What is the recommended immobilization method for a clavicle fracture, a sling or a shoulder immobilizer?

Clavicle Fracture Immobilization: Sling vs. Shoulder Immobilizer

A simple arm sling is the recommended immobilization method for clavicle fractures as it provides better comfort compared to figure-of-eight bandages or shoulder immobilizers. 1

Rationale for Sling Immobilization

The American Academy of Orthopaedic Surgeons specifically recommends sling immobilization for non-displaced or minimally displaced clavicle fractures, citing improved patient comfort over figure-of-eight bracing 1. This recommendation is supported by high-quality evidence showing:

• Slings cause significantly less pain in the initial treatment period compared to figure-of-eight bandages 2
• Slings are easier to apply and maintain 2
• Both methods achieve similar radiological and functional outcomes 2

Clinical Decision Algorithm

For Non-displaced or Minimally Displaced Fractures:

1. Use a simple arm sling for immobilization
2. Maintain for comfort (typically 2-3 weeks)
3. Initiate early pendulum exercises as tolerated 1
4. Progress to gentle passive range of motion exercises at 1-2 weeks
5. Advance to active-assisted range of motion at 2-6 weeks
6. Begin strengthening exercises after 6 weeks if radiographic healing is evident 1

For Displaced Fractures:

• Consider surgical referral for:
  • Displacement greater than one shaft width
  • Shortening greater than 1 cm
  • High physical activity requirements
  • Skin tenting (urgent referral needed)
  • Distal clavicle fractures with disruption of the coracoclavicular ligament complex 1

Evidence Quality and Considerations

The recommendation for sling immobilization is supported by both recent guidelines and randomized controlled studies. A 2015 randomized controlled study directly compared slings to figure-of-eight bandages and found significantly higher pain scores on the first day after treatment in the figure-of-eight group (6.8 vs. 5.6, p=0.034) 2.

While older literature from 1997 suggested either sling or figure-of-eight bandage could be used 3, more recent evidence consistently favors slings for patient comfort. The 2021 evidence-based review specifically states that "nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling" 4.

Common Pitfalls to Avoid

1. Overcomplicating immobilization: Complex immobilization methods like figure-of-eight bandages don't improve outcomes but increase patient discomfort 2

2. Missing associated injuries: Always evaluate for:

   • Pneumothorax
   • Neurovascular compromise
   • Scapular fractures (potential "floating shoulder")

3. Inadequate follow-up: Patients with primary displacement >15mm or shortening observed at follow-up have statistically significantly more pain 5

4. Overlooking pediatric considerations: Children generally have excellent healing potential with conservative management, but adolescents approaching skeletal maturity may benefit from adult treatment algorithms 4

5. Prolonged immobilization: This can lead to unnecessary stiffness and delayed rehabilitation; immobilization averaging 21 days is typically sufficient 5