What is the initial treatment for clavicle fractures?

Initial Treatment for Clavicle Fractures

The initial treatment for clavicle fractures should be nonsurgical management with sling immobilization for minimally displaced or non-displaced fractures, as recommended by the American Academy of Orthopaedic Surgeons. 1

Treatment Algorithm Based on Fracture Type

Midshaft Clavicle Fractures (80% of cases)

• Non-displaced or minimally displaced:

  • Sling immobilization (preferred over figure-of-eight bracing for comfort) 1
  • Pain management as appropriate
  • Early pendulum exercises as tolerated

• Displaced midshaft fractures (consider surgical fixation if):

  • Displacement of one or more shaft width
  • Shortening of more than 1 cm in length
  • High physical activity requirements
  • Plate fixation is recommended in these cases as it offers higher union rates and better early patient-reported outcomes 1

Distal Clavicle Fractures

• Type I and III: Typically managed with sling immobilization 2
• Type II (displaced with disruption of coracoclavicular ligament complex): Surgical treatment recommended to improve union rates and functional outcomes 1, 2

Proximal (Medial) Clavicle Fractures

• Non-displaced: Sling immobilization 2
• Displaced or with sternoclavicular dislocation: Orthopedic referral indicated 2

Special Considerations

Urgent Surgical Indications

• Clavicular fractures with skin tenting require urgent surgical intervention through open reduction and internal fixation (ORIF) to prevent skin necrosis and potential conversion to an open fracture 1

Diagnostic Imaging

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

Rehabilitation Protocol

1. Weeks 1-2: Immobilization in sling with gentle passive range of motion exercises
2. Weeks 2-6: Progress to active-assisted range of motion
3. After 6 weeks: Begin strengthening exercises if radiographic healing is evident
4. Return to full activities typically at 3-4 months based on healing 1

Important Clinical Pearls

• Recent 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 1, 3
• The rate of nonunion following non-operative treatment appears to be higher than previously reported, leading to a paradigm shift toward increased operative fracture treatment in recent years 3
• Patients who smoke should be counseled about increased nonunion risk and inferior outcomes 1
• Adolescent patients (18 years and younger) may not benefit from surgical treatment compared to nonsurgical management unless they have skin tenting 1
• Low-intensity pulsed ultrasonography (LIPUS) should not be used as it does not accelerate healing or lower nonunion rates 1

Surgical Considerations When Indicated

• Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal and deformation 1
• Anterior inferior plating may lead to lower implant removal rates compared to superior plating 1
• Intramedullary nailing is an alternative, but plate fixation may be better for comminuted fractures 1

While the traditional approach has been conservative management 2, 4, more recent evidence suggests that surgical treatment may decrease complication rates and improve functional outcomes, particularly for displaced fractures 5, 6, 3. However, the decision between surgical and nonsurgical treatment should be based on fracture characteristics, patient factors, and functional demands.