What is the recommended treatment for a clavicle fracture with 48 degrees of angulation?

Treatment of Clavicle Fracture with 48 Degrees of Angulation

For a clavicle fracture with 48 degrees of angulation, surgical treatment is recommended due to higher union rates and better early patient-reported outcomes compared to nonsurgical management. 1

Decision Algorithm for Treatment

Surgical Indication Assessment

The significant angulation (48 degrees) represents a displaced midshaft clavicle fracture, which according to the 2023 AAOS Clinical Practice Guidelines, benefits from surgical intervention due to:

• Higher union rates with surgical treatment
• Better early functional outcomes
• Faster time to union and return to activities
• Lower risk of symptomatic malunion
• Reduced rates of nonunion (nonsurgical treatment can have up to 15% nonunion rates) 1

Surgical Approach Options

1. Plate Fixation

   • Preferred for comminuted fractures
   • Options include:
     • Anterior inferior plating (may lead to lower implant removal rates)
     • Superior plating
     • Manufacturer-contoured anatomic plates (lower rates of implant removal/deformation)
   • Provides excellent stability for displaced fractures

2. Intramedullary Nail/Rod

   • Equivalent long-term clinical outcomes compared to plate fixation
   • Similar complication rates to plating
   • Less invasive option

Important Considerations

• Patient Factors

  • Age (surgical benefits are more established in adults than adolescents)
  • Activity level and return-to-work/sport needs
  • Smoking status (increases nonunion risk and leads to inferior outcomes) 1

• Radiographic Assessment

  • Upright radiographs are superior for demonstrating the degree of displacement 1
  • 48 degrees of angulation represents significant displacement

• Postoperative Care

  • Monitor for common complications:
    • Adhesive capsulitis (20% of cases)
    • Paresthesia over surgical site (13.3%)
    • Superficial infection (3.3%) 2

Evidence Quality and Rationale

The 2023 AAOS guidelines provide a strong recommendation for surgical treatment of displaced midshaft clavicle fractures, based on high-quality evidence showing higher union rates and better early patient-reported outcomes 1. While long-term outcomes may be similar between surgical and nonsurgical approaches, the significant angulation (48 degrees) indicates a displaced fracture that would benefit from anatomical restoration.

Recent research (2024) confirms that ORIF for clavicle fractures ensures high rates of bone union and improved functional outcomes, with 81.7% of patients achieving excellent results based on DASH scores 2.

Caveats and Pitfalls

• Surgical treatment carries inherent risks including infection, hardware irritation, and need for hardware removal
• If choosing nonsurgical management despite the recommendation:
  • Avoid figure-of-eight braces (sling is preferred) 1
  • Do not use low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing or lower nonunion rates 1
  • Monitor closely for nonunion or symptomatic malunion
  • Counsel patients that nonsurgical management of widely displaced fractures often results in malunions that may affect shoulder strength and function 1

The decision to proceed with surgery should be made promptly, as surgical treatment provides faster functional recovery and radiographic healing, allowing for earlier return to normal activities 1, 2.