Traditionally, middle third clavicle fractures have been treated non-operatively with sling or Figure-of-Eight brace immobilization. Neer and Rowe reported acceptable results of conservatively treated mid-shaft clavicle fractures [1, 3]. Hill et al. were the first to report unsatisfactory functional results in patients who underwent non-operative treatment for displaced mid-shaft clavicle fractures [11]. The authors argued that open reduction and internal fixation (ORIF) would be the preferred treatment in these cases. In 2006, the first randomized control trial (RCT) performed on this topic by McKee [4] yielded better DASH scores and a lower nonunion rate in patients who underwent ORIF of their displaced mid-shaft clavicle fractures. The reoperation rate for the surgical group was 12%, with irritation of the implant the most common cause for reoperation. In 2007, a meta-analysis [12] by the Canadian Orthopedic Society showed that the majority of clavicle fractures managed non-operatively had normal motion and strength. In a meta-analysis of RCTs, Mckee [6] later found that operative treatment significantly reduces the incidence of nonunion and symptomatic malunion. Nevertheless, the study failed to demonstrate superior long-term outcomes of operative treatment versus non-operative care. Robinson [7] asserted that ORIF reduces the rate of nonunion. However, they reported that the improvement in functional outcomes associated with surgery appears to result from plate fixation as the mechanism of nonunion prevention (Figs. 7.4a, b and 7.5a–d).

The problem remains that 25% of patients develop a nonunion or a symptomatic malunion [12]. The goal of the surgeon is to identify these patients in the acute setting and treat them with ORIF.

The economics of treating these fractures is another variable that should influence our surgical decision making. In 2010, Pearson [5] published in a multicenter RCT that surgery for displaced mid-shaft clavicle fractures was not cost-effective. One major advantage of operative treatment in actively employed patients is a significantly earlier return to work, thus minimizing loss of income, and a decreased usage of pain medication [13, 14]. Conversely, Walton et al. [15] reported that in unemployed individuals, initial non-operative treatment followed by delayed operative treatment only as needed is less costly than initial operative fixation.

Fixation of clavicle fractures is an elective procedure that is technically easier to perform within 2 weeks of injury. Das et al. [16] showed that there is no difference in long-term clinical outcomes whether the fracture is fixed within 3 weeks of injury or between 3 and 12 weeks post-injury. While outcomes are no different, the procedure becomes technically more challenging due to scarring and early callus formation.

Absolute indications for surgical fixation include open or impending open fractures, and neurologic or vascular compromise. Relative indications for surgical treatment include displaced fractures, shortening of two or more centimeters, comminution, poly-trauma, high level athletes, and symptomatic nonunion or malunion [8] (Table 7.1).

Robinson [9] and Zlowodzki et al. [17] showed that there are certain patient- and fracture-specific characteristics that when present predispose to poor outcomes in conservatively treated middle third clavicle fractures. Fracture-specific characteristics that have been shown to lead to poor outcomes include displacement, shortening greater than or equal to two centimeters, and comminution. Patient-specific characteristics associated with poor outcomes include female sex, advanced age, and use of tobacco products.