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Displaced medial clavicle fractures: A systematic review of outcomes after non-operative and operative management

Open AccessPublished:October 14, 2022DOI:https://doi.org/10.1016/j.jseint.2022.09.010

      Abstract

      Background

      Fractures of the medial clavicle are uncommon. There is no consensus regarding the optimal treatment of displaced medial clavicle fractures.

      Aim

      To compare the outcomes following non-operative and operative treatment of displaced medial clavicle fractures.

      Study design

      Systematic review

      Methods

      A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was performed. PubMed, EMBASE and the Cochrane Library were queried using the terms medial clavicle and fracture to identify all studies reporting on outcomes following either non-operative or operative treatment of displaced medial clavicle fractures. Data extracted included patient demographics, fracture classification, surgical technique, patient-reported outcomes, physical and radiographic findings. Study quality was evaluated using the MINORS (Methodological Index for Non-Randomized Studies) scoring system.

      Results

      The analysis included 15 studies (mean MINORS score, 10 + 1.5) with a total of 135 patients (85% male, mean age 47 + 10.9 years [range, 15-87 years]). Five studies (39 patients) reported outcomes following non-operative treatment. At a mean follow-up of 27 months, there were 5 (13%) symptomatic non-unions, 2 (5%) mal-unions and 2 (5%) delayed unions. Eleven studies (96 patients) reported outcomes following surgical treatment with mean follow-up of 23 months. There were no reported non-unions. Complications included plate prominence/ irritation (30%) and additional surgery was performed for plate removal (27%), fixation failure (3%) and wound débridement (1%).

      Conclusion

      There is limited, low-quality evidence in the literature to guide treatment of displaced medial clavicle fractures. The available data suggests that surgical treatment is associated with good functional outcomes and a lower risk of non-union and mal-union, compared to non-operative treatment but plate irritation and further surgery to remove the plate was common.

      Keywords

      Fractures of the medial end of the clavicle are uncommon, accounting for only 2-3% of all clavicle fractures
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      Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data.
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      • Wolf O.
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      • Lindsey M.H.
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      What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?.
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      The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden.
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      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
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      • Postacchini F.
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      Epidemiology of clavicle fractures.
      ,
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      . They are associated with high energy trauma, multisystem injury and death
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      • Bucknill A.
      Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients.
      ,
      • Bakir M.S.
      • Unterkofler J.
      • Honning A.
      • Haralambiev L.
      • Kim S.
      • Ekkernkamp A.
      • et al.
      Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data.
      ,
      • Lindsey M.H.
      • Grisdela P.
      • Lu L.
      • Zhang D.
      • Earp B.
      What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?.
      ,
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      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      . Traditionally, medial end clavicle fractures have been treated non-operatively, even when significantly displaced
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      . However, non-operative treatment of displaced fractures is often unsatisfactory, with reports up to half of all patients are still symptomatic more than a year after injury
      • Nowak J.
      • Holgersson M.
      • Larsson S.
      Sequelae from clavicular fractures are common: a prospective study of 222 patients.
      ,
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      , and a non-union rate approaching 15%
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      .
      In the last decade, there has been a trend toward operative intervention of displaced medial end clavicle fractures. There remain concerns about the close proximity of underlying vital mediastinal structures
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      • et al.
      Sternoclavicular joint surgery: how far does danger lurk below?.
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      • Gomes A.F.
      MEASURING THE DISTANCE BETWEEN STERNOCLAVICULAR JOINT AND HILAR STRUCTURES WITH TOMOGRAPHY.
      and the potential for iatrogenic damage. However, excellent outcomes have been reported with various methods of plate fixation but hardware irritation and plate removal are common
      • Asadollahi S.
      • Bucknill A.
      Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      .
      Whilst there has been reports of outcome with management of undisplaced medial clavicle fractures with both operative and non-operative methods, there remains no consensus on the optimal treatment of displaced medial clavicle fractures mainly due to the rarity of this injury. The purpose of this article was to review the literature regarding outcomes following non-operative and operative treatment of displaced medial end clavicle fractures. Furthermore this current review differs from two recently published systematic reviews which have reported on all medial end clavicle fractures together without an attempt to stratify based on displacement
      • Asadollahi S.
      • Bucknill A.
      Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients.
      ,
      • Vannabouathong C.
      • Chiu J.
      • Patel R.
      • Sreeraman S.
      • Mohamed E.
      • Bhandari M.
      • et al.
      An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis.
      .

