
displacement.
Significantly displaced mid-shaft and distal-third
injuries have a higher incidence of nonunion.
 Nonoperative Treatment
There is new evidence that the outcome of
nonoperative management of displaced
middle-third clavicle fractures is not as good
as traditionally thought, with many patients
having significant functional problems.
 Deficits following nonoperative treatment of
displaced midshaft clavicular fractures
A patient-based outcome questionnaire and muscle-strength
testing were used to evaluate 30 patients after nonoperative
care of a displaced midshaft fracture of the clavicle.
At a minimum of twelve months (mean 55 mos), outcomes
were measured with the Constant shoulder score and the
DASH patient questionnaire. In addition, shoulder muscle-
strength testing was performed with the Baltimore
Therapeutic Equipment Work Simulator, with the
uninjured arm serving as a control.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

 Deficits following nonoperative treatment of
displaced midshaft clavicular fractures

The strength of the injured shoulder was:

– 81% for maximum flexion, 75% for endurance of flexion,
– 82% for maximum abduction, 67% for endurance of abduction,
– 81% for maximum external rotation, 82% for endurance of
external rotation,
– 85% for maximum internal rotation, and 78% for endurance of
internal rotation (p < 0.05 for all).
Mean Constant score = 71 points
Mean DASH score = 24.6 points, indicating substantial
residual disability.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

 Conclusion of McKee study
Displaced midshaft clavicle fractures can
cause significant, persistent disability, even
if they heal uneventfully.
Definite Indications for Surgical
Treatment of Clavicle Fractures
1) Open fractures
2) Associated neurovascular injury
 Relative Indications for Acute
Treatment of Clavicle Fractures
1) Widely displaced fractures
2) Multiple trauma
3) Displaced distal-third fractures
 Relative Indications for Acute
Treatment of Clavicle Fractures
4) Floating shoulder
5) Seizure disorder
6) Cosmetic deformity
7) Earlier return to work.
 Clavicular Displacement Literature
< 5 mm shortening: acceptable results at 5 years (Nordqvist et al,
Acta Orthop Scand 1997;68:349-51.
> 20 mm shortening associated with increased risk of nonunion
and poor functional outcome at 3 years (Hill et al, JBJS
1997;79B: 537-9)
 Plate Fixation
Traditional means of ORIF
Plate applied superiorly or inferiorly
Inferior plating associated with lower risk of
hardware prominence.
Used for acute displaced fractures and
nonunions.
May dissect out supraclavicular
sensory nerves

Courtesy T. Higgins
 Nonoperative Treatment Compared with Plate
Fixation of Displaced Midshaft Clavicular Fractures.
A multicenter, randomized clinical trial

132 patients
– 67 ORIF
– 65 sling
Constant and DASH scores significantly improved in ORIF
group.
Time to union 16 vs 28 weeks in favor of ORIF
9 patients in sling group had symptomatic malunion
9 patients in ORIF group had hardware complications

Canadian Orthopedic Trauma Society; JBJS Am;2007:89A: 1-10

 Intramedullary Fixation
Large threaded cannulated screws
Flexible elastic nails
K-wires
Associated with risk of migration

Useful when plate fixation contra-

indicated
Bad skin
Severe osteopenia
Fixation less secure
 Titanium Elastic Nails

Same as used in pediatric femur fractures.

Accommodate three-dimensional anatomy of the clavicle.
Typically inserted “retrograde” (from medial to lateral)
Best in fractures without comminution
Small incision at fracture site may be needed.
Minimally Invasive Intramedullary Nailing of Midshaft
Clavicular Fractures Using Titanium Elastic Nails

31 cases evaluated 26 mos avg (6-46 mos)

Three groups:
Isolated, n=9
Additional injuries, n=15
Multiple injuries, n=7

Mueller M, et al. J Trauma 2008;64:1528-1534

 Minimally Invasive Intramedullary Nailing of Midshaft
Clavicular Fractures Using Titanium Elastic Nails

No nonunions or refractures in any group.

7 cases medial migration; 1 case lateral
perforation in 1 case req’d shortening of nail.
No differences in outcome between groups in
subjective outcome and objective scores
(DASH, Constant and Murley).

