Successful treatment of clavicle malunion represents a major challenge for orthopedic surgeons.
The aim of this study was to provide an overview of surgical options for the treatment of clavicle malunions regarding their technical details and clinical results.
A comprehensive search of the literature was performed to retrieve articles and conference abstracts regarding the surgical treatment of clavicle malunions. A total of 1873 records were identified and 29 studies were included in the present review, with a total of 103 patients.
The majority of the patients (77/103) were treated with an osteotomy and subsequent open reduction internal fixation (ORIF). The next most frequent management choice was debridement, excision, or removal of excess callus or bone (n = 19), but other techniques like resection of the clavicle (n = 5) or nerve exploration and decompression (n = 2) were also reported. The preferred method of fixation was plate fixation (n = 53) followed by pin fixation (n = 6). The complication rate was low, reported in less than 6% of patients.
All of the currently reported surgical techniques to manage symptomatic clavicle malunion have resulted in good clinical outcomes with a low complication rate. Considering biomechanical aspects, correction osteotomy followed by plate fixation seems to be the preferred method. Further studies are needed to compare the various surgical techniques and their specific outcomes in a prospective manner. Nevertheless, this review article can be used as an overview to help choose an optimal operative treatment for patients presenting with a clavicle malunion.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Basamania CJ. Claviculoplasty and intramedullary fixation of malunited, shortened clavicle fractures. Seventh International Conference on Surgery of the Shoulder [abstract 140]. J Shoulder Elbow Surg. 1999;8(5):501–558.
Bosch U, Skutek M, Peters G, Tscherne H. Extension osteotomy in malunited clavicular fractures. J Shoulder Elbow Surg. 1998;7:402–405. https://doi.org/10.1016/s1058-2746(98)90032-5.
Chan KY, Jupiter JB, Leffert RD, Marti R. Clavicle malunion. J Shoulder Elbow Surg. 1999;8:287–290. https://doi.org/10.1016/s1058-2746(99)90146-5.
Chen CE, Liu HC. Delayed brachial plexus neurapraxia complicating malunion of the clavicle. Am J Orthop. 2000;29:321–322.
Chen DJ, Chuang D, Wei FC. Unusual thoracic outlet syndrome secondary to fractured clavicle. J Trauma Inj Infect Crit Care. 2002;52:393–399. https://doi.org/10.1097/00005373-200202000-00033.
Connolly JF, Ganjianpour M. Thoracic outlet syndrome treated by double osteotomy of a clavicular malunion. J Bone Joint Surg Am. 2002;84:116–119. https://doi.org/10.1302/0301-620x.84b1.12285.
Coughlin LM, Koenig KN, Clark PM. Claviculectomy with thrombectomy for management of Paget-Schroetter syndrome in a patient with chronic clavicular malunion. Ann Vasc Surg. 2013;27:498.e1–498.e4. https://doi.org/10.1016/j.avsg.2012.09.008.
Dannöhl C, Meeder PJ, Weller S. Costoclavicular syndrome—a rare complication of clavicular fracture. Aktuelle Traumatol. 1988;18:149–151.
Daskalakis E, Bouhoutsos J. Subclavian and axillary vein compression of musculoskeletal origin. Br J Surg. 1980;67:573–576.
Enker SH, Murthy KK. Brachial plexus compression by excessive callus formation secondary to a fractured clavicle. A case report. Mt Sinai J Med. 1970;37:678–682.
Fujita K, Matsuda K, Sakai Y, Sakai H, Mizuno K. Late thoracic outlet syndrome secondary to malunion of the fractured clavicle: case report and review of the literature. J Trauma Inj Infect Crit Care. 2001;50:332–335. https://doi.org/10.1097/00005373-200102000-00022.
Gao Y, Chen W, Liu Y-J, Li X, Wang H-L, Chen Z-Y. Plating versus intramedullary fixation for mid-shaft clavicle fractures: a systemic review and meta-analysis. PeerJ. 2016;4:e1540. https://doi.org/10.7717/peerj.1540.
Hillen RJ, Eygendaal D. Corrective osteotomy after malunion of mid shaft fractures of the clavicle. Strat Traum Limb Recon. 2007;2:59–61. https://doi.org/10.1007/s11751-007-0024-6.
Hillen RJ, Burger BJ, Pöll RG, Gast A de, Robinson CM. Malunion after midshaft clavicle fractures in adults. Acta Orthop. 2010;81:273–279. https://doi.org/10.3109/17453674.2010.480939.
Jahn R, Friedrich B. Damage to the arm plexus caused by atypical callus formation following clavicular fracture. Der Unfallchirurg. 1989;92(5):227–228.
Jupiter JB, Leibman MI. Supraclavicular nerve entrapment due to clavicular fracture callus. J Shoulder Elbow Surg. 2007;16:e13–14. https://doi.org/10.1016/j.jse.2006.09.015.
Leroux T, Wasserstein D, Henry P, Khoshbin A, Dwyer T, Ogilvie-Harris D, et al. Rate of and risk factors for reoperations after open reduction and internal fixation of midshaft clavicle fractures: a population-based study in Ontario, Canada. J Bone Joint Surg Am. 2014;96:1119–1125. https://doi.org/10.2106/JBJS.M.00607.
