Management of Proximal Clavicular Fractures
Nondisplaced proximal clavicle fractures should be treated conservatively with sling immobilization, while significantly displaced fractures or those with sternoclavicular dislocation require orthopedic referral for potential surgical intervention. 1
Initial Assessment and Classification
Proximal (medial third) clavicle fractures are uncommon, accounting for only a small percentage of all clavicle fractures. 1, 2 The critical distinction is between displaced and nondisplaced fractures, as this determines management:
- Nondisplaced fractures: Successfully managed with conservative treatment 1
- Displaced fractures: Require careful evaluation for neurovascular compromise and potential surgical intervention 1, 3
Immediate Management
Pain Control
- Provide adequate analgesia with regular paracetamol and carefully titrated opioids 4
- Consider regional nerve blocks (femoral nerve block or fascia iliaca block) for immediate pain relief while awaiting definitive treatment 4
Immobilization
- Use a sling as the preferred immobilization method rather than a figure-of-eight brace 5
- Ensure proper immobilization to prevent further displacement 4
Initial Workup
- Obtain upright radiographs, as they better demonstrate the degree of displacement compared to supine films 5
- Assess for associated injuries, particularly neurovascular compromise 6, 3
Indications for Emergent Orthopedic Consultation
Immediate referral is required for:
- Posteriorly displaced proximal fractures that may impinge on the brachial plexus, subclavian vessels, or common carotid artery 6, 3
- Neurovascular compromise due to posterior displacement of bone fragments 3
- Sternoclavicular dislocation 1
- Open fractures 6
Indications for Urgent Orthopedic Referral
- Fractures with significant displacement (>100% displacement with no cortical contact) 5, 6
- Severe angulation or comminution 3
- Patients unable to tolerate prolonged immobilization due to Parkinson's disease, seizure disorders, or other neuromuscular conditions 3
Conservative Management Protocol
For nondisplaced or minimally displaced proximal fractures without neurovascular injury:
Immobilization
- Sling immobilization for 4-6 weeks 5, 1
- Discontinue sling use by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 5
Pain Management
- Regular paracetamol as baseline analgesia 4
- Opioids titrated carefully, particularly if renal dysfunction is present 4
- Monitor pain scores at rest and with movement 7
Follow-up
- Outpatient orthopedic follow-up within 1-2 weeks 6
- Serial radiographs to monitor healing and ensure no displacement 1
- Imaging healing time typically 3-6 months 8
Surgical Management
When surgical intervention is indicated (posteriorly displaced fractures, neurovascular compromise, or sternoclavicular dislocation), various internal fixation methods can be employed based on fracture pattern:
- Threaded intramedullary wire or pin fixation 3
- Plate fixation with anatomically contoured plates 8
- Cerclage suture techniques for specific fracture patterns 3
Surgery should be performed by an experienced surgeon to minimize operative time and optimize outcomes. 4
Rehabilitation
- By 4 weeks: Discontinue sling for routine activities but continue avoiding heavy lifting 5
- 8-12 weeks: Full weight-bearing activities allowed based on radiographic healing 5
- Include muscle strengthening exercises and long-term continuation of appropriate exercises 5
- Monitor for signs of complications requiring medical attention 5
Common Pitfalls to Avoid
- Do not overlook posteriorly displaced proximal fractures, as they can cause life-threatening neurovascular compromise 3
- Do not use figure-of-eight bracing as the primary immobilization method; slings are preferred 5
- Do not delay orthopedic consultation for significantly displaced fractures or those with sternoclavicular involvement 1, 6
- Exercise caution with opioids in patients with renal dysfunction, which is present in approximately 40% of trauma patients 7