What is the treatment for a mid clavicular fracture?

Treatment of Mid Clavicular Fractures

For mid clavicular fractures, nonsurgical management with a simple arm sling is recommended for nondisplaced or minimally displaced fractures, while surgical treatment with plate fixation is indicated for displaced fractures with >1 cm shortening or displacement of more than one shaft width. 1

Initial Assessment and Classification

• Obtain upright radiographs (superior to supine views) to accurately assess displacement 1
• Evaluate for:
  • Degree of displacement (>1 shaft width indicates surgical consideration)
  • Shortening (>1 cm indicates surgical consideration)
  • Comminution
  • Skin tenting (urgent surgical indication)
  • Patient activity level and functional demands

Treatment Algorithm

Nonsurgical Management

Indicated for:

• Nondisplaced or minimally displaced fractures
• Fractures without significant shortening
• Patients with lower physical demands

Recommended approach:

• Simple arm sling is preferred over figure-of-eight bandage (American Academy of Orthopaedic Surgeons recommendation) 1
• Duration typically 3-6 weeks until clinical healing
• Allow immediate range of motion as tolerated

Caution:

• Avoid low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing or lower nonunion rates 1
• Counsel smokers about increased nonunion risk and inferior outcomes 1

Surgical Management

Indicated for:

• Displacement >1 shaft width
• Shortening >1 cm
• Patients with high physical activity requirements
• Skin tenting (urgent indication)
• Open fractures
• Polytrauma patients

Surgical options:

1. Plate fixation (preferred for comminuted fractures):

   • Manufacturer-contoured anatomic plates are recommended over non-contoured plates 1
   • Anterior inferior plating may lead to lower implant removal rates compared to superior plating 1
   • Ensure adequate screw purchase (at least 6 cortices of fixation on each side) 2

2. Intramedullary nailing:

   • Alternative option but less preferred for comminuted fractures 1
   • Risk of pin migration

Surgical technique highlights:

• Patient positioned in beach-chair, semi-sitting position 2
• Transverse skin incision along anteroinferior aspect of clavicle 2
• Preserve soft tissue attachments when possible 2
• Apply contoured plate to superior or anterior surface 2
• Allow full range of motion immediately post-surgery 2

Expected Outcomes

• Surgical treatment shows shorter time to union and better early functional outcomes compared to nonsurgical treatment for displaced fractures 3
• Constant shoulder scores are typically higher in surgically treated displaced fractures 3
• Return to sports typically occurs after 3 months with surgical fixation 4

Special Considerations

• Adolescents may not benefit from surgical treatment even with displaced fractures 1
• Elderly patients may have higher risk of nonunion with nonsurgical treatment 5
• Female patients may have higher risk of nonunion with nonsurgical treatment 5

Complications to Monitor

• Nonunion (higher risk with nonsurgical treatment of displaced fractures)
• Malunion with cosmetic deformity and potential dysfunction
• Hardware complications requiring removal (less common with anatomic plates)
• Neurovascular injury (rare)

The evidence strongly supports a treatment approach that differentiates between displaced and nondisplaced fractures, with the most recent guidelines from the American Academy of Orthopaedic Surgeons providing clear indications for surgical versus nonsurgical management based on fracture characteristics and patient factors 1.