What is Clavicle Osteosynthesis?

The clavicle is not merely a curved bone connecting the trunk to the upper limb. It is a "strategic bridge" and the sole bony element maintaining the shoulder girdle in its correct anatomical position. A clavicle fracture is one of the most common injuries in traumatology, which, if mismanaged, can transform an active life into a series of limitations. Today, the perspective on this problem has transformed: we no longer view the bone as a "wooden beam" to be simply glued together. The modern approach is a journey from mechanical stabilization to cellular revival.

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Etiology and Classification

 

The etiopathogenesis of clavicle fractures is inextricably linked to its unique S-shaped geometry and its role as a "strut" for the upper limb. Most fractures result from a direct blow to the lateral aspect of the shoulder or a fall on an outstretched hand, where the force vector is transmitted transitionally through the shoulder joint. Inertial forces and bending moments concentrate in the most vulnerable zone - at the junction of the two curvatures in the middle third of the bone. Here, the cortical layer thins, and the absence of a powerful muscular envelope (unlike the proximal and distal ends) leaves this segment defenseless against mechanical aggression.

In clinical practice, the Allman classification is of fundamental importance, dividing the clavicle into three strategic zones based on anatomical and functional characteristics:

 

• Group I: Midshaft fractures (diaphyseal) - accounting for up to 80% of all cases. This is the area of greatest bone narrowing, where powerful ligamentous attachments are absent. They are characterized by a typical "classic" displacement: the medial fragment is pulled upward and posteriorly by the sternocleidomastoid muscle, while the lateral fragment drops downward and rotates anteriorly under the weight of the limb and the pull of the pectoralis major muscles.
• Group II: Distal (acromial) end fractures (approximately 15%). This localization is extremely treacherous due to its proximity to the coracoclavicular ligaments (conoid and trapezoid). If these ligaments are ruptured, the medial fragment displaces sharply upward, making conservative treatment practically impossible. The Neer classification further details these injuries by the degree of stability and involvement of the ligamentous apparatus.
• Group III: Proximal (sternal) end fractures (less than 5%). These occur rarely, usually during massive high-energy impacts (chest compression, motor vehicle accidents). They require careful exclusion of injuries to major vessels, the trachea, and mediastinal organs.

 

For precision surgical planning, the AO/ASIF (Association for the Study of Internal Fixation) classification serves as the foundation. According to this system, the clavicle is designated by code 15. Injuries are ranked by localization (15.1 - proximal, 15.2 - diaphyseal, 15.3 - distal segments) and morphological complexity:

 

• Type A (Simple fractures):Feature a single fracture line and provide full contact between the main fragments after reduction.

   

  • A1: Spiral fracture.
  • A2: Oblique fracture (angle greater than 30°).
  • A3: Transverse fracture (angle less than 30°), most prone to soft tissue interposition.

   

• Type B (Wedge fractures):Characterized by the presence of a third fragment (wedge), while partial contact between the main fragments is maintained.

   

  • B1: Spiral wedge fragment.
  • B2: Comminuted (bending) wedge, often occurring in direct high-energy trauma.
  • B3: Fragmented wedge, requiring particularly careful handling of the blood supply to the fragments.

   

• Type C (Complex comminuted fractures):Complete lack of contact between the main fragments, with multiple intermediate pieces.

   

  • C1: Complex fracture maintaining some spiral structure.
  • C2: Segmental fracture (the bone is broken in two places, forming an isolated "cylinder" in the middle).
  • C3: Irregular comminuted fracture ("explosive" in nature), representing the greatest challenge for stable osteosynthesis.

 

The categorization of injuries by Allman and AO/ASIF serves as the basis for assessing morphological complexity and choosing a strategy, where the key factor is the degree of fragment displacement and the integrity of the ligamentous apparatus.

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Diagnostics

 

The diagnostic algorithm begins with the classic triad: intense pain, visible deformity ("step-off"), and bony crepitus. However, external signs are merely the "tip of the iceberg." Fundamental diagnostics require an assessment of the integrity of the neurovascular bundle, as the subclavian artery, vein, and trunks of the brachial plexus are located directly beneath the clavicle.

Radiography remains the "gold standard." For a full assessment of displacement, imaging in two projections is mandatory: direct (anteroposterior) and axial (with a beam tilt of 15-45°), allowing for the identification of the true degree of angulation and bone shortening. Shortening of more than 15-20 mm is an absolute predictor of an unsatisfactory functional result with conservative treatment.

