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Increasing cross-border migration has brought forensic age assessment into focus in recent decades. Forensic age estimation is based on the three pillars: physical and medical constitution, bone age, and tooth age. Part of the bone age examination includes the assessment of the medial end of the clavicles when the hand bones are already fully developed and a minority must be excluded. Recent research has brought MRI to the forefront as a radiation-free alternative for age assessment. However, there exits only a few studies with large sample size regarding the clavicles and with controversies about staging, motion artifacts, and exclusion based on anatomic norm variants. In the current prospective study, 338 central European male individuals between 13 and 24 years of age underwent MRI examination of the sternoclavicular region. Development was assessed by three blinded raters according to the staging system described by Schmeling et al. and Kellinghaus et al. and related to age by descriptive statistics and transition analyses with a cumulative probit model. In addition, reliability calculations were performed. No statistically significant developmental difference was found between the left and right clavicles. Inter-rater agreement was only moderate, but intra-rater agreement, on the other hand, was good. Stage 3c had a minimum age of 19.36 years and appears to be a good indicator of proof of majority. The minimum age of stage 4 was lower compared with other studies, 20.18 years, and therefore seems not to be an indicator of age of 21 years. In conclusion, we confirmed the value of clavicular MRI in the age estimation process. The transition analysis model is a good approach to circumvent the problems of age mimicry and samples that are not fully equilibrated. Given the moderate agreement between raters, a consensus reading is recommended., (© 2022. The Author(s).)

Introduction: There is a great debate on the routine use of open reduction and internal fixation (ORIF) for midshaft clavicle fractures, and one concern is the adverse events after ORIF, such as implant removal after bone union. In this retrospective study, we assessed the incidence, risk factors, management and outcomes of refracture after plate removal of midshaft clavicle fractures after bone union., Materials and Methods: Three hundred fifty-two patients diagnosed with acute midshaft clavicle fractures who had complete medical records from primary fractures to refracture were recruited. Details of imaging materials and clinical characteristics were carefully reviewed and analysed., Results: The incidence rate of refracture was 6.5% (23/352), and the average interval from implant removal to refracture was 25.6 days. Multivariate analysis showed that the risk factors were Robinson type-2B2 and fair/poor reduction. Females were 2.4 times more likely to have refracture, although it was not significant in multivariate analysis (p = 0.134). Postmenopausal females with a short interval (≤ 12 months) from primary surgery to implant removal had a significant risk for refracture. Tobacco use and alcohol use during bone healing were potential risk factors for male patients, although they were not significant in multivariate analysis. Ten patients received reoperation with or without bone graft, and they had a higher rate of bone union than 13 patients who refused reoperation., Conclusion: The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. Implant removal for postmenopausal female patients is not recommended due to a high rate of refracture., (© 2023. The Author(s).)

Background: Variable innervation of the clavicle is a major challenge in surgery of clavicle fractures with patients under regional anesthesia. An interscalene block (ISB) combined with an intermediate cervical plexus block (ICPB) provides analgesia in clavicle fracture surgery, but this combination does not completely block sensation in the midshaft or medial clavicle. Cervical nerve root block is an alternative to deep cervical plexus block and has recently been used as an analgesic method in the neck and shoulder. Whether it should be used as an alternative for midshaft and medial clavicle fractures is unknown., Questions/purposes: In this randomized controlled trial, we compared a C3, 4, and 5 nerve root block to ISB combined with ICPB in surgery of midshaft and medial clavicle fractures in terms of the (1) proportion of patients achieving a sensory block that is sufficient for surgery, (2) onset time and duration of the block, and (3) effectiveness of postoperative analgesia, as measured by pain scores and consumption of analgesics., Methods: Between November 2021 and December 2021, we treated 154 patients for clavicle fractures. A total of 122 were potentially eligible, 91 of whom agreed to participate in this study. Twenty-nine patients were excluded because the patients chose general anesthesia or declined to undergo surgery. Ultimately, 62 patients were randomly allocated into the C3, 4, and 5 group or ISB + ICPB group, with 31 patients in each group; there were no dropouts. All patients were analyzed in the group they were randomized to under intention-to-treat principles. The assessor and patients were blinded to randomization throughout the trial. The two groups did not differ in any important ways, including age, gender, BMI, American Society of Anesthesiologists classification, and type of clavicle fracture. The two groups received either an ultrasound-guided C3, 4, and 5 nerve root block with 2, 3, and 5 mL of 0.5% ropivacaine or ultrasound-guided ISB with ICPB with 20 mL of 0.5% ropivacaine. The primary outcome was the proportion of patients in each group with a successful nerveba block who did not receive general anesthesia; this was defined as nerve block success. Secondary outcomes included the onset time and duration of the sensory block, defined as the onset to the moment when the patients felt pain and sought rescue analgesia; pain assessment in terms of the numeric rating scale (NRS) score (range 0 to 10) for pain after nerve block before and during surgery; and the median amount of sufentanil consumed intraoperatively and postoperatively in the recovery room. The dosing of sufentanil was determined by the assessor when the NRS score was 1 to 3 points. If the NRS score was more than 3 points, general anesthesia was administered as a rescue method. Complications after the two inventions such as toxic reaction, dyspnea, hoarseness, pneumothorax, and Horner syndrome were also recorded in this study., Results: A higher proportion of patients in the C3, 4, and 5 group had a successful nerve block than in the ISB + ICPB group (97% [30 of 31] versus 68% [21 of 31], risk ratio 6 [95% CI 1.5 to 37]; p < 0.01). The median onset time was 2.5 minutes (range 2.0 to 3.0 minutes) in the C3, 4, and 5 group and 12 minutes (range 9 to 16 minutes) in the ISB + ICPB group (difference of medians 10 minutes; p < 0.001). The sensory block duration was 10 ± 2 hours in the C3, 4, and 5 group and 8 ± 2 hours in the ISB + ICPB group (mean difference 2 hours [95% CI 1 to 3 hours]; p < 0.001). The median sufentanil consumption was lower in the C3, 4, 5 group than in the ISB + ICPB (median 5 µg [range 0.0 to 5.0 µg] versus median 0 µg [range 0.0 to 0.0 µg]; difference of medians 5.0 µg; p < 0.001). There were no differences between the two groups regarding NRS scores after nerve blocks and NRS score for incision and periosteum separation, with the minimum clinically important difference set at a 2-point difference (of 10). There were no severe complications in this study., Conclusion: Based on our analysis of the data, a C3, 4, and 5 nerve root block was better than ISB combined with ICPB for surgery to treat medial shaft and medial clavicle fractures. When choosing the anesthesia method, however, the patient's basic physiologic condition and possible complications should be considered., Level of Evidence: Level I, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons.)

