What is the initial treatment approach for a clavicle fracture in the emergency department (ED)?

Emergency Department Treatment of Clavicle Fractures

In the emergency department, immobilize clavicle fractures with a simple sling and provide analgesia, then determine disposition based on fracture displacement, location, and patient factors. 1

Initial Assessment and Imaging

• Obtain upright radiographs rather than supine films, as they better demonstrate the degree of displacement and shortening 1
• Classify the fracture by location: midshaft (Group I, most common), lateral/distal (Group II, 10% of cases), or medial/proximal (Group III, uncommon) 2
• Assess for displacement, comminution, shortening, and associated injuries 3

Immediate Immobilization

Use a simple sling for immobilization rather than a figure-of-eight brace 1. The American Academy of Orthopaedic Surgeons specifically recommends slings as the preferred method for most acute clavicle fractures 1. This provides adequate support while being more comfortable and easier to apply than alternative devices.

Pain Management

• Provide multimodal analgesia appropriate to the severity of injury 3
• NSAIDs and opioids may be necessary in the acute setting for adequate pain control 3

Disposition: Emergent Consultation Required

Obtain immediate orthopedic consultation for the following high-risk fractures 3:

• Open fractures
• Posteriorly displaced proximal fractures (risk of neurovascular injury)
• Fractures with emergent associated injuries (pneumothorax, vascular injury, brachial plexus injury)
• Floating shoulder (combined clavicle and scapular neck fracture)

Disposition: Urgent Orthopedic Referral (Within Days)

Arrange urgent outpatient orthopedic follow-up for fractures that may benefit from surgical intervention 3:

• Displacement >100% (no cortical contact between fragments)
• Shortening >2 cm (specifically >1.5 cm per AAOS guidelines for midshaft fractures) 1
• Comminuted fractures
• Unstable distal/lateral fractures with coracoclavicular ligament disruption 1

The rationale is that surgical treatment of displaced midshaft fractures provides higher union rates and better early patient-reported outcomes compared to conservative management 1. Surgical intervention also allows faster return to work and reduces the risk of symptomatic malunion or nonunion, which can reach 15% with conservative treatment of displaced fractures 4.

Disposition: Outpatient Management

Discharge with sling immobilization and routine orthopedic follow-up for 3, 5:

• Nondisplaced or minimally displaced fractures
• Stable fractures without significant shortening
• No associated neurovascular injury

These fractures can be managed successfully without surgery, particularly those with minimal displacement 4, 1.

Pediatric Considerations

• Treat pediatric clavicle fractures conservatively in most cases, as they have excellent healing potential 3
• For adolescents (girls >9 years, boys >12 years), use treatment algorithms similar to adults 3
• Younger children rarely require surgical intervention regardless of displacement 3

Key Counseling Points

• Advise patients who smoke that smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Explain that while long-term outcomes are similar between surgical and nonsurgical treatment, surgery may provide faster recovery and earlier return to work 4, 1
• For widely displaced fractures managed conservatively, warn about potential for symptomatic malunion affecting shoulder strength and cosmetic appearance 1

Common Pitfalls to Avoid

• Do not use figure-of-eight braces as the primary immobilization method—slings are preferred 1
• Do not miss distal clavicle fractures, which can be difficult to distinguish from acromioclavicular separations 5
• Do not recommend low-intensity pulsed ultrasonography (LIPUS) for acute midshaft fractures, as it does not accelerate healing 1
• Do not obtain only supine radiographs—upright films are necessary to accurately assess displacement 1