What is the best treatment for a fractured clavicle?

Treatment of Clavicle Fractures

The best treatment for a fractured clavicle depends on the fracture location and displacement, with nonsurgical management recommended for minimally displaced or non-displaced fractures and surgical fixation indicated for significantly displaced fractures, especially those with >1 cm shortening or full shaft width displacement. 1

Treatment Algorithm Based on Fracture Type

Midshaft Clavicle Fractures (Most Common)

• Non-displaced or minimally displaced:

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

• Displaced fractures with any of these characteristics:

  • Displacement of one or more shaft width
  • Shortening >1 cm
  • High physical activity requirements
  • Treatment: Plate fixation (provides higher union rates and better early outcomes) 1
  • Manufacturer-contoured anatomic plates are preferred due to lower rates of implant removal 1

Distal Clavicle Fractures

• Type I & III (stable): Nonsurgical treatment with sling immobilization 1, 2
• Type II (unstable with disruption of coracoclavicular ligaments): Surgical fixation recommended due to high nonunion rates with conservative treatment 1, 2

Proximal Clavicle Fractures (Uncommon)

• Non-displaced: Sling immobilization 2
• Significantly displaced or with sternoclavicular dislocation: Orthopedic referral for possible surgical intervention 2

Special Considerations

Urgent Surgical Indications

• Skin tenting (requires urgent ORIF to prevent skin necrosis) 1
• Open fractures
• Neurovascular compromise
• Floating shoulder

Risk Factors for Poor Outcomes

• Smoking significantly increases nonunion risk and leads to inferior outcomes 1
• Initial shortening ≥20mm has a highly significant association with nonunion (p<0.0001) 3

Surgical Technique Considerations

• Anterior inferior plating may lead to lower implant removal rates compared to superior plating 1
• Intramedullary nailing is an alternative, but plate fixation is preferred for comminuted fractures 1

Rehabilitation Protocol

1. Weeks 1-2: Immobilization with sling; gentle pendulum 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 Caveats

• Despite historical preference for conservative treatment, recent evidence shows higher rates of nonunion or symptomatic malunion than previously thought 4
• While surgical treatment shows better early outcomes and faster union, long-term outcomes are similar between surgical and nonsurgical approaches 1
• Adolescent patients (≤18 years) may not benefit from surgical treatment compared to nonsurgical management unless skin tenting is present 1
• Low-intensity pulsed ultrasonography (LIPUS) does not accelerate healing or lower nonunion rates 1

Imaging Recommendations

• Obtain upright radiographs to accurately demonstrate fracture displacement (superior to supine views) 1
• Consider CT scan of both clavicles for complex or comminuted fractures 1