What is the best management approach for a displaced clavicle fracture with 2 cm of foreshortening?

From the Guidelines

The best management approach for a displaced clavicle fracture with 2 cm of foreshortening is surgical fixation, typically with open reduction and internal fixation (ORIF). This recommendation is based on the most recent and highest quality evidence, which suggests that surgical treatment of displaced clavicle fractures results in higher union rates, better early patient-reported outcomes, and reduced rates of nonunion and symptomatic malunion compared to nonsurgical treatment 1.

Key Considerations

• Significant displacement (2 cm or more of foreshortening) is associated with higher rates of nonunion, malunion, and functional deficits when treated non-operatively.
• Surgical fixation provides better restoration of clavicular length and alignment, which helps maintain shoulder function and strength.
• It also reduces the risk of symptomatic malunion that can cause pain, cosmetic deformity, and functional limitations.
• While non-operative management with a sling remains an option for some patients with significant comorbidities or those who decline surgery, the degree of displacement in this case strongly favors surgical intervention for optimal outcomes.

Surgical Procedure

The procedure is typically performed under general anesthesia, with an incision made along the clavicle to expose the fracture site. Post-operatively, patients usually wear a sling for comfort for 1-2 weeks, followed by progressive range of motion exercises starting at 2 weeks, with strengthening exercises beginning at 6-8 weeks. Full return to activities, including contact sports, typically occurs at 3-6 months depending on healing progress.

Evidence Summary

High-quality evidence from recent studies, including those published in The Journal of the American Academy of Orthopaedic Surgeons 1, supports the use of surgical fixation for displaced clavicle fractures with significant displacement. These studies demonstrate the benefits of surgical treatment in terms of union rates, patient-reported outcomes, and return to function.

From the Research

Management of Displaced Clavicle Fracture with 2 cm of Foreshortening

The management of displaced clavicle fractures with significant foreshortening is a topic of interest in orthopedic surgery.

• Displaced clavicle fractures can be managed nonoperatively or surgically, with the choice of treatment depending on the severity of the fracture and the patient's overall health 2.
• Surgical treatment options include open reduction and internal fixation (ORIF) with plates, intramedullary nailing, and closed reduction and internal fixation with cannulated screws 3, 4, 5.
• A study published in 2024 found that ORIF with plates resulted in excellent functional outcomes and a high rate of bone union in patients with displaced midshaft clavicle fractures 2.
• Another study published in 2018 found that elastic stable intramedullary nailing (ESIN) with a titanium nail was a effective treatment option for displaced midshaft clavicle fractures, with functional outcomes comparable to those of plate fixation after 1 year 3.
• The use of pre-contoured angular stability plates has also been shown to be an effective treatment option for displaced mid-shaft clavicle fractures, with excellent clinical outcomes and a low rate of complications 4.
• Closed reduction and internal fixation with cannulated screws is another alternative treatment option for acute midshaft clavicular fractures, with a high union rate and minimal complications 5.

Treatment Considerations

When managing a displaced clavicle fracture with 2 cm of foreshortening, several factors should be considered, including:

• The severity of the fracture and the amount of foreshortening
• The patient's overall health and activity level
• The potential risks and benefits of surgical treatment
• The choice of surgical treatment option, including ORIF with plates, intramedullary nailing, and closed reduction and internal fixation with cannulated screws 2, 3, 4, 5.
• The potential for complications, such as adhesive capsulitis or stiffness, and the need for postoperative physiotherapy 2.