Management of Acute Mildly Displaced and Angulated Mid-Clavicle Fracture
For an acute mildly displaced and angulated fracture of the right mid clavicle, nonsurgical management with sling immobilization is the recommended initial treatment. 1
Initial Treatment Approach
The American Academy of Orthopaedic Surgeons recommends nonsurgical management for minimally displaced fractures of the clavicle, with the following specific approach:
- Sling immobilization is preferred over figure-of-eight bracing for comfort 1
- Immobilize for comfort while initiating early pendulum exercises as tolerated
- Provide appropriate pain management
Rationale for Conservative Management
Conservative management is appropriate for mildly displaced fractures because:
- Long-term outcomes are similar between surgical and nonsurgical approaches for minimally displaced fractures 1
- The fracture pattern described (mildly displaced and angulated) does not meet the threshold criteria for surgical intervention
When to Consider Surgical Management
Surgery would be indicated if the fracture had:
- Displacement of one or more shaft width
- Shortening of more than 1 cm in length
- Skin tenting (requiring urgent ORIF)
- Patient with high physical activity requirements 1
Rehabilitation Protocol
Following initial immobilization, a structured rehabilitation protocol should be followed:
- Weeks 1-2: Gentle passive range of motion exercises
- Weeks 2-6: Progress to active-assisted range of motion
- After 6 weeks: Begin strengthening exercises if radiographic healing is evident 1
- Return to full activities typically at 3-4 months based on healing 1
Important Monitoring Considerations
- Obtain upright radiographs (not supine) to accurately assess fracture displacement 1
- Monitor for signs of nonunion, which occurs in approximately 15% of displaced clavicle fractures treated conservatively 2
- Be aware that initial shortening at the fracture site of ≥20 mm has been associated with nonunion and unsatisfactory results 2
Special Considerations
- Counsel patients who smoke about increased nonunion risk and inferior outcomes 1
- For adolescent patients (18 years and younger), nonsurgical management is particularly appropriate 1
- Do not use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing or lower nonunion rates 1
While some research suggests better outcomes with surgical fixation for displaced fractures 3, the current case of a mildly displaced and angulated fracture falls within the parameters where conservative management remains the standard of care according to current guidelines.