What is the initial treatment for a displaced clavicular fracture?

Initial Treatment for Displaced Clavicular Fractures

For displaced midshaft clavicular fractures, plate fixation is recommended as the initial treatment, particularly for fractures with displacement of one or more shaft width, shortening of more than 1 cm, or in patients with high physical activity requirements. 1

Assessment and Diagnosis

• Obtain upright radiographs to accurately assess fracture displacement (superior to supine views) 1
• Consider CT scan for complex or comminuted fractures 1
• Evaluate for:
  • Degree of displacement (one or more shaft width)
  • Amount of shortening (>1 cm)
  • Presence of skin tenting (requires urgent surgical intervention)
  • Patient's activity requirements

Treatment Algorithm

Surgical Management (Recommended for Displaced Fractures)

1. Plate Fixation (Preferred Method)

   • Use manufacturer-contoured anatomic clavicle plates (lower rates of implant removal and deformation) 1
   • Consider anterior inferior plating position (may lead to lower implant removal rates compared to superior plating) 1
   • Ensure adequate screw purchase in the distal fragment (often small and osteoporotic) 1

2. Intramedullary Nailing (Alternative Option)

   • Consider for select cases
   • Note: Plate fixation may be more beneficial for comminuted fractures 1

3. Special Considerations

   • Urgent ORIF is required for fractures with skin tenting to prevent skin necrosis and potential conversion to open fracture 1
   • Adolescent patients (≤18 years) may not benefit from surgical treatment compared to nonsurgical management unless skin tenting is present 1

Post-Operative Care

• Immobilize in a sling for comfort (preferred over figure-of-eight bracing) 1
• Initiate early pendulum exercises as tolerated 1
• Follow rehabilitation protocol:
  • Weeks 1-2: Gentle passive range of motion
  • Weeks 2-6: Progress to active-assisted range of motion
  • After 6 weeks: Begin strengthening exercises if radiographic healing is evident
• Return to full activities typically at 3-4 months based on healing 1

Important Caveats

• Smoking significantly increases nonunion risk and leads to inferior outcomes 1
• Do not use low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing or lower nonunion rates 1
• While older literature suggested conservative management with sling or figure-of-8 dressing for most clavicular fractures 2, 3, current guidelines favor surgical intervention for displaced fractures due to higher union rates and better early patient-reported outcomes 1
• Despite the trend toward operative treatment in Scandinavian countries 4, treatment decisions should be based on specific fracture characteristics and patient factors as outlined in current guidelines

Surgical Technique Considerations

• Standard plate fixation remains the gold standard, though newer techniques like low-profile dual plating may offer advantages in specific cases 5
• Intramedullary screw fixation is another option with good reported outcomes in selected patients 6