Management of Clavicle Fractures
For displaced midshaft clavicle fractures in adults, surgical treatment should be strongly considered as it provides higher union rates and better early functional outcomes, though both surgical and nonsurgical approaches are valid since long-term outcomes are similar. 1
Treatment Algorithm by Fracture Type and Displacement
Minimally Displaced Midshaft Fractures
- Nonsurgical management is appropriate with simple sling immobilization (preferred over figure-of-eight brace) 1
- These fractures have low nonunion rates and excellent outcomes with conservative treatment 1
Displaced Midshaft Fractures in Adults
Key Decision Point: Degree of displacement is critical—widely displaced fractures have nonunion rates up to 15% with nonsurgical treatment 1
Surgical treatment advantages:
- Higher union rates (significantly reduced nonunion risk)
- Better early patient-reported outcomes (Constant and DASH scores)
- Faster time to union and return to work
- Lower rates of symptomatic malunion
- Reduced need for physical therapy 1
Nonsurgical treatment considerations:
- Long-term outcomes (beyond 1 year) are equivalent to surgery
- Patient satisfaction ultimately similar between approaches
- Avoids surgical risks and implant-related complications 1
Critical factors favoring surgery:
- Active patients requiring rapid return to work or sport
- Significant displacement creating "Z" deformity
- Patient concerns about cosmetic appearance
- Occupational demands requiring early shoulder strength 1
Surgical Technique Selection
When surgery is chosen, intramedullary nailing and single plate fixation produce equivalent long-term outcomes with similar complication rates 1. However:
- Plate fixation is preferred when fracture comminution is present 1
- Precontoured anatomic plates have lower rates of implant removal or deformation compared to non-precontoured plates 1
- Both superior and anterior plating positions are acceptable
Adolescent Patients (≤18 years)
Nonsurgical management is strongly preferred for displaced midshaft fractures in adolescents, as surgical treatment offers no benefit and is associated with substantial revision surgery rates for implant removal 1
Lateral (Distal) Clavicle Fractures
Displaced lateral fractures with disruption of the coracoclavicular ligament complex should undergo surgical repair 1. This is particularly important as:
- Neer type II and V fractures with displacement have nonunion rates of 31-37% 2
- Nondisplaced fractures (Neer types I, III, IV) can be managed nonsurgically 2
Imaging Considerations
Obtain upright radiographs rather than supine views to accurately assess displacement, as upright positioning better demonstrates the true degree of fracture displacement 1
What NOT to Do
Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management of acute midshaft clavicle fractures—it does not accelerate healing or reduce nonunion rates 1
Common Pitfalls
- Underestimating displacement on supine radiographs: Always obtain upright views for accurate assessment
- Assuming all clavicle fractures heal well conservatively: Displaced fractures have significantly higher nonunion rates (up to 15%) than historically reported 1
- Overlooking coracoclavicular ligament disruption in lateral fractures: This dramatically increases nonunion risk and necessitates surgical intervention
- Using hook plates for distal fractures: These have the highest complication rates among fixation options 2
- Operating on adolescents unnecessarily: They have high revision rates for implant removal without functional benefit 1
Special Populations
Open fractures require management similar to open long bone fractures: urgent debridement, intravenous antibiotics, tetanus prophylaxis, and early surgical fixation 3
Polytrauma patients require individualized assessment beyond the scope of standard clavicle fracture guidelines 1