Martetschläger F, Gaskill TR, Millett PJ. Management of clavicle nonunion and malunion. J Shoulder Elbow Surg. 2013;22:862–868. https://doi.org/10.1016/j.jse.2013.01.022.
McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003;85-A:790–797.
McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. Surgical technique. J Bone Joint Surg Am. 2004;86-ASuppl 1:37–43.
McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94:675–684. https://doi.org/10.2106/JBJS.J.01364.
Naert PAN, Chipchase LS, Krishnan J. Clavicular malunion with consequent impingement syndrome. J Shoulder Elbow Surg. 1998;7:548–550. https://doi.org/10.1016/s1058-2746(98)90213-0.
Nowak J, Stålberg E, Larsson S. Good reduction of paresthesia and pain after excision of excessive callus formation in patients with malunited clavicular fractures. Scand J Surg. 2002;91:369–373.
Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg. 2004;13:479–486. https://doi.org/10.1016/j.jse.2004.01.026.
Onstenk R, Malessy M. Plexus-brachialisletsel door niet genezen of in afwijkende stand genezen claviculafracturen. Ned Tijdschr Geneeskd. 2001;145:2440–2443.
Patel B, Gustafson PA, Jastifer J. The effect of clavicle malunion on shoulder biomechanics; a computational study. Clin Biomech. 2012;27:436–442. https://doi.org/10.1016/j.clinbiomech.2011.12.006.
Payandeh JB, McKee MD. Surgical technique: corrective osteotomy-midshaft malunion of the clavicle. Tech Shoulder Elbow Surg. 2007;8:105–109. https://doi.org/10.1097/01.bte.0000235407.97717.8f.
Peters G, Bosch U, Tscherne H. Die Verlängerungsosteotomie bei fehlverheilter Klavikulafraktur. Unfallchirurg. 1997;100:270–273. https://doi.org/10.1007/s001130050118.
Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg. 2007;16:514–518. https://doi.org/10.1016/j.jse.2007.01.001.
Rosenberg N, Neumann L, Wallace AW. Functional outcome of surgical treatment of symptomatic nonunion and malunion of midshaft clavicle fractures. J Shoulder Elbow Surg. 2007;16:510–513. https://doi.org/10.1016/j.jse.2006.12.002.
Santa Della D, Narakas A, Bonnard C. Late lesions of the brachial plexus after fracture of the clavicle. Ann Chir Main Memb Super. 1991;10:531–540.
Simpson N, Jupiter J. Clavicular nonunion and malunion: Evaluation and surgical Management. J Am Acad Orthop Surg. 1996;4:1–8. https://doi.org/10.5435/00124635-199601000-00001.
Skutek M, Fremerey RW, Zeichen J, Bosch U. Lengthening osteotomy for clavicular malunion with shortening. Orthop Traumatol. 2002;10:200–209. https://doi.org/10.1007/s00065-002-1049-5.
Smekal V, Oberladstaetter J, Struve P, Krappinger D. Shaft fractures of the clavicle: current concepts. Arch Orthop Trauma Surg. 2009;129:807–815. https://doi.org/10.1007/s00402-008-0775-7.
Smekal V, Deml C, Kamelger F, Dallapozza C, Krappinger D. Corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails. Arch Orthop Trauma Surg. 2010;130:681–685. https://doi.org/10.1007/s00402-009-0994-6.
Smekal V, Attal R, Dallapozza C, Krappinger D. Elastic stable intramedullary nailing after corrective osteotomy of symptomatic malunited midshaft clavicular fractures. Oper Orthop Traumatol. 2011;23:375–386. https://doi.org/10.1007/s00064-011-0137-4.
Wang X-H, Cheng L, Guo W-J, Li A-B, Cheng G-J, Lei T, et al. Plate versus intramedullary fixation care of displaced midshaft clavicular fractures. Medicine. 2015;94:e1792–1799. https://doi.org/10.1097/MD.0000000000001792.
Conflict of Interest
Claudia C. Sidler-Maier, MD, and Nicolas J. Dedy, MD, PhD, have declared that they have no conflict of interest. Michael D. McKee, MD, FRCS (C), reports personal fees as a designer from Stryker and as a consultant from Zimmer, Acumed, and ITS, outside the work. In addition, Dr. McKee receives royalties from Stryker for a patent. Emil H. Schemitsch, MD, FRCS (C), reports grants and personal fees from Stryker, Smith & Nephew, and Zimmer; personal fees from Amgen, Bioventus, Acumed, Sanofi, and Pendopharm; and non-financial support from ITS, outside the work.
This article does not contain any studies with human or animal subjects performed by the any of the authors.
Required Author Forms
Disclosure forms provided by the authors are available with the online version of this article.
Level of Evidence: Level IV: Systematic Review
About this article
Cite this article
Sidler-Maier, C.C., Dedy, N.J., Schemitsch, E.H. et al. Clavicle Malunions: Surgical Treatment and Outcome—a Literature Review. HSS Jrnl 14, 88–98 (2018). https://doi.org/10.1007/s11420-017-9583-3
- clavicle malunion
- corrective osteotomy clavicle
- clavicle fracture
- midshaft clavicle fracture
- nonoperative treatment clavicle
- complications clavicle fracture