      Material and methods

      A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Two independent reviewers searched PubMed, EMBASE and the Cochrane Library databases (up to April 15, 2021) using the terms medial clavicle and fracture. The authors sought to include all studies reporting outcomes after either non-operative or operative treatment of displaced medial clavicle fractures. Additional articles were detected by searching through the reference lists of eligible studies. Articles not published in the English language were excluded, as were systematic reviews, technical and single patient case reports, biomechanical and animal studies, segmental clavicle fractures or injuries to the sternoclavicular joint, and studies involving only pediatric patients.
      After duplicates were removed, titles and/or abstracts were reviewed, and full text articles were further assessed for eligibility. Data were extracted and cross-checked for accuracy. Outcomes of interest included patient demographics, fracture classification, surgical technique, complications, patient-reported outcomes, physical and radiographic findings.
      Two reviewers independently assigned a MINORS (Methodological Index for Non-Randomized Studies) score
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological index for non-randomized studies (minors): development and validation of a new instrument.
      for each study to assess for quality and risk of bias. The maximum MINORS score is 16 for non-comparative studies and 24 for comparative studies, with higher scores indicating a lower risk of bias. Meta-analysis was not feasible due to the heterogeneity between articles with regard to patient populations, interventions and outcome assessments.

      Results

      The literature search returned a total of 326 records. After exclusions, our review included 15 studies consisting of 135 patients with a displaced medial clavicle fracture (Figure 1). Outcomes following non-operative treatment were reported for 39 patients
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      and after operative treatment for 96 patients
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      .
      Figure thumbnail gr1
      Figure 1PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram.

      General study characteristics

      The included studies were generally of low quality (mean MINORS score was 10 + 1.5) consisting entirely of retrospective case series or observational cohorts. The mean age of patients across all studies was 47 + 10.9 years (range, 15-87 years) with the majority male (85%). The most common mechanism of injury was a motor vehicle or motorbike accident (36%) followed by sports (25%) and bicycle (23%) injuries
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Singh R.
      • Rambani R.
      • Kanakaris N.
      • Giannoudis P.V.
      A 2-year experience, management and outcome of 200 clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      . About 75% of patients had a CT scan in conjunction with a plain radiograph
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      . All studies, except one
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      , defined the medial end of the clavicle to be either the medial 1/5 or 1/3 of the clavicle. Twelve studies
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      defined fracture displacement using either the Robinson (>100% translation of major fracture fragments)
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      , Throckmorton (>10mm displacement)
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      or AB (no contact between fracture ends)
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      classification systems (Table 1) with 3 studies having no definition
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      . The operative group, which included the treatment of 5 non-unions
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      and 8 physeal fractures
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      , had an overall mean follow-up of 23 months (range, 3-124 months). In 2 studies with non-operatively treated patients
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      , the mean follow-up was 38 months (range, 6-67 months). In the remaining 3 non-operative studies
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      which pooled together all clavicle fractures, including medial fractures, the mean period of follow-up was 5 months (range, 1-72) (Table 1). The Disabilities of the Arm, Shoulder and Hand (DASH) score was the most commonly reported functional outcome measure
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      . Shoulder range of motion
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      , return to work
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      and complications
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      were also frequently reported.
      Table 1Study characteristics between operative and non-operative cohort of medial clavicle fractures
      Operative
      StudyNumber of PatientsMean Age (Range), YearsMale/FemaleExtra/Intra-articular FractureFracture Classification SystemDegree of DisplacementConcurrent Injuries (n)Mean Follow Up (Range), MonthsStudy Quality
      Bartonicek et al (2010)326.3 (19 – 31)3/03/0Robinson