Objective: To determine the association of chronological age through ossification of the medial clavicular epiphysis using computed tomography (CT) scan., Study Design: An Observational study. Place and Duration of the Study: Dow Institute of Radiology, Dow University Hospital, Karachi, Pakistan, from February 2021 till October 2021., Methodology: Subjects aged 10-35 years of either gender reported without any clavicular trauma or fracture, no known chronic illness or malignancy, or no congenital bony abnormalities, or any prior surgical intervention to the sterno-clavicular region were included. The fusion of maturity of medial clavicular epiphyses was evaluated on either side by using the five-stage classification system reported by Schmeling., Results: Of 200 patients, a significant increase in the age of the patients was observed with respect to the increase in the stages (p <0.001). When stratified on the basis of gender, a significant increase in age was also observed with respect to the increase in stages (p <0.001). Stage 4 was observed in majority of the patients, i.e., 81 (40.5%), followed by stages 2 and 3 in 35 (17.5%) each, stage 5 in 32 (16%), while stage 1 was observed in 17 (8.5%) patients. An insignificant difference of age was observed with respect to the gender of the patients (p= 0.472, 95% CI -2.91 - 1.35)., Conclusion: The fusion of the medial clavicular epiphysis showed a considerable degree of variability. Fused clavicles at stage 4 could be observed at age 22 years or less in males while at 21 years or less in females., Key Words: Age estimation, Schmeling method, Medial clavicular epiphysis, Computed tomography.

Background: The modified Neer classification is the most widely used classification system for distal clavicle fractures. However, it provides limited information for treatment decisions. The objective of this study was to revise the modified Neer classification to make it more suitable for treatment decision-making., Hypothesis: The revised version of the modified Neer classification has good intra- and interobserver agreements and provides an instructive treating algorithm., Study Design: Cohort study METHODS: Six observers, including three experienced shoulder specialists and three junior orthopaedic residents, independently reviewed plain radiographs of 52 patients with distal clavicle fractures. They were asked to classify the fracture types according to the modified Neer classification and our revised new classification separately to determine treatment approaches for each patient. Images were mirrored and randomized to verify the intraobserver agreement. Reliabilities were measured using the Fleiss kappa values., Results: Both the modified Neer classification and our revised version had near perfect intraobserver agreement (κ values: 0.87-1.00), whereas our revised Neer classification had a better interobserver agreement (κ values: 0.78 vs. 0.70, z = 4.70, p < 0.01) and stronger relevance to treatment decisions (coefficient of contingency: 0.70 vs. 0.44)., Conclusion: Our study demonstrated a near-perfect intraobserver and substantial interobserver agreement of the revised new classification, indicating that our revised new classification was better than the modified Neer classification. Meanwhile, our revised classification brought few disputes in treatment selection., Clinical Relevance: The modified Neer classification was revised to make it more accurate and suitable for guiding treatment., Type of Study: Study of diagnostic test LEVEL OF STUDY: Level II., Competing Interests: Declaration of Competing Interest All authors, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Echinococcosis, also known as hydatid disease, is a zoonotic parasitic disease prevalent in pastoral areas, mainly involving the liver and lungs, and less frequently the bones and surrounding soft tissues. Diagnosis and treatment of bone hydatid disease is a challenge, and because of the insidious course of the disease, the lesions are often widely disseminated by the time patients seek medical attention., Case Presentation: A 29-year-old woman presented with a painless mass that was gradually increasing in size in the cervical thorax. Imaging revealed an enlarged clavicle with multiple bone cortical defects and the existence of cysts in the soft tissues surrounding the clavicle, for which complete excision of the clavicle and the attached cysts was performed. There was no recurrence of the cyst within one year after the operation, and the patient felt well and had normal shoulder joint movement., Conclusions: Bone hydatid may appear in bones throughout the body, and cysts that leak from the bone into the surrounding soft tissues may spread at a relatively rapid rate. Prompt surgical removal of the affected bone and surrounding cysts is necessary for treatment., (© 2023. The Author(s).)

Background: Clavicle fractures are common injuries, especially in young, active individuals. Operative treatment is recommended for completely displaced clavicle shaft fractures, and plate fixation is stronger than the use of intramedullary nails. Few studies have reported on iatrogenic injuries to the muscle attached to the clavicle during fracture surgery. The aim of this study was to clarify the area of the insertion sites of muscles attached to the clavicle in Japanese cadavers using gross anatomy and three-dimensional (3D) analysis. We also aimed to compare the effects of anterior plate templating and superior plate templating on clavicle shaft fractures using 3D images., Methods: Thirty-eight clavicles from Japanese cadavers were analyzed. We removed all clavicles to identify the insertion sites and measured the size of the insertion area of each muscle. Three-dimensional templating was performed on both the superior and anterior plates of the clavicle using data obtained from computed tomography. The areas covered by these plates on the muscles attached to the clavicle were compared. Histological examination was performed on four randomly selected specimens., Results: The sternocleidomastoid muscle was attached proximally and superiorly; the trapezius muscle was attached posteriorly and partly superiorly; and the pectoralis major muscle and deltoid muscles were attached anteriorly and partially superiorly. The non-attachment area was located mainly in the posterosuperior part of the clavicle. It was difficult to distinguish the borders of the periosteum and pectoralis major muscles. The anterior plate covered a significantly broader area (mean 6.94 ± 1.36 cm 2 ) of the muscles attached to the clavicle than did the superior plate (mean 4.11 ± 1.52 cm 2 ) (p < 0.0001). On microscopy, these muscles were inserted directly into the periosteum., Conclusion: Most of the pectoralis major and deltoid muscles were attached anteriorly. The non-attachment area was located mainly from the superior to posterior part of the clavicle midshaft. Both macroscopically and microscopically, the boundaries between the periosteum and these muscles were difficult to demarcate. The anterior plate covered a significantly broader area of the muscles attached to the clavicle than that by the superior plate., (© 2023. The Author(s).)

