What is the initial step in managing a non-displaced midclavicular fracture?

Management of Non-Displaced Midclavicular Fracture

The initial step in management of a non-displaced midclavicular fracture is immobilization with a simple sling for comfort, as it is preferred over figure-of-eight bracing. 1

Initial Assessment and Immobilization

• Non-displaced midclavicular fractures (defined as having >90% cross-sectional overlap on imaging) can be effectively managed non-operatively with minimal risk of complications
• Sling immobilization is the preferred method over figure-of-eight bracing because:
  • Provides better patient comfort
  • Similar functional outcomes
  • Easier to apply and maintain

Pain Management

• Provide appropriate analgesia:
  • Regular acetaminophen/paracetamol
  • Consider opioids with caution if needed for severe pain
  • NSAIDs may be relatively contraindicated in elderly patients with renal dysfunction

Early Rehabilitation Protocol

1. Weeks 1-2:

   • Immobilize in sling for comfort
   • Begin gentle pendulum exercises as tolerated

2. Weeks 2-6:

   • Progress to active-assisted range of motion exercises
   • Continue sling use when not performing exercises

3. After 6 weeks:

   • Begin strengthening exercises if radiographic healing is evident
   • Gradually return to normal activities

Follow-up and Monitoring

• Obtain upright radiographs (superior to supine views) to accurately assess fracture alignment
• Schedule follow-up at 2-3 weeks to confirm maintained alignment
• Monitor for signs of displacement or non-union

Expected Outcomes and Return to Activities

• Most non-displaced midclavicular fractures heal well with non-operative management
• Return to full activities typically at 3-4 months based on healing 1
• The non-union rate for non-displaced fractures is very low 2

Special Considerations

• Counsel patients who smoke about increased nonunion risk and inferior outcomes 1
• Be vigilant for signs of skin tenting which would require urgent surgical intervention
• Adolescent patients (18 years and younger) generally respond well to non-operative management
• Do not use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing 1

When to Consider Surgical Management

Surgical management may be indicated if the fracture:

• Becomes displaced (>1 shaft width or >1 cm shortening)
• Shows signs of skin tenting
• Occurs in patients with high physical demands requiring faster return to activities
• Develops non-union despite appropriate conservative management

By following this approach, most non-displaced midclavicular fractures will heal successfully with excellent functional outcomes and minimal complications.