In complex clinical cases, especially with intra-articular injuries of the acromioclavicular joint or suspected non-union, CT (Computed Tomography) with multiplanar 3D reconstruction is used. This allows the surgeon not just to see the fracture, but to perform a "virtual surgery," accurately assessing the volume of bone defects and the position of each fragment. MRI (Magnetic Resonance Imaging) is utilized when evaluation of soft tissue structures and the ligamentous apparatus is necessary, which is critical for shoulder girdle stability.

Objectification of the trauma through radiography and 3D reconstruction allows for mathematically precise assessment of bone shortening, which is critical for preventing functional deficit of the shoulder girdle.

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Osteosynthesis

 

When conservative treatment (Desault bandages or Delbet rings) is deemed futile due to the high risk of pseudoarthrosis and cosmetic deformities, osteosynthesis comes into play. The modern philosophy of surgery is stable-functional fixation, providing conditions for primary (direct) bone healing without the formation of excessive callus.

Main surgical techniques:

 

• Plating (Extramedullary Osteosynthesis): The recognized "gold standard." Specialized anatomically pre-contoured LCP (Locking Compression Plates) are used. Their S-shaped contour is perfectly adapted to the bone surface. Screws with locking threads create a single rigid "plate-screw" construct, allowing for the fixation of even fragmented bone and providing reliability in conditions of systemic osteoporosis. The use of plates enables anatomical reduction and allows for early joint mobilization.
• Intramedullary Osteosynthesis: Introduction of TEN (Titanium Elastic Nails) or locking rods into the medullary canal. The method is minimally invasive and performed through micro-incisions. This preserves the periosteal blood supply; however, the method has strict limitations in comminuted fractures and requires high mastery of the C-arm (Image Intensifier).

 

The choice between plating and intramedullary osteosynthesis is based on a balance between fixation stability and minimally invasiveness, where the use of LCP is recognized as the most reliable way to achieve primary healing.

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List of Operations, Accesses and Aesthetic Techniques

 

The clinical effectiveness of clavicle fracture treatment directly depends on the precision choice of the surgical procedure, adapted to the specific injury type according to Allman and AO/ASIF. Modern surgery involves both isolated use of methods and their complex hybrid combinations to achieve maximum stability, merging rigid fixation with aesthetic medicine principles.

Operative interventions and their combinations:

 

• ORIF (Open Reduction Internal Fixation) with Plating: Used for diaphyseal fractures (15.2) of types A, B, and C. It is the method of choice when bone length restoration is necessary for shortening exceeding 2 cm.
• Closed Reduction and Intramedullary Fixation with TEN: Indicated for simple transverse and oblique fractures of the middle third (15.2.A3), where the soft tissue envelope is preserved and fragmentation is minimal.
• Hook Plate Osteosynthesis: A specific operation for distal fractures (Allman Group II, type 15.3). The plate hook is placed under the acromion process of the scapula, ensuring reliable fixation in conditions of bone mass deficiency in the lateral fragment.
• Transosseous Suture or Button Fixation: Used for ruptures of the distal ligamentous apparatus (Neer II fractures) in combination with bone injuries.
• "Plate + Lag Screws" Method: Applied in wedge fractures (Type B). First, the wedge fragment is fixed to the main fragment with a separate lag screw outside the plate to create interfragmentary compression, after which the entire zone is covered by a protective LCP plate.
• Reconstruction with Bone Grafting and LCP Fixation: Used for non-unions and comminuted defects (Type C3). The operation combines stable plate osteosynthesis with filling the defect with an autograft (from the iliac crest) or an allograft.
• Plate Osteosynthesis in Combination with Cerclage Wiring: Used in spiral fractures (Type A1) when fragments have a large contact area; wire sutures or Dacron tapes provide preliminary fragment retention before the main plate is applied.
• Biologically Combined Osteosynthesis: Integration of metalwork with the simultaneous introduction of BMAC (Bone Marrow Aspirate Concentrate) or PRP (Platelet-Rich Plasma) directly into the fracture zone during surgery to stimulate reparative osteogenesis.

 

Surgical Approaches:

 

• Direct Horizontal Approach: The incision is made directly over the clavicle. It provides the best view but carries the risk of damaging supraclavicular nerves and forming a noticeable scar due to skin tension directly over the hardware.
• Infraclavicular (Subclavian) Approach: The incision runs parallel to the clavicle but below its axis. This allows the scar to be hidden under the underwear line and reduces the risk of direct plate contact with the skin, significantly decreasing the probability of tissue irritation and hardware protrusion.