Background: Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood., Purpose: To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process., Study Design: Case series; Level of evidence, 4., Methods: Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction., Results: Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively ( P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling ( P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling., Conclusion: Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

The aim of this study was to identify the hitherto unknown incidence of congenital pseudarthrosis of the clavicle (CPC), based on a cohort of continuous livebirths born in our hospital, to review the literature and investigate if there is evidence supporting the published association between left-sided CPC and dextrocardia. From our electronic medical record and radiology databases, we identified all live births and patients with the diagnosis of CPC born from 2000 to 2016. We reviewed the imaging which included one or both clavicles to search for unrecorded CPC cases and reviewed all retrievable CPC publications listed in PubMed and publications quoted within these publications going back to 1910. We identified 87 407 livebirths of which 41 800 had radiological studies done, 14 885 showing one or both clavicles. We found five cases of CPC, two from the electronic database and three from our imaging review, giving an incidence of 1 of 17 481 livebirths. We identified 138 publications reporting paediatric and adult CPC cases and 12 review articles, including 429 patients (187 female; 159 male; 83 unknown) with 456 CPCs and a minimum of 24 additional patients from case reports for which we could not retrieve details. Two publications reported one case of left-sided CPC with dextrocardia, either not showing left/right marking or only showing the CPC with the aortic knob on the same side. We report the first CPC incidence of 0.0057%, provide the by far most inclusive CPC epidemiology based on 429 patients and could not find reliable proof that there has ever been a patient with left-sided CPC which was associated with dextrocardia., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist., Material and Methods: Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion., Results: Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment., Conclusion: In addition to X‑rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: Over the last few years, treatment of mid-shaft clavicle fractures seems to have shifted from conservative to surgical. Our study reports the results of plate osteosynthesis of mid-shaft clavicle fractures and compares them with literature., Materials and Methods: A retrospective cohort study was conducted on 32 patients with mid-shaft clavicle fractures treated with plate and screws between January 2009 and December 2014. All the patients followed the same post-operative rehabilitation program with radiographic and clinical evaluation (DASH score and Constant score) at a minimum follow-up of 24 months., Results: All the patients healed clinically and radiographically, without deformities or non-unions, with complete and early functional recovery and return to their pre-injury sport activities. At one year follow-up the mean Constant Score was 93.8 (SD 4.8) and the mean DASH score was 42 (SD 5.0)., Conclusions: Osteosynthesis with plate and screws of mid-shaft clavicle fractures allows not only restoration of the anatomy, but also early recovery of shoulder function. For this reason, such surgical treatment should always be considered when facing this particular fracture group, also in accordance with recent literature., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Although clavicle fractures are common injuries in adults, simultaneous bilateral clavicle fractures are rarely reported. The present report describes 13 patients with simultaneous bilateral traumatic clavicle fractures who were treated with surgical management and followed for more than 12 months postoperatively., Methods: This retrospective chart review involved skeletally mature patients with traumatic clavicle injuries. Patients with bilateral clavicle fractures who were followed up for at least 12 months after surgery were included. Data regarding the patients' demographics, injury characteristics, fracture classification, comorbidities, concomitant injuries, and treatment strategies were collected. Each displaced fracture was managed with open reduction and internal fixation. Postoperative follow-up included radiographs for assessment of bone union; calculation of the Constant-Murley score for shoulder function; administration of the Disability of the Arm, Shoulder, and Hand questionnaire for upper limb function; determination of the visual analogue scale score for pain; and assessment of complications., Results: From October 2013 to November 2021, 15 patients (10 men, 5 women) were diagnosed with bilateral clavicle fractures among 1542 patients with clavicle injuries (overall incidence of 1.0%). Of these 15 patients, this study included 13 patients (8 men, 5 women; mean age, 38.3 ± 15.3 years) who were followed up for more than 12 months postoperatively. Among the 13 patients, 10 (77.0%) had associated concomitant injuries, and 25 sides were fixed with internal plate fixation. After a follow-up period of 29.9 ± 28.5 months, all fractures achieved bone healing. Eleven patients attained excellent shoulder function on both sides and returned to their pre-injury daily activities, and the remaining two patients had unilateral shoulder dysfunction. No complications occurred., Conclusions: Bilateral clavicle fractures are extremely rare and associated with polytrauma. Open reduction and internal fixation is recommended for such patients, especially those with severe chest injuries, because osteosynthesis of the clavicle can improve respiratory function and reduce the duration of functional disability., (© 2023. The Author(s).)

Background: The aim of this study was to retrospectively examine the radiological and functional results of midshaft clavicle fractures that were treated with a new, interlocking intramedullary nail, and employing a different locking option., Methods: Between January 2018 and January 2020, 24 displaced midshaft clavicle fractures were operated with new, interlocking intramedullary nail. Fractures were classified according to the AO/orthopedic trauma association classification, according to which there were 22 15.2.B (wedge) and 2 15.2.C (comminuted) fractures. The mean patient age was 35.5±14.2 (range: 18-63) years. Eighteen (75%) of the patients were male and six (25%) were female., Results: Follow-up data were recorded at a minimum of 1 year (range 12-36 months), with an average of 21.5 months (SD±8). The mean interval between the injury and surgery was 4.1 (SD±2.3; range: 1-9) days. Full shoulder movements had been achieved by all patients, relative to the contralateral side. The mean constant score was 95.6 (SD±4.2; range 90-100), and the mean visual analog scale score was 0.8 (SD±0.8; range: 0-3). Union was achieved in all patients. The mean union time was 9.5 (SD±1.8; range 6-12) weeks as assessed by radiograph. Average shortening of the clavicle relative to the contralateral side was 3.4% (SD±1.1; range 1.1-6.3). One patient experienced implant irritation, implant removal was performed after 14 months. No implant migration, hardware loosening, implant breakage, or neurovascular damage occurred. One hypertrophic scarring developed. One wound detachment developed at the 3rd post-operative week., Conclusion: We think that this new intramedullary nail is a good alternative for wedge type fractures in adult, acute, displaced, and midshaft clavicle fractures.

Objectives: To investigate radiological and long-term functional outcomes in modified Neer 2a, 2b, and 5 distal clavicle fractures., Design: Retrospective cohort study., Setting: A single university teaching hospital., Patients/participants: One hundred fifteen patients sustaining displaced distal clavicle fractures between January 01, 2010 and December 12, 2017., Intervention: Operative versus nonoperative management., Main Outcome Measurements: Radiographs were reviewed for fracture management and union. A customised questionnaire consisting of QuickDASH (Disabilities of the Arm, Shoulder and Hand), work, sports/performing arts, global satisfaction, and complication modules was used to determine functional outcome., Results: One hundred fifteen patients were included [mean age of 49 (18-89) years]. Thirty-three (29%) underwent early fixation (<6 weeks from injury) and were younger (37 vs. 53 years, P < 0.0001). Radiographs were available for 96 patients. Nonunion rate was 55% (53/96), and majority had undergone initial nonoperative management (49 vs. 4, P < 0.00001). Eleven patients with symptomatic nonunion were deemed appropriate for delayed fixation with all cases uniting. Of the operatively managed patients, 27% (12/44) underwent metalwork removal. There were no differences in functional outcome between operative versus nonoperative and union versus nonunion patient groups at a mean follow-up of 79 months ( P > 0.05)., Conclusion: Functional outcome and patient satisfaction at long-term follow-up were similar regardless of operative fixation or radiological union. Nonunion in displaced distal clavicle fractures seemed to cause minimal functional deficit in most elderly sedentary individuals, or the outcome measures were not sensitive enough to capture these differences. An individualized approach should be adopted, with less active, comorbid, and elderly patients counseled regarding the minimal functional improvement of surgery and risk of reoperation., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2023. The Author(s).)

