Indications

• Open fracture.

• Painful non-union.

• Associated injury to the brachial plexus and/or subclavian artery.

• Floating shoulder.

• Bilateral fractures.

• Multiple-injured patient.

• Soft tissue interposition between the fragments.

• Impending skin necrosis or penetration from a prominent fragment.

• Consideration for surgical fixation should be given to completely displaced, comminuted midshaft fractures that contain a transverse fragment (Z-shaped fractures). There is evidence in the current orthopaedic literature that these fractures have a high risk of non-union.

• Operative management is indicated in displaced type III, IV and V distal clavicle fractures according to the Neer classification.

Clinical assessment

• Mechanism of injury: motor vehicle collision, sports injury, fall on outstretched hand (FOOSH), direct trauma.

• Deformity, ecchymosis, swelling, tenderness, crepitation.

• Look for pneumothorax or haemothorax, especially in the presence of associated injuries.

• Assess and document the vascular status of the upper extremity and any difference in peripheral pulses between injured and contralateral extremity.

• Assess neurological status (usually brachial plexus injury presents as an upper roots traction injury).

• Pay special attention to the soft tissue envelope around the clavicle.