      Throckmorton
      >10mm or >100% translationNR18.0 (12 – 24)9
      Feng et (2020)549.2 (39-67)3/21/4Robinson>100% translation of major fragmentsThoracic injury with left radial/ ulna fractures (1)20.2 months (12-42)11
      Frima et al (2018)1552.0 (19 – 79)15/011/3Robinson>1 shaft width or displaced intra-articularPolytrauma (3)39.0 (9 – 79)11
      Liu et al (2019)1144.3 (28 – 66)11/08/3Robinson>100% translationIpsilateral clavicle fracture (1)16.0 (11 – 22)9
      Liu et al (2020)561.2 (44 – 72)3/24/1Robinson>100% translationNR8.8 (6 – 12)10
      Low et al (2008)543.0 (25 – 52)5/0NRNRNRNil39.6 (8 – 123.6)9
      Oe et al (2012)1033.9 (15 – 73)9/19/1Robinson>100% translationMultisystem injury (6)38.0 (14 – 52)11
      Sidhu et al (2015)27Median 37 (Interquartile range 7 – 47)26/120 Adult

      7 Physeal injury
      NR>10mmNR12.012
      Sloan et al (2008)233.0 (25 – 41)2/0NRNRNRNil3.07
      Titchener et al (2019)831.3 (15 – 59)7/14/3

      1 Physeal
      NRNRNil32.5 (24 – 45)9
      Xie et al (2018)646.3 (24 – 66)5/13/3Throckmorton>10mmNil12.0 (10 – 14)10
      Non-Operative
      Bartonicek et al (2010)264.5 (63 – 66)2/01/1Robinson

      Throckmorton
      >10mm or >100% translationNR15.5 (13 – 18)9
      Robinson et al (1998)531.0 (13 – 87)2/32/3Robinson>100% translationNR3.7 (1 – 34)10
      Robinson et al (2004)859.5 (26 – 87)7/15/3Robinson>100% translationNR5.613
      Salipas et al (2016)7Median 53.5 (16 – 94)NRNRThrockmorton>10mm (severe)

      2-10mm (moderate)
      NR36.0 (12 – 72)9
      Van Tongel et al (2018)1757.2 (19 – 84)10/7NRAnatomically based (AB)No contact between fragmentsNR41.0 (6 – 67)10
      a. NR = Not reported

      Surgical technique

      Three methods of fracture fixation were reported consisting of plating (88%), sutures (9%) and cerclage wires (3%). Suture fixation was used almost exclusively for physeal fractures
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      . Only one author reported using cerclage wires as their mode of fracture fixation
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      . Half of all plates utilized consisted of an inverted, or reversed, distal clavicle locking plate
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      . Some authors used a variety of plates including distal radius
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      , distal humerus
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      and pilon locking plates
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      . Hook plate fixation
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      and double-plating
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      were also reported. When plating, most authors placed the medial screws in a unicortical fashion
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      due to the close proximity of underlying mediastinal structures. One author reported using bicortical medial screws whenever possible
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      and the remaining authors did not specify whether they used or preferred unicortical or bicortical medial screws
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      .

      Range of motion

      Range of motion following surgery was assessed in 9 studies
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      which included 76 patients (79% of all operative cases). Full shoulder range of movement was achieved in 92% of patients at final follow-up (table 2). One study reported a patient with slight restriction in shoulder movement of less than 15 degrees following a reversed lateral locking clavicle plate
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      . In another study which included 5 patients with an isolated, displaced medial clavicle fracture fixed with a hook plate, the authors reported the mean shoulder forward flexion as 164o (range, 160-170o)
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      .
      Table 2Comparison of outcomes between operative and non-operative cohort of medial clavicle fractures
      Operative
      StudySurgical TreatmentSubjective OutcomesObjective OutcomesReturn to ActivityComplications
      Bartonicek et al (2010)Cerclage wires (3)DASH: 25.0 (24.2 – 25.8)