Background: Previous researchers used transverse fractures centered over the midpoint of the clavicle as the diaphyseal clavicular fracture models. However, as a result of shear stress concentration in sigmoid-shaped structures, most diaphyseal clavicular fractures have coronal fracture edges and are located distal to the midpoint. The purpose of this study was to quantify the morphology and utilize these parameters to establish clinically relevant fracture models., Methods: The computed tomographic DICOM data of 100 consecutive patients were included. We investigated the morphologic characteristics of the fracture edges after virtual fracture reduction. The fracture orientation was determined based on the normal vectors of the best-fit plane of the fracture edges. The fracture location was measured by the extreme points of the edges. The fracture configuration was evaluated using fracture maps., Results: There were 28 simple, 43 wedge, and 29 multifragmentary types. Coronal oriented fracture edges accounted for more than 70% of the simple, wedge, and multifragmentary types. The most proximal point of the proximal edge was located at 46.7% (42.0%-56.5%), 47.6% (42.5%-50.1%), and 46.3% (42.0%-49.3%) of the endpoint line in the simple, wedge, and multifragmentary types, respectively (P = .548). The most distal point of the distal edge was located at 72.2% (68.4%-75.0%), 73.2% (69.5%-76.9%), and 74.0% (69.6%-77.1%) of the endpoint line (P = .353). The longest proximal main fragments occurred in the simple types at 71.9% (66.3%-75.4%) of the endpoint line (P < .001), and the shortest distal main fragments occurred in the multifragmentary types at 55.8% (49.8%-59.3%) of the endpoint line (P = .001). The heatmaps showed a high concentration of anteriorly distributed wedge fragments (88%; n = 38/43) and coronally distributed multifragmentary fragments (62%; n = 18/29)., Conclusions: We showed that typical diaphyseal clavicular fractures have coronal fracture edges and are located within the distal half of the diaphyseal segment. The fractured fragments were initiated anteriorly in the wedge types and then propagated coronally in the multifragmentary types. The features of these fracture edges could be useful in designing osteotomy models and provide different perspectives of anterior and superior plating techniques., (Copyright © 2022. Published by Elsevier Inc.)

Background: Neer type II/bilateral distal clavicular fracture is an extremely rare injury combination, with few cases having been reported., Case Presentation: This paper reports a case of polytrauma in a 16-year-old female following a road traffic accident. The radiographs revealed distal fractures of the bilateral clavicles (Neer type II), and an open reduction and internal fixation procedure was performed. Initially, the distal fracture of the right clavicle was fixed with a six-hole hook plate before the fracture of the left clavicle was fixed using a pre-contoured lateral locking plate following reduction. At the two-year follow-up, the patient had an excellent constant score in terms of the bilateral shoulder joints., Conclusion: It is important to achieve stability and to aim for excellence in terms of full shoulder function in this rare combination injury.

Objectives: The aim of the study was to investigate whether clavicular symmetry was a valid assumption and to assess the factors that could predict clavicular asymmetry., Patients and Methods: Between January 2021 and April 2021, a total of 100 consecutive patients (61 males, 39 females; mean age: 63.6±15.5 years; range, 27 to 94 years) whose both clavicles were adequately seen on chest computed tomography (CT) were retrospectively analyzed. Clavicular lengths were measured on three-dimensional (3D) reconstruction of chest CTs by two independent orthopedic surgeons on two separate occasions. The longest distance passing the straight line between the most lateral part of the clavicle at the acromioclavicular joint and the most medial point of the clavicle on the sternoclavicular joint was given as the clavicle length after adjusting tilt of convertible 3D CTs. Clavicular length difference was calculated by subtracting the short clavicle's length from the long clavicle's length. Patients' age and sex were noted. The calculated clavicular length differences were assigned into three groups: ≤5 mm, >5 mm and ≤10 mm, and >10 mm., Results: The mean right and left clavicle lengths were 13.9±1.3 cm and 14.1±1.2 cm, respectively (p<0.001). A total of 29 patients (29%) had >5 mm clavicle asymmetry and six patients (6%) had more than 10 mm clavicular length difference. Age, sex, and clavicular length were not associated with the clavicular length difference., Conclusion: Our study results showed that 29% of the patients had >5 mm clavicular length asymmetry. The clavicular symmetry may not be a valid assumption in the decision making for the surgical treatment of mid-shaft clavicle fractures; thus, this assumption may lead to maltreatment. More factors that can predict clavicle asymmetry should be investigated in future studies.

Purpose: Clavicle fractures in the lateral third are associated with more complications. Various methods of internal fixation exist; however, there is no consensus which should be employed. The purpose of this study was to evaluate the outcomes of these various methods in our regional trauma unit., Methods: We performed a retrospective review of patients who underwent internal fixation of a lateral clavicle fracture in our unit between 1 August 2014 and 31 July 2019. Demographic and outcome data were extracted from electronic care records and imaging systems., Results: In total, 44 patients were included, with the following demographics: mean age 26 years, 63.6% male, 65.9% high-energy injury, 68.2% Neer II fracture. The following operations were performed: hook plate fixation (HPF) = 10, locking plate fixation (LPF) = 16, coracoclavicular ligament reconstruction (CCLR) = 12, and LPF + CCLR = 6. Patients having LPF had a significantly larger post-operative coracoclavicular distance (7.6 mm vs 13.5 mm, p < 0.01), and trends towards a lesser decrease in CCD (9.9 mm vs 12.6 mm, p = 0.37) and incomplete ACJ reduction (50.0% vs 89.3%, p = 0.11). There was a significantly higher re-operation rate after HPF (100% vs 23.5%, p < 0.01). There were no differences in time to union or duration of follow-up., Conclusion: In our unit there is no clearly favoured method of internal fixation of lateral clavicle fractures. When LPF is used, there should be consideration of concomitant CCLR. The high rate of re-operation after HPF is concordant with previous research., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Non-union of the clavicle in the paediatric population is extremely rare. Some anecdotal case reports show non-union following clavicle fracture. However, we could not find any report of non-union following osteotomy for brachial plexus surgery. We report non-union of clavicle following its osteotomy for brachial plexus exploration surgery in a 6-month child. We present successful management of the clavicle non-union in this patient and propose preventive steps. Level of Evidence: Level V (Therapeutic).

