Triple Clavicle Injury: A Fracture of the Middle Third Associated With Acromioclavicular Dislocation and Sternoclavicular Subluxation

In this report, we present a case of a triple clavicle injury, acromioclavicular joint (ACJ) dislocation, a middle third clavicle fracture, and a sternoclavicular joint (SCJ) subluxation, and describe its successful surgical treatment. A 49-year-old female patient sustained a 3 m fall, resulting in direct trauma to her left shoulder. Initial radiographs and computed tomography (CT) scans revealed a displaced middle third clavicle fracture, a high-grade ACJ dislocation, and a posterior SCJ subluxation. Surgical intervention was proposed due to the severity of the ACJ dislocation. The patient underwent open reduction and internal fixation (ORIF) of the clavicle fracture with an anatomical locking plate (EVOS Clavicle Plate®; Smith & Nephew, Andover, MA) and ACJ stabilization using an Endobutton® (Smith & Nephew, Andover, MA) along with the transposition of the coracoacromial ligament. The SCJ subluxation was reduced indirectly. She returned to work after four weeks and, after six months, demonstrated excellent functional recovery achieving a full, pain-free range of motion. Outcome scores were favorable (Constant Shoulder Score: 73 bilaterally; University of California, Los Angeles {UCLA} Shoulder Rating Scale: 33). Follow-up radiographs at nine months demonstrated stable fixation with satisfactory anatomical alignment and fracture healing. Given the absence of specific guidelines for managing this combination, we based our method on established protocols for isolated injuries. Our patient's favorable outcome supports the effectiveness of this strategy and highlights the potential for successful functional recovery with careful management. This case underscores the importance of a high index of suspicion for concomitant ACJ and SCJ injuries in patients with midshaft clavicle fractures. This triad requires an individualized treatment plan for optimal outcomes, and future studies should focus on further documenting and evaluating treatment strategies for this rare injury pattern.