The clavicle is in the shape of an “S” between the sternal stalk and the acromion, and is the only bony scaffold connecting the upper limb to the trunk. The clavicle is subcutaneous and superficial, and is susceptible to fracture when subjected to external forces, accounting for 5% to 10% of all fractures. It occurs mostly in children and young adults. If the fracture is displaced and overlaps, the distance between the shoulder peak and the sternal stalk becomes shorter. The function of the injured side of the limb is limited, the shoulder droops, the upper arm is too close to the chest to move, and the affected elbow is supported by the healthy hand. In young children, the deformity of cyanotic fracture is not obvious, and they often cannot complain about the painful area, but their heads are more inclined to the affected side and their jaws are turned to the healthy side, which is helpful for clinical diagnosis. Sometimes the fracture caused by direct violence can puncture the pleura and cause pneumothorax, or damage the subclavian vessels and nerves, and the corresponding symptoms and signs appear. The principle of treatment for clavicle fracture is to restore its anatomical form to the greatest extent possible, while also taking into account the local aesthetic requirements. The majority of clavicle fractures can be treated non-operatively. However, for clavicle fractures with significant displacement, it is difficult to achieve good fracture repositioning by simple manipulation, and external fixation cannot maintain good alignment of the fracture, but can only achieve the release of excessive abnormal activity of the broken end of the bone and maintain the fracture end in a certain deformed position of healing, which may leave significant local deformity. Non-surgical treatment Non-displaced fractures or green branch fractures in infants and children do not require manipulation, and appropriate external fixation can be given to limit the activity. For children or adults with overlapping displacement or angular deformity, manipulation and fixation should be given. In case of comminuted fracture, if the fracture fragment is pressed hard, it is difficult to flatten the vertical fracture fragment, but it may cause injury to the subclavian artery or vein or brachial plexus nerve. The vertical bone fragments usually do not affect the fracture healing process. During the fracture healing process, with the growth of bone scabs, these bone fragments can be gradually wrapped by the new bone scabs, and only a bulge will be formed locally after the fracture heals, which usually does not cause pain or discomfort at the fracture site, and will not affect the function of the shoulder and upper limb. However, there are a few patients who may form bone spurs because the vertical bone fragments are not wrapped by the bone crust, or the fracture heals abnormally and the bone ends protrude, which can be surgically corrected. (1) Knee top repositioning method: The patient sits on a stool with chest up and head up. The arms are abducted and the hands are crossed. The assistant stands behind the patient, with one foot on the edge of the stool, puts the knee top between the scapulae on both sides of the patient’s back, holds the patient’s two lateral shoulders with both hands, and draws the patient’s shoulders backward to correct the overlapping displacement of the fracture end and connect the distal end of the fracture upward to the proximal end of the fracture. The operator faces the patient and pinches the proximal and distal ends of the fracture with the thumb, index finger, and middle finger of each hand to correct the lateral displacement with the hold-down technique. (2) Lateral traction repositioning method: The patient sits on a stool, an assistant stands on the healthy side and holds his body with both hands around the axilla of the affected side. The other assistant stands on the affected side, holds the forearm of the affected limb with both hands, and tracts and stretches it backward and upward slowly. The operator faces the patient and pinches the proximal and distal ends of the fracture with both thumbs, fingers, and middle fingers, respectively, and corrects the lateral displacement with the press-up technique. (3) Supine repositioning method: suitable for patients with thin physique or multiple fractures. The patient is placed in a supine position with a pillow between the two scapulae (midline of the back) in a longitudinal row. The assistant stands on the patient’s head side and presses the patient’s two shoulders anteriorly with both hands to make the patient present a straight chest and shrugged shoulders to correct overlapping displacement and angulation. The operator stands on the patient’s side and uses the thumbs, fingers and middle fingers of both hands to lift and hold the fracture at the broken end to reset it. This method is safe and secure, and the repositioning effect is also good. (4) Through the axillary repositioning method: the patient sits on the stool, the operator stands behind the affected side, taking the right side as an example, the operator’s