Anterior-inferior Plate Fixation of Middle-third Fractures and Nonunions of the Clavicle

Objective: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. Design: Consecutive clinical series. Setting: 3 tertiary care academic trauma centers (Level 1 and 2). Patients: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. Intervention: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. Main Outcome Measurements: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. Results: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. Conclusions: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.