Bilateral Displaced Midshaft Clavicle Fractures Following High-energy Road Traffic Trauma: A Case Report and Review of the Literature

Abstract

Bilateral clavicle fractures represent one of the rarest patterns of shoulder girdle trauma, occurring predominantly after high-energy mechanisms and posing unique challenges in diagnosis and management. Their simultaneous disruption compromises both clavicular struts, resulting in impaired shoulder biomechanics and necessitating timely stabilization for optimal functional recovery. A 25-year-old male sustained high-velocity trauma following a motorcycle accident and presented with severe bilateral shoulder pain, deformity, swelling, and markedly restricted arm elevation. Neurological and distal vascular examinations were normal. Radiographs demonstrated displaced bilateral midshaft clavicle fractures (Allman Group I), with no associated thoracic or systemic injuries. Due to significant displacement and bilateral involvement, open reduction and internal fixation was performed using 8-hole titanium anatomical locking plates on both sides through an anterior approach. Stable fixation was confirmed intraoperatively. Early pendulum exercises were initiated, followed by progressive passive and active range-of-motion rehabilitation. Postoperative recovery was uneventful. At 1 month, the patient achieved shoulder abduction of 110° on the right and 100° on the left, with full muscle strength bilaterally. Serial imaging demonstrated progressive fracture consolidation with maintained anatomical alignment. Bilateral displaced midshaft clavicle fractures, though rare, can be effectively managed with anatomical locking plate fixation, providing stable reconstruction and permitting early mobilization. This case reinforces the value of operative intervention in high-energy bilateral clavicular injuries, contributing to the limited but growing evidence guiding treatment of this uncommon trauma pattern.

INTRODUCTION

Among the many injuries encountered in trauma care, fractures of the clavicle are often expected, but fractures of both clavicles are not.[1] The clavicle, with its characteristic S-shaped curve, is the body’s only horizontal long bone and a crucial strut that maintains upper-limb alignment and shoulder mechanics. While unilateral clavicle fractures are frequent, representing 2.6%–4% of all fractures, their bilateral counterparts lie at the extreme end of rarity.[2,3]

Large epidemiological reviews highlight this contrast clearly: Postacchini et al. documented the routine nature of clavicle fractures,[2] yet bilateral involvement has been reported in only 0.43% of these injuries.[1] Even more striking, the landmark review by van den Bout and Snyckers spanning over a century of published literature estimated the global incidence to be as low as 0.011%–0.017%.[1] Most bilateral fractures arise from high-energy mechanisms or polytrauma, where they may be easily overlooked due to competing, more critical injuries.[4]

Because such injuries are so uncommon, management strategies remain debated, and decisions often rely on clinical judgment rather than established guidelines. Reporting individual cases, therefore, remains essential to improving understanding and guiding treatment decisions.

CASE REPORT

A 25-year-old male software engineer presented following a motorcycle accident with complaints of severe bilateral shoulder pain, marked restriction in overhead activities, and difficulty lifting the upper limbs. There was no history of loss of consciousness, chest pain, or respiratory difficulty. Clinical examination revealed swelling, ecchymosis, and visible deformity over both clavicular regions. Palpation elicited significant tenderness and positive crepitus bilaterally. Shoulder movements were severely limited due to pain, whereas full active motion of the fingers, wrists, and elbows was preserved. Distal neurovascular examination was normal, and no additional skeletal or soft-tissue injuries were identified.

Anteroposterior (AP) radiographs of both clavicles [Figure 1a and b] demonstrated displaced midshaft fractures bilaterally. Based on the Allman classification, both fractures were categorized as Group I – midshaft (type I) injuries. Thoracic imaging excluded associated intrathoracic trauma. Routine preoperative investigations, including hematological parameters, ECG, and chest X-ray, showed no abnormalities that contraindicated surgery.

Figure 1.

(a) Preoperative anteroposterior (AP) radiograph of the right clavicle showing displaced midshaft fracture. (b) Preoperative AP radiograph of the left clavicle showing displaced midshaft fracture

Based on the bilateral involvement and significant displacement, operative stabilization was planned.