      Pain VAS at rest: 0

      Pain VAS with normal activity: 0

      Pain VAS with heavy activity: 0
      Full ROM in all patientsNRRemoval of cerclage wires (3, 100%)
      Feng et al (2020)Basler Hook plate (5)DASH: 4.2 (0-8.3)

      Pain VAS: 0.6 (0-2)

      CMS: 94.4 (87-100),

      All patients satisfied
      FF 1674 degrees (160-170)NRWound haematoma day 3 post-op (healed after debridement)
      Frima et al (2018)Inverted LCP superior anterior clavicle plate (8), radial VA-LCP distal humerus plate (6), LCP 3.5 plate (1)QuickDASH: 0.81 (0-4.5)

      SSV: 96 (80-100)
      15-degree ROM restriction in 1 patient, otherwise full ROM100% return to activity, 82% return to workPlate removal (7, 47%), plate irrigation (1, 7%), implant failure (1, 7%)
      Liu et al (2019)Reverse lateral locking plate (with unicortical medial screws)DASH: 8 (0-13)

      All patients satisfied

      9 excellent, 2 good
      Full ROM in all patients100% return to activityPlate removal (2, 18%), mild SCJ pain on movement (1, 9%)
      Liu et al (2020)Double LCP plates 2.4/2.7mmPain VAS at rest: 0

      Pain VAS with overhead work: 0.4 (0-2)

      Satisfaction VAS: 9.6 (8-10)

      ASES: 94.8 (89-100)

      CMS: 94.2 (87-100)

      Rowe: 95.8 (91-100)
      Full ROM in all patientsNRPlate breakage and removal (1, 20%)
      Low et al (2008)Plate (4), screws and sutures (1)DASH: 9 (0-17)

      Pain VAS at rest: 0.75 (0-2)

      Pain VAS with normal activity: 0.75 (0-2)

      Pain VAS with heavy activity: 1 (0-2)

      Satisfaction VAS: 10
      Full ROM in all patients100% return to activity and workPlate removal (1, 20%)
      Oe et al (2012)T-locking plate (5), pilon locking plate (2), reconstruction locking plate (1), DCP plate (1), BOS plate (1)DASH: 13.5 (0-66.7)

      4 excellent, 2 good
      Full ROM in 9 out of 10 patientsNRPlate removal (7, 70%), implant failure 1, 10%)
      Sidhu et al (2015)Reverse lateral clavicle plate (15), distal radius locking plate (2), standard locking compression plate (2), transosseus sutures (8)DASH: median 0.4 (IQR 0-5)

      All patients satisfied
      Full ROM in all patients100% return to work, 96% return to sportPlate removal (3, 13%), mild plate irritation (17, 71%), wound dysaesthesia >6 months (5, 19%)
      Sloan et al (2008)Inverted distal clavicle locking plate (with unicortical medial screws)NRFull ROM in all patients100% return to activity and workNil
      Titchener et al (2019)Inverted distal clavicle locking plate (with unicortical medial screws)QuickDASH: 0.6 (0-2.3)

      All patients satisfied
      NRNRPlate prominence (2, 25%)
      Xie et al (2018)Inverted distal clavicle locking plate (with unicortical medial screws)DASH: 8.6 (7-9)

      5 excellent, 1 good
      NRNRPlate removal necessary
      Non-Operative
      Bartonicek et al (2010)NilDASH: 30.2 (27.1-33.3)

      Pain VAS at rest: 0

      Pain VAS with normal activity: 1.5 (1-2)

      Pain VAS with heavy activity: 3 (2-4)
      ROM restriction of 10-degrees ER (1), 25-degrees ER and 20-degrees FF (1)NRSymptomatic malunion (1, 50%)
      Robinson et al (1998)NilNRNRNRNR
      Robinson et al (2004)NilNRNRNRNon-union (14%)
      Salipas et al (2016)NilASES: 96.3 (83.3-100)

      SSV: 8.4 (5-10)

      Pain VAS: 0.6 (0-3)
      NRNRPainful atrophic delayed union (2, 29%), intra-operative vascular complication during subsequent surgery (1, 14%)
      Van Tongel et al (2018)NilCMS: 72