Mueller M, et al. J Trauma 2008;64:1528-1534

 30 patients: simple shoulder sling 30 patients elastic nail
90% union 100% union
2 symptomatic malunions req’d OR 7 cases medial nail protrusion
2 refractures
Better DASH and Constant outcome
scores, significantly different during first
18 weeks.
Patients more satisfied with cosmetic
appearance and overall outcome.
 Comparison of Techniques
No studies available that compare one
operative technique to another.
Both elastic nails and plates seem equivalent
in stable fractures; benefits of minimally
invasive approach used in elastic nailing
awaiting study.
Plate fixation best in comminuted fractures,
but again no evidence.
Does Timing of Surgery Matter?

Matched group comparison of 15 patients who

underwent early compression plate fixation
to 15 other patients who had operative
repair of a malunion/nonunion at avg of 63
months.

Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Does Timing of Surgery Matter?

Outcome Early Delayed

Strength = =
Endurance 109% 80% (p=.05)
Constant score 95 89 (p=.02)
DASH score 3.0 7.2 (p=.15)
Satisfaction exc exc

Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Does Timing of Surgery Matter?

Conclusion: Late reconstruction provides

outcome similar to acute repair, except for
subtle decreases in endurance strength.

Such information might be of value in initial

decision-making.

Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Complications of Clavicular
Fractures and its Treatment
Nonunion
Malunion
Neurovascular Sequelae
Post-Traumatic Arthritis
Risk Factors for the Development
of Clavicular Nonunions

Location of Fracture
– (outer third)
Degree of Displacement
– (marked displacement)
Primary Open Reduction
Principles for the Treatment of
Clavicular Nonunions
Restore length of clavicle
– May need intercalary bone graft
Rigid internal fixation, usually with a plate
Iliac crest bone graft
– Role of bone-graft substitutes not yet defined.
Correction of symptomatic nonunion with IM screw
 Clavicular Malunion
Symptoms of pain, fatigue, cosmetic deformity.
Initially treat with strengthening, especially of
scapulothoracic stabilizers.
Consider osteotomy, internal fixation in rare cases in
which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx

 Neurologic Sequelae
Occasionally, fracture fragments or abundant
callus can cause brachial plexus symptoms.
Treatment is reduction and fixation of the
fracture, or resection of callus with or
without osteotomy and fixation for
malunions.
 Osteotomy for Clavicular
Malunion
15 patients with malunion after nonoperative treatment of a
displaced midshaft clavicle fracture of the clavicle.
Average clavicular shortening was 2.9 cm (range, 1.6 to
4.0 cm).
Mean time from the injury to presentation was three years
(range, 1 to 15 years).
Outcome scores revealed major functional deficits.
All patients underwent corrective osteotomy of the malunion
through the original fracture line and internal fixation.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

 Osteotomy for Clavicular
Malunion
At follow-up (mean 20 months postoperatively) the
osteotomy site had united in 14 of 15 patients.
All 14 patients satisfied with the result.
Mean DASH score for all 15 patients improved from 32
points preoperatively to 12 points at the time of follow-up
(p = 0.001).
Mean shortening of the clavicle improved from 2.9 to 0.4 cm
(p = 0.01).
There was 1 nonunion, and 2 patients had elective removal of
the plate.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

 Functional Outcome of Surgical Treatment of
Symptomatic Nonunion and Malunion of Midshaft
Clavicle Fractures

13 cases plate fixation / autogenous grafting of a clavicle

nonunion / malunion, followed mean 41 months.
All united
46% returned to previous job and sport
Constant scores remained lower than opposite arm
<25% free of pain.

Rosenberg N, et al. J Shoul Elbow Surg 2007;16:510-513

Distal Third Clavicle Fractures
 Classification of Distal
Clavicular Fractures
(Group II Clavicle Fractures)

Type I-nondisplaced
– Between the CC and
AC ligaments with
ligament still intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Classification of Distal
Clavicular Fractures
Type II
– Typically displaced secondary to a fracture
medial to the coracoclavicular ligaments,
keeping the distal fragment reduced while
allowing the medial fragmetn to displace
superiorly
– Highest rate of nonunion (up to 30%)
– Two Types
 Type IIA