right arm holds around the upper arm of the right affected limb, passes through its axilla, the palm of the hand is against the affected scapula, using the leverage to extend the shoulder backward, thus pulling the distal end of the fracture to the outside and correcting the overlapping displacement of the fracture. The left thumb, finger and middle finger of the operator pinch the proximal end of the fracture and press it forward and downward to join the distal end of the fracture. During the revision process, attention should be paid to: do not use rough techniques; do not push and press repeatedly; do not emphasize anatomical alignment; repeated techniques are strictly prohibited for comminuted fractures. During the revision, pay attention to observe the patient’s condition to prevent accidents, especially in elderly and frail patients. External fixation method (1) “8” bandage fixation method: The patient is seated, with cotton pads under each axilla, and the bandage is applied from the back of the affected shoulder through the axilla and around the top of the anterior shoulder. Across the back, around the opposite side of the axilla, through the upper front of the shoulder, back around the back to the affected side of the axilla. After wrapping 8 to 12 layers, the bandage is applied and the affected limb is suspended from the chest with a triangular scarf. (2) Double-loop fixation method: With the patient in sitting position, choose the right size gauze cotton loops and put them on the patient’s two shoulders, tie them on the double loop with a cloth strip flat clavicle in front of the chest, then pull the double loop tightly behind the back to force the two shoulders to extend backwards, tie them firmly with cloth strips on the upper and lower part of the two loops, and finally add one to two cotton pads outside the loop in the axilla of the affected side to increase the shoulder abduction and maintain the fracture alignment by using the force of the drooping shoulder. (3) “T” shaped splint fixation method: Use a “T” shaped splint of equal width to both shoulders, with cotton padding in front of the splint. Place a thick cotton pad between the two scapulae, and then place the “T” shaped splint on the back with the upper part flush with the two shoulders, and then wrap the two scapulae and the back of the chest with bandages to fix the splint properly (Figure 8-6). (4) Clavicle fracture – fixator: after fixation, attention should be paid to: observe whether there are symptoms of vascular and nerve compression; if there is weakened radial artery pulsation, hand numbness and increased pain, all indicate that the fixation is too tight and should be relaxed appropriately until the symptoms are released; for fractures with overlapping displacement, fixation should be released only after 4-6 weeks of rectification and clinical healing. Surgical treatment (1) Indications for surgery: Only a few cases require early surgical reduction and internal fixation. The reference indications for surgical treatment are: combined with nerve and vascular injury; open clavicle fracture; severe displacement of the outer 1/3 of the clavicle fracture; clavicle fracture combined with ipsilateral scapular neck fracture, forming a floating shoulder, requiring surgical fixation of the clavicle to stabilize the scapular neck fracture; clavicle comminuted fracture with soft tissue between the bone blocks affecting bone healing, or with potential risk of skin breakdown that cannot be closed and repositioned; multiple injuries, the limb needs (1) When the patient has multiple injuries and the limb needs to start functional exercise at an early stage; a few patients do not want to accept the deformed healing shape and require incisional internal fixation treatment; the patient has concomitant neurological or neurovascular lesions, such as Parkinson’s disease, and cannot tolerate non-operative braking for a long time. (2) Precautions for surgical treatment: Intramedullary pin fixation should be preferred for fresh clavicle fractures. When incision is made to reveal the clavicle, the soft tissue should be stripped as little as possible to maintain the blood supply to the fracture end. Intramedullary pins can generally be retained for only 8 to 10 weeks and then removed. Over time the pin will loosen and may even move into the lung. When using a kerfing needle, the end of the needle must be bent in order to effectively prevent the kerfing needle from shifting. Some scholars advocate the use of intramedullary needles with threads. The intramedullary needle should not be relied on alone and other methods of fixation should not be used, and a triangular scarf suspension should be used. The time of fixation should be longer than the time of fixation by manipulation, usually not less than 6 weeks, because the surgery needs to expose the soft tissues and delay the healing time of the fracture. Fractures of the external end of the clavicle can also be fixed with a Kirschner pin via the acromioclavicular joint, or with a plate to fix multiple injuries, and the limb needs to start functional exercises early.