Management

Initial immobilization was provided with a clavicle brace and bilateral shoulder arm pouches. Considering the bilateral involvement, significant displacement, and the high functional requirement of the patient, operative management was selected. After detailed counseling and informed consent, open reduction and internal fixation using anatomical locking plates was planned for both sides.

Under general anesthesia, the patient was positioned in the beach-chair position. An anterior approach was utilized for both clavicles. The left clavicle was addressed first. Sharp and blunt dissection was performed to expose the fracture site, followed by anatomical reduction and stabilization using an 8-hole titanium anatomical locking plate. The right clavicle was subsequently exposed through a similar approach and stabilized using an 8-hole titanium anatomical locking plate. Intraoperative assessment confirmed stable fixation on both sides. Postoperative radiographs [Figure 2] demonstrated appropriate alignment, restoration of clavicular length, and satisfactory plate positioning.

Figure 2.

Postoperative anteroposterior radiograph showing bilateral clavicle fixation with anatomical locking plates

Postoperative immobilization with bilateral shoulder arm pouches was continued. The patient was monitored for 24 h in the postoperative care unit, and analgesics along with prophylactic antibiotics were administered. Early gentle pendulum exercises were initiated as tolerated.

Rehabilitation consisted of passive range-of-motion (ROM) exercises from postoperative day 3, followed by active ROM exercises initiated at 6 weeks after evidence of early fracture healing. Strengthening exercises were commenced at 12 weeks. Functional evaluation during follow-up demonstrated progressive improvement.

At the 1-month follow-up, clinical assessment showed:

1. Right shoulder ROM: 110°

2. Left shoulder ROM: 100°

3. Muscle power: 5/5 bilaterally.

At this stage, the patient exhibited good functional recovery with the ability to abduct both upper limbs without discomfort, as demonstrated clinically [Figure 3a and b]. Serial radiographs confirmed progressive fracture consolidation with maintained reduction.

Figure 3.

(a) Clinical photographs at follow-up demonstrating restored range of motion of right upper limbs. (b) Clinical photographs at follow-up demonstrating restored range of motion of left upper limbs

The postoperative course remained uneventful, and fracture healing progressed satisfactorily.

DISCUSSION

Bilateral clavicle fractures, although uncommon, require precise clinical assessment and early decision-making because simultaneous disruption of both clavicular struts compromises shoulder suspension and upper-limb function. In the present case, the bilateral displaced midshaft pattern warranted operative fixation to restore anatomical alignment and allow early rehabilitation.

Recent evidence supports surgical intervention in displaced midshaft fractures due to improved functional outcomes and reduced nonunion risk. In a prospective randomized study, the Canadian Orthopaedic Trauma Society demonstrated that plate fixation results in significantly faster return of shoulder function and lower rates of symptomatic malunion compared with nonoperative treatment.[5] The early recovery observed in the present case, with functional abduction achieved by 1 month, corresponds with these findings.

Restoration of clavicular length is a critical factor influencing postoperative shoulder mechanics. Bajuri et al. reported that shortening exceeding 2 cm following nonoperative management correlates with persistent pain, weakness, and reduced endurance.[4] This reinforces the rationale for anatomical reduction achieved through internal fixation in the present patient, particularly given the simultaneous bilateral involvement.

Biomechanical advantages of precontoured locking plates have been increasingly recognized. Vellingiri et al. demonstrated that locking plates provide superior torsional and axial stability, particularly in comminuted or displaced midshaft fractures, enabling earlier mobilization without compromising construct integrity.[6] The stable fixation documented radiographically in this case aligns with these mechanical principles.

Rehabilitation plays a decisive role in functional restoration following clavicle fixation. Mishra et al. highlighted that early postoperative mobilization, when combined with stable internal fixation, leads to improved shoulder kinematics and quicker return to daily activities.[7] A similar protocol was followed in this case, allowing progressive gains in range of motion and strength without complications.

The uneventful postoperative course observed in this patient further aligns with multicenter data by Feng et al., who reported low complication rates including infection and implant irritation when modern locking plates were used in midshaft fractures under standardized perioperative protocols.[8] Consistent radiological consolidation and absence of implant-related issues in this case support these outcomes.

Overall, the findings of the present case correspond closely with contemporary orthopedic evidence, demonstrating that bilateral displaced midshaft clavicle fractures can be effectively managed with anatomical locking plate fixation, enabling early mobilization and resulting in favorable clinical and radiographic outcomes.