      OSS: 39
      NRNRSymptomatic non-union (4, 24%), malunion (1, 6%)
      *Numerical outcomes expressed as mean (range)
      b. DASH = disabilities of arm, shoulder and hand score
      c. VAS = visual analogue scale
      d. ASES = American shoulder and elbow surgeons shoulder score
      e. CMS = Constant-Murley score
      f. SSV = subjective shoulder value score
      g. ROM = range of movement
      h. SCJ = sternoclavicular joint
      i. OSS = Oxford Shoulder Score
      j. ER = external rotation
      k. FF = forward flexion
      Only one study assessed range of motion following non-operative treatment which consisted of only 2 patients (5% of all non-operative cases)
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      . One patient had 10o restriction of external rotation and the other a restriction in both forward flexion of 20o and external rotation of 15o (table 2).

      Patient reported outcomes

      Disabilities of the Arm, Shoulder and Hand (DASH)
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      or QuickDASH
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      scores following surgery were included in 9 studies. After a minimum mean follow-up of 12 months, mean DASH and QuickDASH scores ranged from 0.4-25 and 0.6-0.8 respectively (table 2). Four studies reported VAS pain scores, at rest or with activity, after surgery with all mean scores ranging from 0-1
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      . Two studies utilized the Constant score with mean scores of 94.2 and 94.4 reported after a mean follow-up of 8.8 months and 20.2 months, respectively following surgery
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      . In addition to the QuickDASH score, one study also included a subjective shoulder value (SSV) with a mean score of 96 after mean follow-up of 39 months
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      . Another study also utilized ASES (American Shoulder and Elbow Surgeons score) and Rowe Scores in addition to VAS pain and Constant scores
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      . Two studies reported mean VAS satisfaction scores of 9.6 and 10 after mean follow-up of 8.8 months and 39.6 months, respectively
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      . In 4 studies, all patients were either happy to undergo the same procedure again
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      or were satisfied with the outcome of surgery
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      . Five studies reported 100% return to pre-injury activities and 96% return to previous occupation following surgery
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      .
      Three studies included patient reported outcomes following non-operative treatment
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      . Two studies reported VAS pain scores, at rest or with activity, with all mean scores ranging from 0-3
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      . In addition to VAS pain scores, one study reported a mean DASH score of 30.23
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      and in another study, a mean SSV of 8.4 and ASES of 96
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      . The final study reported a mean Constant score of 72 and Oxford score of 39 after a mean follow-up period of 41 months
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      .

      Complications and additional surgery

      Fracture healing complications were only reported after non-operative treatment of displaced medial end clavicle fractures
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      . At a mean follow-up of 27 months, there were 5 (13%) symptomatic non-unions and 2 (5%) mal-unions
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      . There were 2 (5%) painful atrophic delayed unions which proceeded to plate fixation and iliac crest bone graft after an average of 4 months post injury
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      . One patient had metalware removed at 9 months and there was one intra-operative vascular complication with no long term adverse outcome
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      .
      All operatively treated displaced medial end clavicle fractures united successfully with no reported non-unions (table 2). Plate prominence or irritation was reported in 4 studies, affecting 7-71% of patients
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      . Altogether 30% of all operative patients in this review experienced plate prominence/ irritation and 27% of patients had additional surgery for implant removal. Rates of plate removal in individual studies, ranged from 0-80%
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      . One author after utilizing an inverted distal clavicle locking plate as fixation, stated that it was necessary to remove the plate as soon as possible following fracture healing
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      . All 3 patients who underwent cerclage wire fixation subsequently had their wires removed
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      . In a study of 5 patients, at a mean of 20.2 months following Hook plate fixation, no patient required implant removal but one patient developed a wound hematoma 3 days postoperatively which healed after a débridement
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      .
      Implant or fixation failure occurred in 3 patients (3%)
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      . After a double-plating technique using 2.4mm/2.7mm LCP plates
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      , one patient at 3 months was noted on x-ray to have a broken plate with the fracture well-healed. The plate was removed at 12 months after surgery without complication. In another study
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      , one patient was observed to have plate loosening (Pilon plate, non-locking screws) and superficial wound infection 5 days after surgery. The plate was removed and the wound débrided. The patient then received additional treatment for recurrent infection 7 months later and underwent resection of the medial two-thirds of the clavicle. In the final study
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      , a patient treated with a radial (VA)-LCP distal humeral plate placed in a suboptimal position experienced cut-out of the medial screws after 2 days, then underwent revision fixation with the same implant and the fracture united. Eighteen months later, a skin perforation with subsequent infection occurred due to a broken and displaced screw. The plate was removed and the infection successfully treated with antibiotics.