Purpose: This study aims to examine the use of 3D printing technology to treat clavicular fractures by skilled and inexperienced surgeons., Methods: A total of 80 patients with clavicle fractures (from February 2017 to May 2021) were enrolled in this study. Patients were divided randomly into four groups: group A: Patients underwent low-dose CT scans, and 3D models were printed before inexperienced surgeons performed surgeries; group B: Standard-dose CT were taken, and 3D models were printed before experienced surgeons performed surgeries; group C and D: Standard-dose CT scans were taken in both groups, and the operations were performed differently by inexperienced (group C) and experienced (group D) surgeons. This study documented the operation time, blood loss, incision length, and the number of intraoperative fluoroscopies., Results: No statistically significant differences were found in age, gender, fracture site, and fracture type (P value: 0.23-0.88). Group A showed shorter incision length and fewer intraoperative fluoroscopy times than groups C and D (P < 0.05). There were no significant differences in blood loss volume, incision length, and intraoperative fluoroscopy times between group A and group B (P value range: 0.11-0.28). The operation time of group A was no longer than those of groups C and D (P value range: 0.11 and 0.24)., Conclusion: The surgical effectiveness of inexperienced surgeons who applied 3D printing technology before clavicular fracture operation was better than those of inexperienced and experienced surgeons who did not use preoperative 3D printing technology., (© 2022. The Author(s).)

Background: Clavicle fractures account for approximately 5% of all fractures in adults and 75% of clavicle fractures occur in the midshaft. Shortening greater than two centimeters is an indicative of surgical treatment. Radiographic exams are often used to diagnose and evaluate clavicle fractures but computed tomography (CT) scan is currently considered the best method to assess these deformities and shortening., Goal: 1- To investigate whether different methods of performing the radiographic exam interfere on the measurement of the fractured clavicle length. 2- Compare the clavicle length measurements obtained by the different radiographic exam methods with the CT scan measurements, used as a reference., Materials and Methods: Twenty-five patients with acute (< 3 weeks) midshaft clavicle fracture were evaluated. Patients underwent six radiographic images: PA Thorax (standing and lying), AP Thorax (standing and lying) and at 10° cephalic tilt (standing and lying), and the computed tomography was used as reference., Results: The mean length (cm) obtained were: 14,930 on CT scan, 14,860 on PA Thorax Standing, 14,955 on PA Thorax Lying, 14,896 on AP Thorax Standing, 14,960 AP Thorax Lying, 15,098 on 10° cephalic tilt Standing and 15,001 on 10° cephalic tilt Lying, (p > 0,05)., Conclusion: 1- There is no significant statistical difference in the clavicle fracture length measurement among the variety of radiographic exam performances. 2- The method that comes closest to computed tomography results is the PA thorax incidence, with the patient in the lying position., (© 2022. The Author(s).)

Rationale: To our knowledge, no study has investigated concomitant injuries of the sternoclavicular joint (SCJ) in acute clavicle fractures. The purpose of this study was to determine the effect of an ipsilateral clavicle fracture on the SCJ in a systematic computer tomography (CT) morphologic evaluation., Methods: CT scans in the axial and coronal plane of 45 consecutive patients with clavicle fractures were retrospectively analyzed. The scans were assessed regarding anatomic congruence of bilateral SCJs-joint space width (JSW); the position of bilateral medial clavicles (PC); and the non-fusion of epiphyses, arthritis, calcifications, and intra-articular gas., Results: The mean SCJ JSW was significantly different in the coronal (cJSW; 8.70 mm ± 2.61 mm in affected vs. 7.63 mm ± 2.58 mm in non-affected side; p = 0.001) and axial plane (aJSW; 9.40 mm ± 2.76 mm in affected vs. 9.02 ± 2.99 in non-affected SCJs; p = 0.044). The position of the medial clavicle showed a significant difference in the coronal plane (cPC; 14.31 mm ± 3.66 mm in the affected vs. 13.49 ± 3.34 in the non-affected side; p = 0.011), indicating a superior shift., Conclusion: Acute clavicle fractures may be associated with an enlargement of the ipsilateral SCJ space width and a superior shift of the proximal clavicle. Both morphologic alterations could indicate concomitant injuries of the SCJ as well as a potential increase in the risk of SCJ instability.

The goal of this study was to compare outcomes among children treated nonoperatively vs operatively for completely displaced clavicle fractures. This was a retrospective cohort study of nonoperative vs operative treatment of completely displaced clavicle fractures sustained between 2006 and 2015 among pediatric patients. Data were collected on patient demographics, fracture characteristics, time to return to full activities, treatment complications, and patient-reported outcome measures. Fifty-five patients were identified in the nonoperative group, with a mean age of 11.6 years (range, 8-14 years). The operative group contained 55 patients, with a mean age of 14.3 years (range, 9-17 years). All fractures healed, with a mean time to return to full activities of 90.4 days in the nonoperative group and 89.7 days in the operative group ( P =.941). Twelve (22%) nonoperative patients sustained a refracture of their clavicle compared with 4 patients in the operative group ( P =.031). Fifteen patients (27%) in the operative group required a second surgery for removal of surgical implants. On the shortened form of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, 17 of the 22 nonoperative patients reported a score of zero (indicating no disability) (range, 0-7) vs 22 of 25 in the operative group (range, 0-9) ( P =.329). Patients treated nonoperatively had a 22% rate of refracture, whereas patients treated operatively had a 27% rate of undergoing a second surgery for removal of surgical implants. These data can aid in the shared decision-making process with patients and families when deciding on treatment for displaced pediatric clavicle fractures. [ Orthopedics . 2022;45(6):373-377.].

Purpose: To assess the efficacy of autogenous "structured" bone grafting (ASBG), it was combined with superior plate (SP) revision operations for recalcitrant clavicular midshaft aseptic nonunion (CMAN)., Methods: This retrospective study included 12 patients who suffered from failure of autologous cancellous bone grafting (ACBG) and SP fixation because of CMAN. Visual analogue scale (VAS) data for pain and disabilities of arm, shoulder, and hand (DASH) scores of patients who underwent these procedures from January 2019 to December 2020, obtained before surgery and at the final follow-up time, were analysed., Results: The average time between primitive fracture and this operative treatment was 29 months (15-38 months). The average duration of surgery was 153 minutes (range, 115-230 min), and the average blood loss was 560 ml (range, 350-860 ml). Complications occurred in two cases (16.67%): one was persistent pain at the donor site, and the other was a calf muscle vein thrombosis. No tissue infection was observed during follow-up. The mean follow-up time was 18 months (range, 12-30 months). All fractures progressed to osseous healing at a mean time of 14 weeks (range, 12-16 weeks). The mean pain VAS score significantly improved, from 4.8 ± 1.7 pre-operatively to 1.9 ± 1.1 at the final follow-up (P = 0.01). The mean DASH score improved significantly from 30.1 ± 11.2 pre-operatively to 7.8 ± 4. 2 at the final follow-up (P < 0.01)., Conclusions: ASBG combined with SP revision surgery achieved excellent clinical outcomes in patients with recalcitrant CMAN., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