A. Conoid and trapezoid

attached to distal fragment

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Type IIB

Type IIB: Conoid

torn, trapezoid
attached

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Classification of Distal
Clavicular Fractures

Type III:articular
fractures

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Treatment of Distal-Third (Type II)
Clavicle Fractures
Nonoperative treatment
– 22 to 33% failed to unite
– 45 to 67% took more than three months to heal

Operative treatment
– 100% of fractures healed within 6 to 10 weeks after
surgery
 Displaced Type II fractures of the distal
clavicle are often treated more aggressively
because of the increased risk of nonunion
with nonoperative treatment
 Techniques for Acute Operative
Treatment of Distal Clavicle Fractures

Kirschner wires inserted into the distal fragment

Dorsal plate fixation
CC screw fixation
Tension-band wire or suture
Transfer of coracoid process to the clavicle
Clavicular Hook Plate
For most techniques of clavicular fixation,
coracoclavicular fixation is also needed to
prevent redisplacement of the medial
clavicle.
The Hook Plate (Synthes USA, Paoli, PA) was
specifically designed to avoid this problem of
redisplacement.
 Hook Plate - Results
Recent series of distal clavicle fractuers
treated with the Hook Plate document high
union rates of 88% - 100%. Complications
are rare but potentially significant,
including new fracture about the implant,
rotator cuff tear, and frequent subacromial
impingement.
Preferred technique for fixation
of acute distal third clavicle
fractures
Horizontal incision
Manual reduction of fracture
Dorsal tension band suture and
reconstruction/augmentation of
coracoclavicular ligaments.
Look for avulsion fracture of CC
ligament attachment

If present, this fragment can be sutured to

proximal (eg. medial) clavicle to restore
stability, without need for hardware.

Jackson WFM, et al. J Trauma 2006;61:222-225

Indications For Late Surgery For
Distal Clavicle Fractures

Pain
Weakness
Deformity
Techniques For Late Surgery For
Distal Clavicle Fractures

Excision of distal clavicle

– With or without reconstruction of
coracoclavicular ligaments (Modified
Weaver-Dunn procedure)
Reduction and fixation of fracture
Case Example 1
 Case Example 1

Medial Clavicle
Distal Clavicle
Case Example 1
Fixation to Acromion

Coracoclavicular
fixation not visible
 Case Example 2

This fragment likely has CC ligament attached; need

to reduce and hold clavicle shaft to this piece.
 Case Example 2

Sutures passed into this

This fragment
fragment likely has CC ligament attached; need
(not visible)
to reduce and hold clavicle shaft to this piece.
 Case Example 2

Sutures passed into this

This fragment
fragment likely has CC ligament attached; need
(not visible)
to reduce and hold clavicle shaft to this piece.

4 months
 Case Example 2

Sutures passed into this

This fragment
fragment likely has CC ligament attached; need
(not visible)
to reduce and hold clavicle shaft to this piece.

2 years
Acromioclavicular Joint
 Mechanism
Sports injury or trauma.
Impact to superior acromion, driving the arm
down and rupturing the AC joint capsule
(first) and then the the coracoclavicular
ligaments (second).
 Physical Findings
Pain over lateral clavicle / AC joint
May have prominent distal clavicle
May have skin abrasions
Unwilling to lift arm.
Should have full passive ROM of the
shoulder.
 Radiographic Evaluation of the
Acromioclavicular Joint
Proper exposure of the AC joint requires one-third to
one-half the x-ray penetration of routine shoulder
views
Initial Views:
– Anteroposterior view
– Zanca view (15 degree cephalic tilt)
Other views:
– Axillary: demonstrates anterior-posterior displacement
– Stress views: not generally relevant for treatment
decisions.
 Classification For
Acromioclavicular Joint Injuries
Initially classified by both Allman and Tossy et al.
into three types (I, II, and III).
Rockwood later added types IV, V, and VI, so that
now six types are recognized.
Classified depending on the degree and direction of
displacement of the distal clavicle.

Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation.
JBJS 49A: 774-784, 1967.
Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In
Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp.
413-476.
 Type I
Sprain of
acromioclavicular
ligament
AC joint intact
Coracoclavicular
ligaments intact
Deltoid and trapezius
muscles intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Type II
AC joint disrupted
< 50% Vertical
displacement
Sprain of the
coracoclavicular
ligaments
CC ligaments intact
Deltoid and trapezius
muscles intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Type III
AC ligaments and CC
ligaments all disrupted
AC joint dislocated and the
shoulder complex
displaced inferiorly
CC interspace greater than
the normal shoulder(25-
100%)
Deltoid and trapezius
muscles usually detached
from the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
 Type III Variants

“Pseudo-dislocation” through an
intact periosteal sleeve
Physeal injury
Coracoid process fracture
 Type IV
AC and CC ligaments
disrupted
AC joint dislocated and
clavicle displaced
posteriorly into or
through the trapezius
muscle
Deltoid and trapezius
muscles detached from
the distal clavicle
From Nuber GW and Bowen MK, JAAOS, 5:11, 1997
 Type V
AC ligaments disrupted
CC ligaments disrupted
AC joint dislocated and
gross disparity between
the clavicle and the
scapula (100-300%)
Deltoid and trapezius
muscles detached from
the distal half of clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Type VI
AC joint dislocated and
clavicle displaced inferior
to the acromion or the
coracoid process
AC and CC ligaments
disrupted
Deltoid and trapezius
muscles detached from the
distal clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Treatment Options For Types I - II
Acromioclavicular Joint Injuries

Nonoperative: Ice and protection until pain

subsides (7 to 10 days).
Return to sports as pain allows (1-2 weeks)
No apparent benefit to the use of specialized
braces.
 Type II operative treatment
– Generally reserved only for the patient with
chronic pain.
– Treatment is resection of the distal clavicle and
reconstruction of the coracoclavicular
ligaments.
Treatment Options For Type III-VI
Acromioclavicular Joint Injuries
Nonoperative treatment
– Closed reduction and application of a sling and harness
to maintain reduction of the clavicle
– Short-term sling and early range of motion
Operative treatment
– Primary AC joint fixation
– Primary CC ligament reconstruction (usually with
allograft, often with augmentation)
– Excision of the distal clavicle
– Dynamic muscle transfers
 Type III Injuries: Need for acute surgical
treatment remains very controversial.
Most surgeons recommend conservative
treatment except in the throwing athlete or
overhead worker.
Repair generally avoided in contact athletes
because of the risk of reinjury.
Literature unable to support operative
or nonoperative treatment as superior

Functional outcomes appear similar.

Cosmesis not different (scar vs bump)
Only 50% of surgical cases reduced at follow-
up.
10% complications after surgery.

Ceccarelli et al. J Orthopaed Traumatol 2008;9:105-108.

 Indications for Acute Surgical
Treatment of Acromioclavicular
Injuries
Type III injuries in highly
active patients

Type IV, V, and VI

injuries
 Surgical Options for AC Joint
Instability
Coracoid process transfer to distal transfer
(Dynamic muscle transfer)
Primary AC joint fixation
Primary Coracoclavicular Fixation
CC ligament reconstruction +/- distal clavicle
excision.
 Weaver-Dunn Procedure

The distal clavicle is excised.

The CA ligament is transferred to
the distal clavicle.
The CC ligaments are repaired
and/or augmented with a
coracoclavicular screw or
suture.
Repair of deltotrapezial fascia

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

 Indications for Late Surgical
Treatment of Acromioclavicular
Injuries

Pain
Weakness
Deformity
 Techniques for Late Surgical
Treatment of Acromioclavicular
Injuries

Reduction of AC joint and repair of AC and

CC ligaments
Resection of distal clavicle and reconstruction
of CC ligaments (Weaver-Dunn Procedure)
 Case Example

AP View

Zanca View
 Case Example

After Weaver-Dunn
procedure
 Sternoclavicular Joint

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

 The Anatomy of the Sternoclavicular Joint

Diarthrodial Joint
“Saddle shaped”
Poor congruence
Intra-articular disc
ligament. Divides SC
joint into two separate
joint spaces.
Costoclavicular ligament-
(rhomboid ligament)
Short and strong and
consist of an anterior
and posterior
fasciculus
 Interclavicular ligament- Connects the
superomedial aspects of each clavicle with the
capsular ligaments and the upper sternum
Capsular ligament- Covers the anterior and
posterior aspects of the joint and represents
thickenings of the joint capsule. The anterior
portion of the ligament is heavier and stronger
than the posterior portion.
Epiphysis of the Medial Clavicle
Medial Physis- Last of the ossification
centers to appear in the body and the last
epiphysis to close.
Does not ossify until 18th to 20th year
Does not unite with the clavicle until the 23rd
to 25th year
 Radiographic Techniques for
Assessing Sternoclavicular
Injuries
40-degree cephalic tilt
view
CT scan- Best
technique for
sternoclavicular joint
problems

