What is the recommended treatment for a comminuted fracture of the clavicle?

Treatment of Comminuted Fracture of the Clavicle

For comminuted fractures of the clavicle, surgical treatment with plate fixation is recommended over intramedullary nailing due to better stabilization of the comminuted fragments, leading to improved union rates and better early functional outcomes. 1

Decision Algorithm for Treatment

Initial Assessment

• Obtain upright radiographs (superior for demonstrating displacement compared to supine views) 1
• Evaluate fracture location (midshaft, lateral, or proximal)
• Assess degree of displacement and comminution
• Consider patient factors (age, activity level, occupation)

Treatment Based on Fracture Location

Midshaft Comminuted Fractures (Most Common)

1. Surgical Treatment (Preferred for comminuted fractures)

   • Plate fixation is recommended over intramedullary nailing for comminuted fractures 1
   • Consider manufacturer-contoured anatomic plates (lower rates of implant removal/deformation) 1
   • Anterior inferior plating may lead to lower implant removal rates compared to superior plating 1

2. Non-surgical Treatment (For minimally displaced comminuted fractures)

   • Sling immobilization (preferred over figure-of-eight brace) 1
   • Duration: Typically 3-4 weeks
   • Not recommended for significantly displaced comminuted fractures due to higher risk of nonunion

Lateral Comminuted Fractures

• If displaced with disruption of coracoclavicular ligament complex, surgical repair is beneficial 1
• For severe comminution with bone defect, specialized reconstruction may be required (in rare cases, prosthetic replacement might be considered) 2

Proximal/Medial Comminuted Fractures

• Nondisplaced: Sling immobilization
• Displaced or with sternoclavicular joint instability: Orthopedic referral for possible surgical intervention 3

Special Considerations

Age-Based Approach

• Adults: Surgical treatment of displaced comminuted fractures shows higher union rates and better early outcomes 1
• Adolescents (≤18 years): Surgical treatment offers no significant benefit over non-surgical management and has substantial rates of revision surgery for implant removal 1

Risk Factors for Poor Outcomes

• Smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Displacement >15mm is associated with more pain and poorer outcomes 4

Post-Treatment Management

Surgical Approach

• Early mobilization after adequate fixation
• Physical therapy to restore range of motion and strength
• Implant removal may be necessary in some cases (more common with superior plating)

Non-surgical Approach

• Sling immobilization for 3-4 weeks
• Avoid bone stimulators (LIPUS) as they do not accelerate healing or lower nonunion rates 1
• Progressive rehabilitation after adequate healing

Clinical Pearls and Pitfalls

• Pearl: Surgical treatment may provide faster functional recovery and earlier return to work, which is particularly relevant for active adults 1
• Pitfall: Overlooking associated injuries (especially in lateral fractures which may be confused with AC joint separation) 5, 6
• Caveat: While early outcomes favor surgical treatment, long-term patient-reported outcomes and satisfaction are similar between surgical and non-surgical approaches for many fracture patterns 1

The 2023 American Academy of Orthopaedic Surgeons guidelines provide strong evidence that surgical treatment of displaced clavicle fractures results in higher union rates and better early outcomes, with plate fixation being particularly beneficial for comminuted fractures 1.