We present a case of a nondislocated clavicular fracture that was conservatively treated for 4 weeks with a sling. The patient was a smoker and suffered from type 2 diabetes mellitus. After 2 months a suppurative infection occurred due to an escalation based on a clavicular osteomyelitis. Through antibiotic treatment and an aggressive surgical approach the infection was cured but ended up with a painful malunion of the clavicle. The bone reconstruction was achieved with a long locking plate with an additional vascularized medial femoral condyle free flap. After 18 months the patient was subjectively very satisfied with the outcome, had no pain and excellent functional results in the Constant Murley and DASH (Disabilities of Arm, Shoulder and Hand) scores. The X‑ray assessment showed full bone union., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Open reduction and internal fixation have been frequently applied for displaced midshaft clavicular fracture. Plate and screw fixation of clavicular fractures could provide rigid fixation and rotational control. Proper implant positioning in surgical fixation is critical to prevent iatrogenic complications. Fluoroscopy plays an important role in the intraoperative evaluation of implants. This study aimed to introduce a new fluoroscopic projection to evaluate the positioning of plates and screws., Methods: Adult patients with a diagnosis of acute displaced midshaft clavicular fracture were included in this study. The slope angle of the midshaft clavicle was measured on sagittal reconstructions of preoperative computed tomography (CT) scans. The incidence of screw revision based on intraoperative standard posteroanterior (PA) and PA 25° cephalic skyline projections was compared. The interobserver agreement for the two projections was calculated., Results: Twenty-nine patients with midshaft clavicular fractures were enrolled from January 2020 to June 2021. The PA 25° skyline projection could clearly display the tangential line of the plate and inferior border of the clavicle. The slope angle on the superior surface of the midshaft clavicle was 26.0 ± 5.8° (range: 18.5-38.3°). The incidence of screw revision using the PA projection (72.4%) was significantly different from that using the PA 25° skyline projection (34.5%) (P < 0.05). The concordance of the screw revision rate based on the standard PA and PA 25° skyline projections was strong, with kappa coefficients of 0.680 (95% CI: 0.394-0.968) and 0.776 (95% CI: 0.537-0.998)., Conclusion: The PA 25° skyline projection corresponds to the slope angle of the midshaft clavicle. It can provide more accurate information regarding the proper screw length and be applied as a routine method for intraoperative evaluation., (© 2022. The Author(s).)

Background: Distal clavicular fracture is a shoulder joint injury that is common in clinical settings and is generally surgically treated using the clavicular hook plate technique with a confirmed curative effect. However, symptoms, such as shoulder abduction limitation, shoulder discomfort, and postoperative joint pain, may occur in some patients. To overcome these problems, after a previous study we developed an acromial height-measuring device and a new type of clavicular hook plate. This study aimed to investigate whether an acromial height-measuring device combined with an improved new-type clavicular hook plate can better reduce the incidence of complications and improve postoperative function. To provide patients with better treatment effects, an acromion gauge and clavicular hook plate are used., Methods: A retrospective analysis was performed on 81 patients with distal clavicular fractures admitted to our hospital. They were divided into experimental and control groups according to different plates, and the Constant-Murley score, visual analogue scale score, incidence of acromion osteolysis, and incidence of subacromial impingement syndrome were compared., Results: Compared with the standard clavicular hook plate, the acromial height-measuring device combined with the new-type clavicular hook plate in the treatment of distal clavicle fractures has a lower incidence of subacromial impingement syndrome with better postoperative functional recovery and quality of life., Conclusions: We considered the acromial height-measuring device combined with the new clavicular hook plate to be a safe and promising alternative to distal clavicular fractures., (© 2022. The Author(s).)

Background: In infant abuse investigations, dating of skeletal injuries from radiographs is desirable to reach a clear timeline of traumatic events. Prior studies have used infant birth-related clavicle fractures as a surrogate to develop a framework for dating of abuse-related fractures., Objective: To develop and train a deep learning algorithm that can accurately date infant birth-related clavicle fractures., Materials and Methods: We modified a deep learning model initially designed for face-age estimation to date infant clavicle fractures. We conducted a computerized search of imaging reports and other medical records at a tertiary children's hospital to identify radiographs of birth-related clavicle fracture in infants ≤ 3 months old (July 2003 to March 2021). We used the resultant database for model training, validation and testing. We evaluated the performance of the deep learning model via a four-fold cross-validation procedure, and calculated accuracy metrics: mean absolute error (MAE), root mean square error (RMSE), intraclass correlation coefficient (ICC) and cumulative score., Results: The curated database consisted of 416 clavicle radiographs from 213 infants. Average chronological age (equivalent to fracture age) at time of imaging was 24 days. This model estimated the ages of the clavicle fractures with MAE of 4.2 days, RMSE of 6.3 days and ICC of 0.919. On average, 83.7% of the fracture age estimates were accurate to within 7 days of the ground truth., Conclusion: Our deep learning study provides encouraging results for radiographic dating of infant clavicle fractures. With further development and validation, this model might serve as a virtual consultant to radiologists estimating fracture ages in cases of suspected infant abuse., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Clavicle is an upper limb locomotory bone which helps in formation of pectoral girdle and connected the upper limb with axial skeleton. There is no baseline data of clavicle in contrast to demographic variation in our country, so the study was designed to obtain baseline data on clavicle for anthropological, forensic and clinical use. This descriptive cross-sectional study was done among 150 (65 right and 85 left) fully ossified dry human clavicle in Mymensingh Medical College, Mymensingh, Bangladesh from January 2020 to December 2020. Sample was collected by the help of nonrandom purposive sampling technique from Department of Anatomy of Mymensingh Medical College and Community Based Medical College, Bangladesh, Mymensingh. The parameters were the antero-posterior diameter and vertical diameter of sternal and acromial ends of clavicle, measured with the help of digital vernier slide caliper and expressed in millimeter. In the current study the mean±SD antero-posterior diameter of sternal end of 65 clavicles of right side was 21.97±2.889mm and 85 clavicles of left side were 20.30±3.459mm. The mean±SD antero-posterior diameter of acromial end of 65 right sided clavicles was 21.96±5.161mm and 85 clavicles of left side were 21.00±4.002mm. Correlation was done in between antero-posterior diameter and vertical diameter of sternal end of clavicle and the differences were highly significant on both sides. Similarly, when correlation was done for the acromial end of clavicle the difference was found non-significant on right side and highly significant on left side.