 

Aesthetic Wound Closure Technique:

To minimize the postoperative scar, a multilayered suture is applied, aimed at eliminating the "ladder effect":

 

1. Deep Layer: Thorough suturing of the periosteum and fascial-muscular envelope with absorbable sutures to relieve tension from the upper layers.
2. Subdermal Layer: Intradermal continuous monofilament suture, ensuring ideal approximation of the skin edges without visible punctures on the surface.
3. Finish Processing: Use of medical glue or sterile strips (Steri-Strip) for additional epidermis fixation and creating optimal conditions for the formation of a thin, almost invisible scar.

 

The application of the ORIF method in combination with an infraclavicular approach and a cosmetic suture allows for a synergy between mechanical strength and aesthetic result.

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Engineering Biological Revival

 

Modern orthopedics has moved from the concept of "pure mechanics" to biological management of regeneration. If the hardware is a temporary "reinforcement," then cellular biotherapy acts as the "active biological concrete," triggering a cascade of natural restoration.

For delayed union, massive bone defects, or patients with risk factors (smoking, diabetes), advanced methods are applied:

 

1. PRP (Platelet-Rich Plasma Therapy): Local injection of autoplasma with a high concentration of platelets. Platelets release growth factors (PDGF, TGF-β, IGF) that induce neoangiogenesis - the growth of new microvessels into the fracture zone, ensuring nutrient supply and osteoblast stimulation.
2. BMAC (Bone Marrow Aspirate Concentrate): Application of the patient's own bone marrow aspirate concentrate. This substrate is rich in mesenchymal stem cells capable of differentiating into bone tissue. This is a targeted "deployment" of precursor cells that fill biological voids and accelerate callus mineralization.
3. Osteoinductive Materials: Use of synthetic or allogeneic grafts saturated with morphogenetic proteins, creating a scaffold for the growth of the patient's own bone.

 

Integrating PRP and BMAC into the treatment protocol transitions surgery from the field of fixation to the field of biotechnological management, vastly accelerating angiogenesis and shortening consolidation times.

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Fundamental Rehabilitation Protocol

 

Surgical success depends only 50% on the surgeon; the other 50% is delicate and methodical postoperative management. Modern rehabilitation is not merely rest, but an active process of managing tissue adaptation.

Phase I: Period of Primary Protection and Early Mobilization (0-3 weeks)

The main task is controlling edema, preventing lymphostasis and contractures while maintaining fixation stability.

 

• Isometric Gymnastics: The patient performs tension of the shoulder and scapula muscles without committing movement. This maintains muscle tone and microcirculation in the osteosynthesis zone.
• Passive Movements: Movements in the wrist and elbow joints are performed in full. In the shoulder joint, pendulum movements (Codman exercises) are permitted to prevent adhesive capsulitis ("frozen shoulder").
• Scapular Hygiene: Exercises for scapular retraction and depression are crucial, as a correct scapulothoracic rhythm determines the future health of the joint.

 

Phase II: Period of Callus Formation (4-8 weeks)

By this point, primary signs of consolidation are radiologically confirmed.

 

• Active-Passive Movements: Use of a gymnastics stick or pulley systems to gradually increase the angle of shoulder abduction and flexion (up to 90° in the first two weeks of the phase, then higher).
• Proprioceptive Training: Light limb balance exercises that allow the nervous system to "recalibrate" management of the operated area.
• Physiotherapy: High-intensity magnetotherapy SIS (Super Inductive System) and laser therapy are applied to accelerate cell division and bone mineralization.

 

Phase III: Period of Functional Remodeling and Strengthening (8-12 weeks and beyond)

Goal - full restoration of shoulder girdle biomechanics.

 

• Resistive Exercises: Working with Thera-Band elastic bands. Focus on strengthening the rotator cuff (external and internal rotation) and scapular stabilizers (serratus anterior and rhomboid muscles).
• Dynamic Stabilization: Exercises on unstable platforms and working with low-weight resistances with high repetitions.
• Return to Sport: Begins with imitation of specialized movements (throws, swings) only after full clinical and radiological consolidation (usually 4-6 months).

 

Prevention: Preventive Strategy

Prevention of recurrences and complications is built on three pillars:

 

1. Metabolic Support: Monitoring levels of vitamin D (as 25-OH), calcium, and parathyroid hormone. Optimal nutrient levels are the key to high bone regenerate density.
2. Ergonomics and Protection: Use of orthopedic splints in the early period and specialized protection upon returning to contact sports.
3. Kinesiological Control: Teaching the patient the correct pattern for lifting weights, excluding excessive axial loads on the clavicle until full biological remodeling of the bone is complete (up to 1 year).

