What is the recommended management for a clavicle fracture?

Management of Clavicle Fractures

For displaced midshaft clavicle fractures in adults, surgical treatment is recommended as it offers higher union rates and better early patient-reported outcomes compared to nonsurgical treatment. 1

Classification and Initial Assessment

• Location-based classification:

  • Midshaft fractures (most common)
  • Distal fractures
  • Proximal fractures

• Assessment:

  • Obtain upright radiographs to accurately demonstrate fracture displacement 1
  • Consider CT scan for complex or comminuted fractures 1

Treatment Algorithm

Midshaft Clavicle Fractures

1. Displaced fractures in adults:

   • Surgical treatment recommended when:
     • Displacement of one or more shaft width
     • Shortening of more than 1 cm in length
     • Patient has high physical activity requirements 1
   • Surgical approach: Plate fixation (preferred) using manufacturer-contoured anatomic plates 1
   • Consider anterior inferior plating position (lower implant removal rates) 1

2. Minimally displaced or non-displaced fractures:

   • Nonsurgical management with sling immobilization 2, 3
   • Sling is preferred over figure-of-eight bracing for comfort 1

Distal Clavicle Fractures

• Surgical treatment recommended for displaced distal clavicle fractures with disruption of the coracoclavicular ligament complex 1
• Nondisplaced fractures can be treated nonsurgically 2

Special Considerations

• Urgent surgical intervention required for:

  • Fractures with skin tenting (to prevent skin necrosis) 1
  • Open fractures
  • Neurovascular compromise 3
  • Posteriorly displaced proximal fractures 3

• Pediatric and adolescent patients:

  • Generally managed conservatively 4
  • Surgical intervention may not provide additional benefit compared to nonsurgical management except in cases with skin tenting 1
  • Adolescents older than 9 years for girls and 12 years for boys may be treated using algorithms similar to adults 3

Rehabilitation Protocol

1. Weeks 1-2:

   • Immobilization in a sling for comfort
   • Gentle pendulum exercises as tolerated 1

2. Weeks 2-6:

   • Progress to active-assisted range of motion 1

3. After 6 weeks:

   • Begin strengthening exercises if radiographic healing is evident 1

4. Return to full activities:

   • Typically at 3-4 months based on healing 1

Important Considerations

• High-quality evidence shows higher union rates and better early outcomes with surgical treatment of displaced clavicle fractures, though long-term outcomes are similar between surgical and nonsurgical approaches 2
• Surgical fixation may lead to faster time to union, which is relevant for patients seeking quick return to work or sports 2
• Counsel patients who smoke about increased nonunion risk and inferior outcomes 1
• Do not use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing or lower nonunion rates 1

Pitfalls and Caveats

• Distal clavicle fractures may be mistaken for acromioclavicular separations 5
• Supine radiographs may underestimate fracture displacement; upright views are preferred 1
• When performing plate fixation, ensure adequate screw purchase in the distal fragment, which is often small and osteoporotic 1
• While surgical treatment offers better early outcomes, both surgical and nonsurgical approaches remain valid treatment options as long-term outcomes are similar 2