Purpose: Displaced midshaft clavicle fractures have a non-union rate of 10-20%. Those who unite with conservative treatment have similar outcomes to those who undergo operative treatment; therefore, protocols to identify potential non-unions are important to avoid unnecessary surgery. The aim of this study is to report one such protocol., Methods: A protocol was introduced, where all isolated closed displaced midshaft clavicle fractures were initially managed non-operatively in a sling. At 2 weeks patients were assessed clinically and those who were struggling with their symptoms were offered surgery, with the remainder mobilised as comfortable. All cases treated at one centre over a three-year period, with a minimum follow-up of one-year underwent case note review., Results: Between 2015 and 2017 613 clavicle fractures were managed through clinic. 347 were middle third (56%), 75% were male, mean age 41(range16-97). Forty-one middle third clavicle fracture patients underwent early fixation. Eleven patients required late fixation for symptomatic delayed, non- or malunion, 6 for symptomatic non-unions and 1 was a symptomatic malunion. For displaced fractures the early operative rate was 17.8%, and symptomatic non/malunion rate was 3.2%. This led to a total operative rate of 21%., Conclusion: A protocol for managing clavicle fractures has demonstrated an effective management of these injuries. It is cost-effective reducing the number of patients with displaced fractures requiring fixation with a fixation rate of 21% whilst reducing the rate of symptomatic non- and malunion (3.2%). The management pathway is simple and could be introduced into any orthopaedic outpatient department with ease., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objective: An agreement has not been reached on optimal locations of bone tunnels for coracoclavicular ligament (CCL) reconstruction for acromioclavicular joint dislocation (ACD). This study aims to identify the convergence point (cP) between the coracoid process and clavicle in the Chinese population to assist surgeons in reconstructing the CCL for ACD., Methods: From 2014 to 2020, 483 CT scans of the shoulders of 270 male and 213 female patients (247 right and 236 left shoulders) were collected and studied retrospectively. By overlapping the images of the transverse plane of the coracoid process and the clavicle, points a and b, and the midpoint ab (cP) were determined. Then, a series of parameters through point cP in the transverse and sagittal planes were measured. In the transverse plane this included the distance from point cP to the tip of the coracoid process (cP-cor),the distance between the medial and lateral margins of the coracoid process through point cP (Med-lat cor), the distance from point cP to the acromioclavicular joint (cP-ac), and the distance between the anteroposterior margin of the clavicle through point cP (Ap-clav). In the sagittal plane, this included the craniocaudal segment of the coracoid process (Cc-cor), and the craniocaudal segment of the clavicle (Cc-clav). The sex and side differences of these measurements were also analyzed by two radiologists., Results: Based on the following measurements, point cP was determined. For male patients, the cP-cor was 28.02 ± 3.43 mm, Med-lat cor was 22.78 ± 2.80 mm, Cc-cor was 15.11 ± 2.13 mm, cP-ac was 29.24 ± 3.84 mm, Ap-clav was 18.27 ± 2.46 mm, and Cc-clav was 10.09 ± 1.56 mm. For female patients, the cP-cor was 25.20 ± 3.26 mm, Med-lat cor was 20.21 ± 2.97 mm, Cc-cor was 13.03 ± 1.77 mm, cP-ac was 26.66 ± 3.45 mm, Ap-clav was 16.10 ± 2.30 mm, and Cc-clav was 8.91 ± 1.40 mm. All the measurements of female patients were lower than those of male patients (p < 0.01). Between sides, only cP-ac of the left shoulders was significantly lower than those of the right shoulders (p < 0.05), with no significant differences in other parameters between sides (p > 0.05)., Conclusion: The results of this study identified the locations of bone tunnel-cP in the coracoid process and clavicle for the CCL reconstruction in ACD. Moreover, the findings indicated that surgeons should be more cautious in operating on female patients and that the cP-ac of left shoulders should be set lower than that of right shoulders., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Summary: Brachial plexopathy after conservative therapy or surgical treatment of clavicular fractures is an uncommon, yet serious complication that is associated with compression of the brachial plexus or the subclavian artery and vein because they traverse through the thoracic outlet. Surgical decompression of the brachial plexus is the recommended treatment if this condition is to occur. Although there are multiple reports of these cases in the literature, at present, there are no clear guidelines for their management. We are highlighting an institutional management algorithm, illustrated by a small retrospective case series, that uses a multidisciplinary approach in an effort to minimize complications associated with the management of clavicle nonunion., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Sternoclavicular joint infections and osteomyelitis of the clavicle are extremely rare infections, especially in the pediatric population. Early signs of these infections are nonspecific and can be mistaken for common upper respiratory infections such as COVID-19 and influenza. Rapid diagnosis and treatment are critical for preventing potentially fatal complications such as mediastinitis. We present three cases of sternoclavicular joint infections in the past year during the COVID-19 pandemic. All three patients had delayed diagnoses likely secondary to COVID-19 workup. Each patient underwent surgical irrigation and débridement. Two of three patients required multiple surgeries and prolonged antibiotic courses. Placement of antibiotic-impregnated calcium sulfate beads into the surgical site cleared the infection in all cases where they were used. All three patients made a full recovery; however, the severity of their situations should not be overlooked. Children presenting to the hospital with chest pain, fever, and shortness of breath should not simply be discharged based on a negative COVID-19 test or other viral assays. A higher index of suspicion for bacterial infections such as clavicular osteomyelitis is important. Close attention must be placed on the physical examination to locate potential areas of concentrated pain, erythema, or swelling to prompt advanced imaging if necessary., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Competing Interests: Competing interests: None declared.

Clavicle fractures are a common injury in the pediatric and adolescent population. Most fractures are located in the middle third of the clavicle. There has been no information in the literature regarding the management of extra-physeal medial clavicle shaft fractures in this population. The objective of this study is to evaluate demographic and injury characteristics, management options and clinical outcomes of medial clavicle fractures in children and adolescents and differentiate them from those in adults. A retrospective review was performed at a single institution to identify patients with medial clavicle shaft fractures. Radiographs, clinical features and patient-reported outcomes (QuickDASH) were analyzed. Eight patients were identified with medial clavicle fractures. Two fractures could not be diagnosed on anteroposterior radiographs. Both operative (four patients) and nonoperative (four patients) treatment had excellent radiographic and clinical outcomes, irrespective of initial displacement. Compared to high-energy and life-threatening injuries in adults, these fractures in children and adolescents were sports-related and isolated fractures. Conservative treatment should be considered for medial clavicle fractures in children and adolescents. These fractures are distinct from their adult counterparts and do not lead to increased morbidity or mortality., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation., Purpose/hypothesis: The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes., Study Design: Cohort study; Level of evidence, 2., Methods: Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity-based confounders for creation of comparable subgroups for analysis., Results: Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of "suboptimal" scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ-5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups., Conclusion: Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury., Registration: NCT04250415 (ClinicalTrials.gov identifier).

