What is the management of a displaced clavicle fracture?

Management of Displaced Clavicle Fractures

For displaced midshaft clavicle fractures in adults with shortening exceeding 1.5cm, surgical treatment is indicated and provides higher union rates and better early functional outcomes compared to conservative management. 1

Initial Assessment and Imaging

• Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and guide treatment decisions 1, 2
• Assess for specific displacement characteristics: shortening >1.5cm, displacement >100% (no cortical contact between fragments), and presence of comminution 1

Treatment Algorithm Based on Fracture Characteristics

Absolute Surgical Indications

• Open fractures requiring debridement and stabilization 2
• Polytrauma patients where early mobilization is critical 2
• Displaced lateral (distal) fractures with disruption of the coracoclavicular ligament complex 1
• Fractures with significant neurovascular compromise 3

Relative Surgical Indications (Adults)

• Midshaft fractures with shortening >1.5cm - surgery provides higher union rates and reduces risk of symptomatic malunion/nonunion (which can reach 15% with conservative treatment) 1
• Displacement >100% with no cortical contact between fragments - these require urgent orthopedic follow-up 1
• Patients requiring faster return to work or athletic activities 1

Conservative Management Appropriate For

• Non-displaced or minimally displaced fractures can be managed successfully without surgery 1
• Fractures with <1.5cm shortening and maintained cortical contact 1

Surgical Options When Indicated

Plate Fixation

• Manufacturer-contoured anatomic clavicle plates are 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
• Plate fixation may be more beneficial in the presence of fracture comminution 2

Intramedullary Nailing

• Provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 1, 2
• Both techniques are acceptable surgical options 2

Conservative Management Protocol

Immobilization

• Use a simple sling as the preferred immobilization method rather than a figure-of-eight brace 1, 2
• Immobilization duration should be brief, followed by range of motion exercises 3

What NOT to Use

• Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management, as it does not accelerate healing or reduce nonunion rates 1

Post-Operative Rehabilitation (If Surgery Performed)

• By 4 weeks: discontinue sling use for routine activities, but avoid lifting, pushing, or pulling with the affected arm 1
• 8-12 weeks: full weight-bearing activities typically allowed, depending on radiographic evidence of healing 1
• Include muscle strengthening exercises and patient education about pain management 1

Critical Risk Factors and Complications

Smoking

• Smoking increases nonunion rates and leads to inferior clinical outcomes - this must be addressed preoperatively if surgery is planned 1, 4

Complications of Conservative Treatment (Displaced Fractures)

• Higher nonunion rates (up to 15%) 1
• Symptomatic malunion affecting shoulder strength and function 1
• Cosmetic concerns from persistent deformity 1
• Longer time to return to work 1

Surgical Complications

• Need for hardware removal, particularly with non-precontoured plates 1
• In adolescents specifically, there is a high rate of subsequent surgeries for hardware removal 2

Special Population: Adolescents (≤18 years)

• For adolescents, nonsurgical management is generally preferred as the primary treatment approach 2
• Surgical treatment in adolescents has not demonstrated significant benefits over conservative management 2
• Long-term functional outcomes are typically excellent with nonsurgical management in this population 2
• Surgery in adolescents should be reserved only for absolute indications (open fractures, polytrauma, neurovascular compromise) 2

Long-Term Outcomes Perspective

While surgical treatment provides better early patient-reported outcomes and faster return to function, long-term patient-reported outcomes and satisfaction are similar between surgical and nonsurgical approaches 1. This information is important for shared decision-making with patients who have relative rather than absolute surgical indications.