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

 Injuries Associated with
Sternoclavicular Joint
Dislocations
Mediastinal Compression
Pneumothorax
Laceration of the superior
vena cava
Tracheal erosion

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

 Treatment of Anterior
Sternoclavicular Dislocations
Nonoperative treatment
• Analgesics and immobilization
• Functional outcome usually good
Closed reduction
• Often not successful
• Direct pressure over the medial end of
the clavicle may reduce the joint
 Treatment of Posterior
Sternoclavicular Dislocations
Careful examination of the patient is
extremely important to rule out vascular
compromise.
Consider CT to rule out mediastinal
compression
Attempt closed reduction - it is often
successful and remains stable.
Closed Reduction Techniques

Abduction traction
Adduction traction
“Towel Clip” - anterior force applied to
clavicle by percutaneously applied towel
clip
 Operative techniques
Resection arthroplasty
– May result in instability of remaining
clavicle unless stabilization is done.
– Suggest minimal resection of bone and
fixation of medial clavicle to first rib.
Sternoclavicular reconstruction with suture,
tendon graft.
 Literature – For those interested in further review.

Clavicle Fractures
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): p71-4.
Canadian Orthopaedic Trauma Society. Nonoperative Treatment Compared with Plate Fixation of
Displaced Midshaft Clavicular Fractures. A multicenter, randomized clinical trial. J Bone Joint Surg
2007;89-A:1-10.
McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced
midshaft clavicular fractures. J Bone Joint Surg 2006;88-A:35-40.
Mueller M, Rangger C, Striepens N, Burger C. Minimally Invasive Intramedullary Nailing of Midshaft
Clavicular Fractures Using Titanium Elastic Nails. J Trauma 2008;1528-1534.
Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle
based on initial findings? A prospective study with nine to ten years of follow up. J Shoudler Elbow
Surg 2004;13:479-486.
Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of
objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus
delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg
2007;16:514-518.
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion
following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-
1365.
Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic Stable
Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular
Fractures—A Randomized, Controlled, Clinical Trial. J Orthop Trauma 2009;23:106-112.
Literature – For those interested in further review.

Distal – Third (lateral) Clavicle Fractures

Jackson WF, Bayne G, Gregg-Smith SJ. Fractures of the lateral third of the
clavicle: an anatomic approach to treatment. J Trauma;61(1):222-225.
Meda PV, Machani B, Sinopidis C, et al. Clavicular hook plate for lateral end
fractures:- a prospective study. Injury;2006:37(3):277-283.
 Literature – For those interested in further review.
Acromioclavicular Joint Injuries
Calvo E, Lopez-Franco M, Arribas IM. Clinical and radiologic outcomes of
surgical and conservative treatment of type III acromioclavicular joint injury. J
Shoulder Elbow Surg. 2006;15(3):300-305.
Ceccarelli E, Bondi R, Alviti F, et al. Treatment of acute grade III
acromioclavicular dislocation: a lack of evidence. J Orthopaed Traumatol
2008;9:105-108.
Lizaur A, Marco L, Cebrian R. Acute dislocation of the acromioclavicular joint.
Traumatic anatomy and the importance of deltoid and trapezius. JBJS
1994;76B: 602-606.
Mikek M. Long-term shoulder function after type I and II acromioclavicular joint
disruption. Am J Sports Med. 2008;36:2147-2150.
Nadarajah R, Mahaluxmivala J, Amin A, Goodier DW. Clavicular hook—plate:
complications of retaining the implant. Injury 2005;36:681-683.
Spencer EE. Treatment of grade III acromioclavicular joint injuries: a systematic
review. Clin Orthop Relat Res. 2007;455:38-44.
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