Purpose: Symptomatic acromioclavicular joint (ACJ) osteoarthritis causes pain and limitations in activities of daily living. Open and arthroscopic distal clavicle excision techniques have been described with good outcomes. However, both techniques have their own sets of advantages and disadvantages. This study describes a novel technique of percutaneous distal clavicle excision for symptomatic ACJ osteoarthritis and our two-year results., Methods: Fifteen consecutive patients underwent percutaneous distal clavicle excision for ACJ arthritis. These patients had failed a trial of conservative treatment. The ACJ was confirmed as the pain generator with an intraarticular steroid/lignocaine injection, and shoulder MRI was used to exclude alternative pain generators in the shoulder. They had a minimum of two years of follow-up., Results: At a mean of 26.8 months postoperatively, the mean VAS pain score was 0, and the mean Constant score for the shoulder was 87.3 points (range 50-94), which corresponded to 1 good, 1 very good and 13 excellent results. The mean SF-36 score was 94.9 points (range 65-100). There were statistically significant improvements in the VAS scores, Constant shoulder scores and SF-36 scores at one year and two years of follow-up (p < 0.05). Three unique complications, namely subcutaneous emphysema, "missing" of the distal clavicle and thermal skin injury, were encountered. Our surgical technique has since been modified to circumvent these complications., Conclusion: Our novel technique of percutaneous distal clavicle excision yields a 93.3% good-to-excellent results based on the Constant shoulder score and durable pain relief based on VAS at two years., (© 2021. Istituto Ortopedico Rizzoli.)

Background: The best option for the treatment of Neer type IIB lateral clavicle fractures remains controversial. The aim of this study was to compare outcomes and complications between pre-contoured locking plate osteosynthesis (PLPO) and coracoclavicular stabilization (CCS) using a TightRope for the treatment of type IIB fractures., Methods: Forty-six consecutive type IIB fractures were treated with PLPO (17 cases) or CCS (29 cases). The mean follow-up period was 33.7 months (range, 12-144 months). Radiographic outcomes were evaluated using serial plain radiographs. Clinical outcomes were evaluated using the University of California, Los Angeles (UCLA) score, the American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV)., Results: Of the 46 cases, complete bony union within 6 months after surgery was achieved in 42 cases (91.3%). The union rate was 100% (17/17) in the PLPO group and 86.2% (25/29) in the CCS group, showing a statistically significant difference ( p = 0.043). No significant differences in terms of UCLA score (32.8 vs. 32.1), ASES score (93.2 vs. 90.8), or SSV (89.1% vs. 90.3%) were observed between the PLPO and CCS groups. The complication rates were 17.6% (3/17; 2 cases of screw breakage and 1 case of stiffness) in the PLPO group and 37.9% (11/29; 4 cases of nonunion, 3 cases of stiffness, 2 cases of skin irritation, 1 case of superficial infection, and 1 case of coracoid button migration) in the CCS group, showing no statistically significant difference ( p > 0.05). Four cases with nonunion after CCS did not require reoperation because they had good to excellent clinical outcomes without radiographic progression., Conclusions: Although a higher nonunion rate was observed in the CCS group compared with the PLPO group, satisfactory clinical outcomes were obtained for both groups. Both techniques can be regarded as useful options for the treatment of Neer type IIB lateral clavicle fractures., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2022 by The Korean Orthopaedic Association.)

Background: The aim of the present study was to compare the clinical efficacy of arthroscopic-assisted fixation using the Tight-rope system and clavicular hook plate fixation in the treatment of Neer IIB distal clavicle fractures., Methods: We enrolled 48 consecutive patients with Neer IIB distal clavicle fractures who were treated at our institution from February 2016 and August 2020. These patients were divided into 2 groups based on the fixation method (16 cases with Tight-rope system and 32 cases with clavicular hook plate), and demographics and clinical characteristics of patients in different groups were compared., Results: All 48 patients had functional outcome scores of the affected shoulder available at a mean of 23.8 ± 5.1 months, and there was a statistically significant improvement in the constant score, American shoulder and elbow surgeons (ASES) score, visual analogue scale (VAS) score at the end of follow-up (p < 0.001 respectively). However, the smaller length of skin incision, less estimated blood loss and shorter hospital stay were detected in the Tight-rope technique group patients than those of clavicular hook plate group patients (p < 0.001, respectively). Furthermore, the constant score, ASES score and VAS score were significantly improved in the Tight-rope technique group patients than those of clavicular hook plate group patients (p < 0.05, respectively)., Conclusions: Both Tight-rope technique and clavicular hook plate fixation can provide satisfactory clinical and radiological results in the treatment of distal clavicular Neer IIB fracture. However, arthroscopic-assisted fixation using the Tight-rope technique showed better results in terms of length of hospital stay, surgical trauma, clinical scores, and diagnose and treat concomitant glenohumeral pathologies., Levels of Evidence: III, Case-control study Retrospective comparative study., (© 2022. The Author(s).)

Medial end clavicle fractures are rare injuries and typically treated conservatively. In contrast, displaced fractures have a higher incidence of delayed healing or non-union and might benefit from operative treatment. Thus, assessments of the stability and fracture morphology are essential for selection of the optimal treatment procedure. This article describes the diagnostics and surgical treatment of a displaced extra-articular fracture of the clavicle with a small medial fragment using an anatomically preformed radius plate., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures., Methods: A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMS pain , CMS activities of daily living , CMS range of motion (ROM) , and CMS strength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery., Results: Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMS pain  = 13.0 vs. 12.3, P = 0.03; CMS ROM  = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed., Conclusion: Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures., (© 2022. The Author(s).)

Background: The risk of displaced and comminuted midshaft clavicle fractures is increased in high-energy traumas such as sport injuries and traffic accidents. Open reduction and plate fixation have been widely used for midshaft clavicle fractures. Among various plates for clavicle shaft fractures, superior locking compression plates (LCPs) have been mostly used. In plate fixation, nonunion caused by implant failure is the most difficult complication. The most common reasons for metal plate failure are excessive stress and stress concentration caused by cantilever bending. These causes were easily addressed using a locking screw cap (LSC)., Methods: The clavicle 3-dimensional image was made from a computed tomography scan, and the clavicle midshaft fracture model was generated with a 10-mm interval. The fracture model was fixed with a superior LCP, and finite element analysis was conducted between the presence (with LSC model) and absence (without LSC model) of an LSC on the site of the fracture. The stresses of screw holes in models with and without LSCs were measured under 3 forces: 100 N cantilever bending force, 100 N axial compression force, and 1 N·m axial torsion force. After the finite element analysis, a validation test was conducted on the cantilever bending force known as the greatest force applied to superior locking plates., Results: The mean greatest stress under the cantilever bending force was significantly greater than other loading forces. The highest stress site was the screw hole edge on the fracture site in both models under the cantilever bending and axial compression forces. Under the axial torsional force, the maximum stress point was the lateral first screw hole edge. The ultimate plate stress of the with LSC model is completely lower than that of the without LSC model. According to the validation test, the stiffness, ultimate load, and yield load of the with LSC model were higher than those of the without LSC model., Conclusions: Therefore, inserting an LSC into an empty screw hole in the fracture area reduces the maximum stress on an LCP and improves biomechanical stability., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)