What is the treatment approach for a clavicle fracture and when is consultation with an orthopedic specialist necessary?

Treatment of Clavicle Fractures and Orthopedic Consultation Guidelines

Nonsurgical management with sling immobilization is recommended for minimally displaced or non-displaced clavicle fractures, while surgical treatment is indicated for significantly displaced fractures, shortening >1 cm, or skin tenting requiring urgent orthopedic consultation. 1

Initial Assessment and Treatment Approach

Fracture Classification and Treatment Decision

• Midshaft fractures (69-81% of cases):

  • Non-displaced or minimally displaced: Sling immobilization for comfort 1, 2
  • Displaced (>1 shaft width) or shortened (>1 cm): Consider surgical fixation 1

• Distal fractures:

  • With intact coracoclavicular ligaments: Conservative management 1, 3
  • With disrupted coracoclavicular ligaments: Surgical treatment recommended 1

• Proximal fractures (least common):

  • Non-displaced: Sling immobilization 3
  • Posteriorly displaced: Emergent orthopedic referral 2

Immediate Management

• Use upright radiographs to accurately assess displacement 1
• Sling immobilization is preferred over figure-of-eight bracing for comfort 1
• Initiate early pendulum exercises as tolerated 1
• Provide appropriate pain management 2

When to Consult Orthopedics

Emergent Consultation (Same Day)

• Open fractures 2
• Fractures with skin tenting (risk of skin necrosis) 1
• Posteriorly displaced proximal fractures 2
• Neurovascular compromise 2

Urgent Consultation (Within Days)

• Displacement >100% 2
• Shortening >2 cm 2
• Comminuted fractures 2
• Unstable distal fractures 2
• "Floating shoulder" (clavicle fracture with scapular neck fracture) 2
• Patients with high physical demands requiring quick return to activities 1

Routine Referral

• Displaced midshaft fractures with >1 shaft width displacement 1
• Shortening >1 cm 1
• Distal fractures with coracoclavicular ligament disruption 1

Rehabilitation Protocol

• Weeks 1-2: Sling immobilization with gentle passive range of motion exercises 1
• Weeks 2-6: Progress to active-assisted range of motion exercises 1
• After 6 weeks: Begin strengthening exercises if radiographic healing is evident 1
• 3-4 months: Typical timeframe for return to full activities 1

Special Considerations

• Adolescents: Generally managed conservatively, but follow adult algorithms for those >9 years (girls) or >12 years (boys) 2
• Smokers: Counsel about increased nonunion risk and inferior outcomes 1
• Surgical options: Plate fixation preferred for comminuted fractures; manufacturer-contoured anatomic plates have lower removal rates 1
• Avoid: Low-intensity pulsed ultrasonography does not accelerate healing 1

Pitfalls to Avoid

• Failing to obtain upright radiographs, which may underestimate displacement 1
• Overlooking distal clavicle fractures, which can be confused with acromioclavicular separation 3
• Delaying surgical intervention for fractures with skin tenting 1
• Using figure-of-eight bandages, which are less comfortable than simple slings 1
• Neglecting to consider patient's activity level and occupation in treatment decisions 1

The American Academy of Orthopaedic Surgeons guidelines emphasize that while nonsurgical management remains appropriate for minimally displaced fractures, surgical treatment offers higher union rates and better early outcomes for significantly displaced fractures 1. Though long-term outcomes are similar between approaches, the decision should consider fracture characteristics, patient activity level, and associated injuries.