To support the interpretation of the present findings, Table 1 summarizes key published reports on bilateral clavicle fractures.

Table 1.

Previously key published reports on bilateral clavicle fractures

Author, year	Study type/sample	Mechanism of injury	Fracture pattern	Management	Outcome
Lakhotia et al., 2016[5]	Case series (three patients; ages 6, 25, 45 years)	High-velocity RTA, crush injury, fall with motorcycle	Bilateral displaced midshaft fractures in two cases; midshaft + lateral end fracture in one case	All treated conservatively using figure-of-eight bandage and arm slings	Radiological union by 6–12 weeks; full, pain-free shoulder function in all cases
Bajuri and Boon, 2018[4]	Single-adult case (40-year-old male)	Motorcycle accident; thrown forward and struck by vehicle	Bilateral midshaft clavicle fractures	Simultaneous bilateral plating using 3.5-mm reconstruction plates	Early improvement in shoulder elevation; union by 5 months; return to activity within 2 months
Vellingiri and Seenappa, 2020[6]	Single-adult case (22-year-old male)	Four-wheeler rollover trauma	Bilateral fractures at junction of middle and lateral third	Left side: ORIF with locking compression plate; Right side: Conservative immobilization	Radiographic union on both sides; earlier union and superior early ROM on surgically treated side; return to work at 3 months
Mishra et al., 2022[7]	Single-adult case (39-year-old male)	Fall from moving tractor	Bilateral displaced clavicle fractures with shortening and mild comminution	Right: Locking plate; Left: Lag screw fixation	At 1 month, able to elevate both arms; radiographs showed progressive union; satisfactory shoulder ROM
Feng et al., 2023[8]	Retrospective series (13 adults; among 1542 clavicle injuries)	High-energy trauma: Car accidents, crushing, bicycle, motorcycle	Bilateral medial-, mid-, distal third and mixed patterns	ORIF in 25 of 26 sides using plates/hook plates; 1 side treated conservatively	All fractures healed; majority achieved excellent shoulder function; no major complications

ROM=Range of motion, ORIF=Open reduction and internal fixation, RTA=Road traffic accident

Across the reports summarized in Table 1, including the present case, road traffic accidents (RTAs) consistently emerge as the predominant mechanism of bilateral clavicle fractures, highlighting the increasing burden of high-energy trauma particularly in countries like India, where RTA incidence remains one of the highest globally.

CONCLUSION

Bilateral clavicle fractures represent an uncommon but clinically significant high-energy injury pattern, most frequently associated with RTAs. Early recognition, appropriate imaging, and timely surgical decision-making are essential to prevent functional compromise, particularly when both clavicular struts are disrupted simultaneously. In this case, anatomical locking plate fixation on both sides achieved stable reduction, enabled early rehabilitation, and resulted in favorable functional recovery without complications. The outcome reinforces current evidence that operative management is a reliable and effective strategy for displaced bilateral midshaft clavicle fractures, especially in young adults with high functional demands.

Limitations

This case report has several limitations. First, it describes a single patient and therefore cannot provide generalizable conclusions regarding optimal management strategies or prognostic outcomes of bilateral clavicle fractures. Second, the short follow-up duration limits the ability to evaluate long-term functional scores, hardware-related complications, or patient-reported outcomes. Third, the absence of validated scoring systems, such as the Constant–Murley score or the Disabilities of the Arm, Shoulder and Hand (DASH) score, restricts quantitative assessment of the functional recovery achieved.

Nevertheless, despite these limitations, this report highlights a rare and clinically important injury pattern and emphasizes that timely surgical stabilization using anatomical locking plates may facilitate early mobilization and favorable short-term outcomes in young adults sustaining bilateral displaced clavicle fractures.

Ethics approval and consent to participate

This case report describes clinical management undertaken as part of routine patient care and did not involve any experimental interventions. Formal ethical approval was not required in accordance with institutional policy for single-patient case reports that do not disclose identifiable personal data.

Patient privacy

Every effort has been made to protect the patient’s identity, and no potentially identifiable personal data, including names, hospital numbers, or facial images, have been disclosed in this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.