Do I need surgery for a clavicle fracture?

Management of Clavicle Fractures: Surgical vs. Non-surgical Approach

Surgery is NOT needed for most clavicle fractures, but is indicated for specific cases including displaced midshaft fractures with shortening exceeding 1.5cm, displaced lateral fractures with disruption of the coracoclavicular ligament complex, open fractures, or cases with neurovascular complications. 1

Decision Algorithm for Clavicle Fracture Management

Non-surgical Management (First-line for most fractures)

• Non-surgical management is appropriate for non-displaced fractures, with a sling being the preferred immobilization method rather than a figure-of-eight brace 1
• For adolescents (18 years and younger), non-surgical management is generally preferred as the primary treatment approach for midshaft clavicular fractures 2
• Functional outcomes are typically excellent with non-surgical management in the adolescent population 2
• Most patients can discontinue sling use by 4 weeks for routine activities but should continue to avoid lifting, pushing, or pulling with the affected arm 1

Surgical Indications

• Displaced midshaft fractures in adults with shortening exceeding 1.5cm 1, 3
• Displaced lateral fractures with disruption of the coracoclavicular ligament complex 1
• Open fractures requiring debridement and stabilization 2, 4
• Polytrauma patients where early mobilization is critical 2
• Cases with neurovascular compromise or significant soft tissue complications 5, 4

Radiographic Assessment

• Upright radiographs are recommended for proper assessment as they better demonstrate the true degree of displacement compared to supine radiographs 1, 2
• Consider CT scan for complex fractures, especially for periarticular medial clavicle fractures to aid in operative planning 6

Surgical Options When Indicated

• Plate fixation is a common surgical option, with manufacturer-contoured anatomic clavicle plates preferred due to lower rates of implant removal or deformation 1, 2
• Anterior inferior plating may lead to lower implant removal rates compared with superior plating 1, 2
• Intramedullary nailing provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 1, 2
• For periarticular medial clavicle fractures (when surgery is indicated), locking plates with at least three screws in the medial fragment provide rigid fixation 6

Potential Complications and Considerations

• Non-surgical treatment of widely displaced fractures may result in higher nonunion rates (up to 8% for medial fractures), symptomatic malunion affecting shoulder strength and function, cosmetic concerns, and longer time to return to work 1, 6
• Surgical complications include need for hardware removal, particularly with non-precontoured plates 1
• Surgical treatment in adolescents has not demonstrated significant benefits over conservative management and is associated with high rates of subsequent surgeries for hardware removal 2
• Smoking increases the rate of nonunion in clavicle fractures and leads to inferior clinical outcomes 1

Rehabilitation

• Full weight-bearing activities are typically allowed between 8-12 weeks, depending on radiographic evidence of healing and clinical examination 1
• Rehabilitation should include muscle strengthening exercises, long-term continuation of appropriate exercises, and patient education about pain management strategies 1
• After surgical fixation, the arm is typically immobilized in a sling for 2-3 weeks, followed by careful passive and increasing active motion exercises 6

Special Considerations for Different Fracture Locations

• Midshaft fractures are most common and treatment should be personalized based on displacement and the patient's activity level 3
• Distal clavicle fractures require careful assessment as they can be confused with acromioclavicular separation; Type II distal fractures are displaced due to ligamentous disruption and usually require surgical repair 7
• Proximal third fractures are uncommon; non-displaced proximal fractures can be successfully treated with sling immobilization, but orthopedic referral is indicated for significant displacement or sternoclavicular dislocation 7