 

Early mobilization and adherence to scapulothoracic rhythm are decisive factors in preventing contractures and achieving full biomechanical adaptation.

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Schedule and Method of Therapeutic Exercises

 

To achieve an anatomical-functional ideal, strict adherence to cyclicity and dosing of physical loads is necessary. The entire process is divided into clearly structured blocks, excluding overstressing the hardware.

Block A: Early Rehabilitation (1-21 days post-op)

Exercises are performed 3-4 times a day for 10-15 repetitions.

 

• Hand Squeezes: Intensive squeezing of a soft expander to maintain the pumping function of the forearm muscles.
• Elbow Flexion: Active movements without resistance in full range.
• Shoulder Rolls: The movement vector is directed exclusively backward and downward (scapular retraction), allowing for unloading of the anterior joint capsule.
• Pendulum Exercise: Light swinging of the relaxed arm forward-backward and in circles, leaning the trunk forward.

 

Block B: Intermediate Recovery (4-7 weeks)

Transition to active exercises upon reaching a painless range.

 

• "Wall Crawl": The patient "walks" fingers up a vertical surface, gradually increasing the height of the arm lift.
• Gymnastics Stick Work: Holding the stick with both hands, the healthy hand gently assists the operated one in flexion and external rotation movements.
• Isometric Abduction: Attempting arm abduction against resistance (e.g., pressing the palm against a door frame) without an actual change in muscle length.

 

Block C: Power and Proprioceptive (8-14 weeks)

Transition to elastic resistance and functional loads.

 

• Horizontal Band Rows: The band is fixed at chest level; the patient spreads straight arms, bringing the scapulae toward the spine.
• Internal and External Rotation: Elbow pressed to the trunk, the forearm overcomes band resistance in the horizontal plane.
• Forearm Plank: Starts from the knees, then transitions to classic form, ensuring stabilization of the entire shoulder girdle under axial load.

 

Step-by-step execution of the kinesitherapeutic algorithm guarantees a smooth transition from joint protection to strength strengthening and proprioceptive control.

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Summary Protocol and Forecasting Recovery Timelines

 

Based on the AO/ASIF classification and the chosen surgical tactics, a detailed multilevel list of predicted consolidation timelines and rehabilitation stages has been developed. Data are provided considering the use of LCP systems and biological stimulation.

 

1. Type A (Simple fractures: transverse, oblique, spiral)

    

   • Surgical Strategy: Primarily ORIF or TEN (for 15.2.A).
   • Primary Consolidation Timelines (radiological signs of callus): 4-6 weeks.
   • Full Functional Recovery (100% range): 8-10 weeks.
   • Return to Physical Labor and Sport: 3-4 months.

    

2. Type B (Wedge fractures with fragmentation)

    

   • Surgical Strategy: ORIF using locking plates and interfragmentary screws + mandatory PRP therapy.
   • Primary Consolidation Timelines: 6-8 weeks.
   • Full Functional Recovery: 10-12 weeks.
   • Return to Physical Labor and Sport: 4-5 months.

    

3. Type C (Complex, segmental, and comminuted fractures)

    

   • Surgical Strategy: Complex LCP reconstruction + BMAC + possible autologous bone grafting.
   • Primary Consolidation Timelines: 8-12 weeks.
   • Full Functional Recovery: 14-16 weeks.
   • Return to Physical Labor and Sport: 6-8 months.

    

4. Special Cases (Distal fractures Neer II / Allman II)

    

   • Surgical Strategy: Hook Plate fixation or button fixators.
   • Primary Consolidation Timelines: 6-10 weeks.
   • Hardware Removal Stage (when using Hook Plate): in 3-4 months to avoid impingement syndrome.

 

A differentiated approach to forecasting timelines allows for adapting an individual program for a specific morphological fracture type.

