Can displaced mid shaft clavicle fractures be treated non-operatively?

From the Guidelines

Displaced mid-shaft clavicle fractures can be treated non-operatively, but surgical treatment is associated with higher union rates and better early patient-reported outcomes, as stated in the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1. The standard non-operative treatment involves pain management with analgesics such as acetaminophen (1000 mg every 6 hours) or NSAIDs like ibuprofen (400-600 mg every 6-8 hours) for 1-2 weeks as needed, along with immobilization using a simple sling or figure-of-eight bandage for 2-6 weeks depending on comfort and fracture stability. Patients should begin early range of motion exercises within pain tolerance after the initial acute pain subsides, typically starting with pendulum exercises at 1-2 weeks and progressing to active-assisted range of motion by 4-6 weeks. Non-operative management is particularly appropriate for non-athletes, those with less than 2 cm of displacement, minimal shortening, and no significant comminution. The clavicle has excellent healing potential due to its rich blood supply and thick periosteum, with non-operative treatment resulting in union rates of 80-90% 1. However, patients should be informed about potential complications including malunion with shortening, which may cause cosmetic deformity but rarely functional limitations in non-athletic individuals. Regular follow-up with radiographs at 2,6, and 12 weeks is recommended to monitor healing progress. It's also important to consider the patient's individual circumstances, values, and preferences when deciding between surgical and non-surgical treatment, as both are associated with similar long-term patient-reported outcomes and patient satisfaction 1. Ultimately, the decision to treat displaced mid-shaft clavicle fractures non-operatively or surgically should be based on the strongest and most recent evidence, as well as the patient's unique needs and preferences. Some key points to consider when making this decision include:

• The patient's activity level and occupation
• The degree of displacement and comminution
• The patient's overall health and medical history
• The potential risks and benefits of surgical versus non-surgical treatment. By carefully considering these factors and weighing the evidence, healthcare providers can make informed decisions that prioritize the patient's morbidity, mortality, and quality of life.

From the Research

Treatment Options for Displaced Mid Shaft Clavicle Fractures

• Displaced mid shaft clavicle fractures can be treated both operatively and non-operatively, with various studies comparing the effectiveness of these approaches 2, 3, 4, 5, 6.
• Non-operative treatment is often considered for less severe fractures or for patients who are not good candidates for surgery, while operative treatment is typically recommended for more severe fractures or for patients who require a faster return to function 4, 6.

Operative Treatment

• Operative treatment options include intramedullary nailing, reconstruction plating, and compression/pre-contoured plating, with each having its own advantages and disadvantages 2, 3.
• Studies have shown that operative treatment can result in a lower risk of nonunion and faster return to function compared to non-operative treatment 2, 4, 5.
• Plate fixation has been shown to be an effective treatment option, with excellent anatomic restoration and functional recovery after surgery 3, 6.

Non-Operative Treatment

• Non-operative treatment typically involves immobilization and physical therapy, with the goal of promoting healing and restoring function 4, 6.
• While non-operative treatment can be effective for less severe fractures, it may result in a higher risk of nonunion and longer recovery time compared to operative treatment 2, 4, 5.
• However, non-operative treatment may be preferred for patients who are not good candidates for surgery or who have a lower activity level 4, 6.

Comparison of Treatment Options

• A systematic review and network meta-analysis found that operative treatment resulted in a lower risk of nonunion and faster return to function compared to non-operative treatment 2.
• Another study found that plate fixation resulted in excellent anatomic restoration and functional recovery after surgery, with a lower risk of nonunion and faster return to function compared to non-operative treatment 6.
• However, the decision between operative and non-operative treatment should be made on a case-by-case basis, taking into account the individual patient's needs and preferences 4, 6.