      Discussion

      This systematic review exposed a paucity of studies, all of low quality, reporting on the outcomes following non-operative or operative treatment of displaced medial clavicle fractures. There are very few cases of non-operatively treated patients in the literature to guide recommendations for surgical treatment. With the available outcome data, the principle findings of this review suggest that when compared to non-operative treatment, surgical treatment of displaced medial end clavicle fractures in experienced hands, is a safe procedure which is associated with good functional outcomes and a lower risk of non-union.
      Traditional radiographic-based studies have reported medial end clavicle fractures to be uncommon, accounting for only 2-3% of all clavicle fractures
      • Bakir M.S.
      • Unterkofler J.
      • Honning A.
      • Haralambiev L.
      • Kim S.
      • Ekkernkamp A.
      • et al.
      Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data.
      ,
      • Kihlstrom C.
      • Moller M.
      • Lonn K.
      • Wolf O.
      Clavicle fractures: epidemiology, classification and treatment of 2 422 fractures in the Swedish Fracture Register; an observational study.
      ,
      • Lindsey M.H.
      • Grisdela P.
      • Lu L.
      • Zhang D.
      • Earp B.
      What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?.
      ,
      • Nowak J.
      • Mallmin H.
      • Larsson S.
      The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Postacchini F.
      • Gumina S.
      • De Santis P.
      • Albo F.
      Epidemiology of clavicle fractures.
      ,
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      . Displacement of medial end clavicle fractures is most commonly defined in the literature using either the Robinson (>100% translation of major fracture fragments)
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      or Throckmorton (>10mm displacement)
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      classification systems. By this definition, up to a third of all medial end clavicle fractures are considered displaced
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      . Non-operative treatment of medial end clavicle fractures, especially of displaced fractures, may not be as benign as previously believed. At a mean of 15.5 months, Throckmorton et al
      • Throckmorton T.
      • Kuhn J.E.
      Fractures of the medial end of the clavicle.
      reported that 28% of surviving patients still had moderate or severe pain following non-operative treatment, and 9% had undergone surgery for their medial end clavicle fracture. Robinson et al
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      found a non-union rate of 6.3% for non-displaced fractures and 14.3% for displaced fractures at 24 weeks after non-operative treatment.
      The current review identified only 5 studies, consisting of 39 patients, in the literature which reported outcomes following non-operative treatment of displaced medial end clavicle fractures
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Robinson C.M.
      Fractures of the clavicle in the adult. Epidemiology and classification.
      • Robinson C.M.
      • Court-Brown C.M.
      • McQueen M.M.
      • Wakefield A.E.
      Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Van Tongel A.
      • Toussaint A.
      • Herregods S.
      • Van Damme S.
      • Marrannes J.
      • De Wilde L.
      Anatomically based classification of medial clavicle fractures.
      . In total, there were 5 (13%) symptomatic non-unions, 2 (5%) mal-unions and 2 (5%) delayed unions. Treatment of established non-union of the medial end clavicle has rarely been reported but some studies suggest that successful union can be achieved with surgical plate fixation and bone grafting
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      ,
      • Sasaki Y.
      • Lee S.Y.
      • Iwakura T.
      • Fukui T.
      • Oe K.
      • Matsumoto T.
      • et al.
      Medial clavicle pseudarthrosis successfully treated with an inverted distal clavicle locking plate.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      . However, when symptomatic non-union occurs after plate fixation, case reports have shown that partial medial claviculectomy with
      • Dion M.O.
      • Martel S.
      • Pelet S.
