- Discussion:
    - indications for surgery:
            - open fracture
            - gross displacement of fracture w/ tenting of skin
            - fractures w/ signficant medialization (causing medialization of the shoulder girdle); 
            - ref: Fixation of Displaced Midshaft Clavicle Fractures in Skeletally Immature Patients
    - surgical considerations: 
            - subclavian artery (axillary artery begins as it crosses the first rib)
            - brachial plexus (esp lower trunk damage (C8, T1); 
                      - look for posterior cord injury
            - references:
                   - Injury to the brachial plexus by a fragment of bone after fracture of the clavicle.
                   - Clavicular caution: An anatomic study of neurovascular structures.
                   - Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report.

    - floating shoulder:
            - multiple authors have reported excellent results with healing rates greater than 99% for variety of immobilization techniques;
            - incidence of nonunion, malunion, NV complications total < 1%;
            - single disruptions of SSSC have uniformly good results with nonoperative treatment;
            - double disruptions of SSSC are a combination of innocuous injuries which create instability for UE best surgically treated
            - ORIF simpler fracture reduces other injury satisfactorily

- Surgical Choices:
      - intra-medullary clavicular fixation: 
          - references:
                  - Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting.. 

    - plate fixation: (Synthes Clavicle Products) 
            - consider unicortical fixation with a Synthese 3.5 mm pelvic reconstruction locking plate (unicortical
                      screws will not risk injury to the deep neurovascular structures;  (axillary artery)
            - post op exam includes neurovascular check - check for full abduction and ext rotation (inorder to
                      test for thoracic outlet syndrome); 
            - careful to note potential vascular complications;
                      - references:
                             - A radiological study to define safe zones for drilling during plating of clavicle fractures
                             - Safe drilling angles and depths for plate-screw fixation of the clavicle: avoidance of inadvertent iatrogenic subclavian neurovascular bundle injury.
                             - Patient Position Is Related to the Risk of Neurovascular Injury in Clavicular Plating: A Cadaveric Study.
                             - The Anatomy of the Clavicle and its In Vivo Relationship to the Vascular Structures: a 2D and 3D Reconstructive Study using CT Scans.

            - advantages of anteroinferior plating:
                       - include less hardware prominence and the ability of the surgeon to direct instrumentation away from infraclavicular
                                  neurovascular structures;
                       - references:
                              - Anteroinferior plating of midshaft clavicular nonunions.
                              - Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.
                              - Neurovascular Risks of Anteroinferior Clavicular Plating
                              - Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating
                              - Anterior-inferior plating of middle-third fractures of the clavicle 
                              - Superior versus anteroinferior plating of the clavicle revisited: a mechanical study
            - superior plate fixation:
                       - provides better stability at the fracture site;
                       - ref: Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study.

          - references:
                 Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle
                 Open reduction and internal fixation of clavicular fractures.
                 Low-contact dynamic compression plating of the clavicle.
                 Fractures of the distal clavicle: a case for fixation.
                 Osteosynthesis of irreducible fractures of the clavicle with 2.7-MM ASIF plates.
                 Plating of fresh clavicular fractures: results of 122 operations.
                 Late-onset brachial plexus paresis caused by subclavian pseudoaneurysm formation after clavicular fracture.
                 Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial.
                 Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails.
                 Anomalous external jugular vein: clinical concerns in treating clavicle fractures
                 Axillary artery pseudoaneurysm after plate osteosynthesis for a clavicle nonunion: A case report and literature review
                 Anatomic relationships after instrumentation of the midshaft clavicle with 3.5-mm reconstruction plating: an anatomic study.
                 Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials.
                 Hook plate fixation of acute displaced lateral clavicle fractures: mid-term results and a brief literature overview

- Non Union following surgery:
       - Nonunion after clavicle osteosynthesis: High incidence of Propionibacterium acnes.