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Clinical Study Results

 

Analysis of clinical practice applying combined methods of osteosynthesis and biotherapy demonstrates a statistically significant advantage over isolated techniques. Studies conducted on groups of patients with diaphyseal fractures (15.2) revealed the following patterns:

 

1. Consolidation Timelines: The use of LCP plating combined with intraoperative PRP introduction reduces callus formation time by an average of 25-30% compared to the control group (from 12-14 weeks to 8-9 weeks).
2. Functional Outcomes: According to the DASH (Disabilities of the Arm, Shoulder and Hand) scale, patients who passed the early mobilization stage via the kinesitherapy algorithm show a result of 10-15 points by the 12th week, corresponding to excellent functional recovery, while with prolonged immobilization this indicator varies within 35-45 points.
3. Complications: The frequency of pseudoarthrosis formation when using pre-contoured anatomical plates is less than 1.5%, whereas with straight reconstructive plates the risk of non-union increases to 7-9% due to mechanical fatigue of the metal and inadequate adaptation to the S-shaped profile of the bone.
4. Aesthetics and Neurosensory: Use of the infraclavicular approach allowed for reducing the frequency of iatrogenic supraclavicular nerve injuries (paresthesia under the skin) by 60% and avoiding the formation of hypertrophic scars in 92% of patients.

 

Clinical data confirm that a multimodal protocol minimizes non-union risks and ensures the earliest return to professional activity.

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Modern clavicle osteosynthesis has evolved from a purely mechanical discipline into a multimodal regenerative strategy. The use of LCP (Locking Compression Plate) systems in combination with minimally invasive approaches and cellular technologies, such as PRP and BMAC, ensures not just mechanical strength, but a biologically active environment for accelerated consolidation. The key factor for success is precision diagnostics through CT and MRI, allowing for the choice of an optimal algorithm from a wide list of operations - from classic ORIF to the most complex reconstructive combinations with bone grafting. The integration of aesthetic wound closure techniques and a scientifically based kinesitherapy protocol completes this cycle, guaranteeing the patient functional recovery to a premorbid state.

Given the critical role of the clavicle as the sole bony connection between the axial skeleton and the upper limb, any delay in diagnosis verification and the initiation of pathogenetic treatment inevitably leads to the formation of a persistent functional deficit, chronic pain syndrome, and irreversible degenerative changes in adjacent joints. Only immediate referral to a qualified orthopedic traumatologist in the shortest time after trauma allows for the realization of the full potential of modern medical technologies. Timely intervention within the "golden window" of therapeutic opportunities is the only guarantee for minimizing non-union risks and achieving an optimal clinical result, ensuring the fastest possible return to full social and professional activity.

Timely pathogenetic treatment within the "golden window" is the only way to exclude chronic pain syndrome and ensure social activity.

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A clavicle fracture today is not a sentence to long plaster wearing and subsequent disability. Thanks to the synergy of precision surgical technique, innovative cellular biotherapy, and scientifically based rehabilitation, medicine is capable of not just mechanically approximating fragments, but initiating a deep biological revival, returning the patient to flawless anatomy and full freedom of movement.

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References

 

1. Ankin L. N., Ankin N. L. Practical Traumatology. European Standards of Diagnosis and Treatment. - M.: Kniga plus, 2021.
2. Müller M. E., Allgöwer M., Schneider R., Willenegger H. Manual of Internal Fixation. - Springer-Verlag, 3rd ed.
3. Rockwood C. A., Matsen F. A., Wirth M. A. The Shoulder. - 5th Edition. Elsevier, 2017.
4. Banaszkiewicz P. A., Kader D. F. Classic Papers in Orthopaedics. - Springer, 2014. (Chapter on Neer and Allman Classifications).
5. Marx R. E. Platelet-Rich Plasma (PRP): What Is PRP and What Is Not PRP? // Implant Dentistry. - 2011. - Vol. 20, No. 5.
6. Giannoudis P. V., Einhorn T. A., Marsh D. Fracture Healing: The Diamond Concept // Injury. - 2007. - Vol. 38, Suppl 4.
7. Kotelnicki J. J., et al. Clavicle Fractures: A Review of Current Concepts and Treatment Strategies // Journal of Orthopaedic Surgery and Research. - 2023.
8. AO Surgery Reference. Internal Fixation of Clavicle Fractures: Surgical Techniques and Clinical Outcomes. - AO Foundation, 2025.
9. Neer C. S. Fractures of the distal third of the clavicle // Clinical Orthopaedics and Related Research. - 1968. - Vol. 58.
10. Robinson C. M. Fractures of the clavicle in the adult. Epidemiology and classification // Journal of Bone and Joint Surgery. - 1998. - Vol. 80-B.

 

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If you need consultation about clavicle osteosynthesis ☎ call +38 (063) 310-30-50, we will always help!

Consultation on the issue of clavicle osteosynthesis is conducted by the orthopedic traumatologist Vdovichenko Konstantin Vitalievich

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