      Surgical Treatment of a Medial Clavicle Fracture Nonunion with Medial Clavicle Resection and Stabilization to the Sternum with Palmaris Longus Graft.
      , or without
      • Teng H.G.
      • Liu A.L.
      Partial claviculectomy after non-union of proximal clavicle fracture.
      , reconstruction can lead to satisfactory outcomes.
      In the last decade, there has been a trend toward operative intervention of displaced medial end clavicle fractures with perceived advantages of quicker return of function, increased patient satisfaction and fewer healing complications. The current review identified 11 studies, consisting of 96 patients, in the literature which reported outcomes following surgical treatment of displaced medial end clavicle fractures
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      . Subjective outcomes and satisfaction rates were high
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      , shoulder movement mostly restored
      • Bartonicek J.
      • Fric V.
      • Pacovsky V.
      Displaced fractures of the medial end of the clavicle: report of five cases.
      ,
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      and there were no reported non-unions. However, complications were relatively common including plate prominence or irritation (30%)
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      and additional surgery was performed for plate removal (27%)
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      • Low A.K.
      • Duckworth D.G.
      • Bokor D.J.
      Operative outcome of displaced medial-end clavicle fractures in adults.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      and fixation failure (3%)
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu H.
      • Peng C.
      • Zhang Z.
      • Yuan B.
      • Ren G.
      • Yu J.
      • et al.
      Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study.
      ,
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      . Authors mostly utilized anatomically contoured locking plates originally designed for other sites such as the lateral clavicle
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      , distal radius
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      , pilon
      • Oe K.
      • Gaul L.
      • Hierholzer C.
      • Woltmann A.
      • Miwa M.
      • Kurosaka M.
      • et al.
      Operative Management of Periarticular Medial Clavicle Fractures-Report of 10 Cases.
      and distal humerus
      • Frima H.
      • Houwert R.M.
      • Sommer C.
      Displaced medial clavicle fractures: operative treatment with locking compression plate fixation.
      , placed superiorly on the clavicle. Titchener et al
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      used an inverted distal clavicle locking plate which was twisted such that the medial part of the plate was positioned anteriorly and the lateral part superiorly over the clavicle. The advantages of an anterior plate are that the anterior surface of the medial clavicle is wider
      • Grantham W.J.
      • Halverson S.J.
      • Lee D.H.
      Medial Clavicle Osseous Dimensions with Implication on Plate Fixation.
      , damage to the clavicular head of sternocleidomastoid can be avoided and that the patient’s head does not interfere with accessing correct drill and screw trajectories
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      .
      When the medial clavicle fragment is small or very comminuted and fixation is of concern, hook plates
      • Feng W-l
      • Cai X.
      • Li S-h
      • Li Z-j
      • Zhang K.
      • Wang H.
      • et al.
      Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review.
      ,
      • Gille J.
      • Schulz A.
      • Wallstabe S.
      • Unger A.
      • Voigt C.
      • Faschingbauer M.
      Hook plate for medial clavicle fracture.
      ,
      • Zhang C.
      • Lin L.
      • Liang J.
      • Wang B.
      • Chen G.
      • Chen H.
      Efficacy analysis of a novel sternoclavicular hook plate for treatment of unstable sternoclavicular joint dislocation or fracture.
      , bridging plates to the sternum
      • Li Z.
      • Liu H.
      • Chen D.
      • Chen C.
      • Zhang Y.
      • Xue E.
      A new technique for medial-end comminuted clavicle fractures.
      ,
      • Schultz M.J.
      • Barcak E.A.
      Medial Clavicle Fracture Fixation Including the Sternum: A Case Report.
      ,
      • Zheng Y.
      • Yuan X.H.
