What is the management plan for a minimally displaced distal clavicle fracture?

Management of Minimally Displaced Distal Clavicle Fracture

For minimally displaced distal clavicle fractures, conservative management with sling immobilization is the recommended treatment approach, as it typically leads to good functional outcomes without the need for surgical intervention. 1

Assessment and Diagnosis

• Obtain upright radiographs (posteroanterior, lateral, and oblique views) to accurately assess fracture displacement, as upright views are superior for demonstrating the true degree of displacement compared to supine radiographs 1
• Carefully evaluate the coracoclavicular ligament complex integrity, as disruption would influence treatment decisions 1
• Consider CT imaging if radiographs are equivocal but clinical suspicion remains high 2

Treatment Algorithm

Conservative Management (First-line for minimally displaced fractures)

1. Immobilization

   • Use a simple arm sling rather than figure-of-eight bandage for immobilization 1
   • The American Academy of Orthopaedic Surgeons (AAOS) work group specifically recommends sling immobilization over figure-of-eight braces for most clavicle fractures 1

2. Duration of Immobilization

   • Typically 2-4 weeks, with gradual return to activities as pain allows
   • Limit immobilization duration to prevent stiffness complications 2

3. Pain Management

   • NSAIDs for pain and inflammation control 2
   • Consider supplementation with vitamin C to help prevent disproportionate pain 2

4. Rehabilitation

   • Begin directed home exercise program after immobilization period 2
   • Progress through active range of motion exercises to prevent stiffness 2

Indications for Surgical Management

Surgery should be considered if:

• Fracture becomes displaced during follow-up (>3mm displacement) 2
• Disruption of the coracoclavicular ligament complex is present 1
• Patient has high functional demands and requires faster return to activities 3

Follow-up and Monitoring

• Clinical and radiographic follow-up at 2,6, and 12 weeks to monitor healing
• Assess for potential complications including:
  • Joint stiffness
  • Chronic pain
  • Nonunion (though even asymptomatic nonunion may have good functional outcomes) 4

Special Considerations

• Smoking: Advise smoking cessation as it increases nonunion rates and leads to inferior clinical outcomes 1, 2
• Elderly patients: Consider evaluation for osteoporosis risk factors 2
• Functional outcomes: Research shows that even when nonunion occurs with conservative treatment, many patients still achieve good functional outcomes 4

Evidence Strength and Controversies

• The AAOS guideline notes limited evidence for lateral clavicle fracture management, with recommendations based primarily on expert opinion 1
• While some studies report higher nonunion rates with conservative treatment of displaced distal clavicle fractures, Robinson et al. found that only 14% of conservatively treated patients eventually required surgery, and asymptomatic nonunion did not significantly affect functional outcomes 4
• The decision between operative and nonoperative management should consider the degree of displacement, ligamentous disruption, and patient factors 3