      • Yin Y.H.
      • Wang W.B.
      • Fu Q.S.
      • Pang Q.J.
      T-plate fixation for unstable proximal clavicula fractures.
      and double-plating techniques
      • Grantham W.J.
      • Halverson S.J.
      • Lee D.H.
      Medial Clavicle Osseous Dimensions with Implication on Plate Fixation.
      ,
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Zúñiga D.G.
      • García L.F.
      • Leal J.A.
      Biplanar Osteosynthesis for Severely Displaced Proximal-Third Clavicle Fracture: A Case Report.
      have been utilized to minimize the risk of fixation failure in multiple studies. However, despite high satisfaction and union rates, such fixation modalities typically require later removal. Distant migration of K-wires to other parts of the body have been documented in case studies as a cause of concern
      • Fransen P.
      • Bourgeois S.
      • Rommens J.
      Kirschner wire migration causing spinal cord injury one year after internal fixation of a clavicle fracture.
      as well as migration of medial locking screws into the chest
      • Dion M.O.
      • Martel S.
      • Pelet S.
      Surgical Treatment of a Medial Clavicle Fracture Nonunion with Medial Clavicle Resection and Stabilization to the Sternum with Palmaris Longus Graft.
      . Fortunately, the most serious potential complication, vascular injury, has been very rarely reported
      • Khalil H.
      • Bourchier R.
      • Walsh S.
      Case report-Vascular injury in association with posteriorly displaced medial clavicle fracture.
      ,
      • Salipas A.
      • Kimmel L.A.
      • Edwards E.R.
      • Rakhra S.
      • Moaveni A.K.
      Natural history of medial clavicle fractures.
      . The closest underlying vital vascular structures have been reported to be only a few millimetres away from the sternoclavicular joint
      • Ponce B.A.
      • Kundukulam J.A.
      • Pflugner R.
      • McGwin G.
      • Meyer R.
      • Carroll W.
      • et al.
      Sternoclavicular joint surgery: how far does danger lurk below?.
      ,
      • Sola W.J.
      • Colferai T.A.
      • Ramos C.H.
      • Santos P.S.D.
      • Gerlack J.S.
      • Gomes A.F.
      MEASURING THE DISTANCE BETWEEN STERNOCLAVICULAR JOINT AND HILAR STRUCTURES WITH TOMOGRAPHY.
      . Unicortical medial screws
      • Liu Z.
      • Zhang J.
      • Tian X.
      • Kan S.
      Displaced Medial-End Clavicle Fractures Treated with Locking Plate Osteosynthesis.
      ,
      • Sidhu V.S.
      • Hermans D.
      • Duckworth D.G.
      The operative outcomes of displaced medial-end clavicle fractures.
      ,
      • Sloan A.
      • Howcroft D.
      • Wykes P.R.
      Operative treatment of medial clavicle fractures: An alternative surgical technique.
      ,
      • Titchener A.
      • See A.
      • Van Rensburg L.
      • Tytherleigh-Strong G.
      Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees.
      ,
      • Xie W.P.
      • Zhang Y.K.
      • Chen Y.H.
      • Wang S.L.
      • Xu H.H.
      • Bi R.X.
      A novel surgical method for treating medial-end clavicle fractures.
      have been shown to minimize risk but due to the concerns about potential iatrogenic vascular damage, surgery for displaced medial end clavicle fractures is safest performed by surgeons experienced in operating around the sternoclavicular region with cardiothoracic support available if necessary.

      Limitations

      The main limitation is the small number of studies which were included, all of which had relatively poor level of evidence. This is further reflected in the lower low MINOR scores (10 + 1.5). Some studies did not provide sufficient detail regarding fracture displacement, outcomes, complications and postoperative protocol. Last, the small number of patients and heterogeneity of patient populations, interventions, protocols and outcome assessments did not allow for a meta-analysis for treatment comparison.

      Conclusion

      Medial end clavicle fractures may be more common than previously reported. There is a strong association with high energy trauma, multisystem injury and death. The available data suggests that surgical treatment is associated with good functional outcomes and a lower risk of non-union and malunion compared to non-operative treatment but plate irritation and further surgery to remove the plate was common.

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