What is the treatment for a clavicle fracture?

Treatment of Clavicle Fractures

Most clavicle fractures should be treated with sling immobilization, reserving surgery for displaced midshaft fractures with >1.5cm shortening or displaced lateral fractures with coracoclavicular ligament disruption. 1

Initial Assessment and Imaging

• Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and are essential for accurate treatment planning 1, 2
• Assess fracture location (medial, midshaft, or lateral third), degree of displacement, shortening, and ligamentous integrity 1

Treatment Algorithm by Fracture Type

Midshaft Fractures (80% of all clavicle fractures)

Non-displaced or minimally displaced fractures:

• Treat with sling immobilization (preferred over figure-of-eight brace) 1
• This is appropriate for fractures without significant displacement and provides effective healing 1

Displaced midshaft fractures in adults:

• Surgery is indicated when shortening exceeds 1.5cm, as this provides higher union rates and better early patient-reported outcomes compared to conservative management 1
• Displaced fractures managed conservatively carry up to 15% risk of symptomatic malunion or nonunion 1
• Surgical treatment offers faster recovery and earlier return to work, though long-term outcomes at several years are similar between approaches 1

Lateral (Distal) Clavicle Fractures

• Surgical repair is recommended for displaced lateral fractures with disruption of the coracoclavicular ligament complex (Neer Type II and V), as these are inherently unstable 1, 2
• Stable, non-displaced lateral fractures can be managed conservatively with sling immobilization 2

Special Population: Adolescents (≤18 years)

• Nonsurgical management is strongly preferred as the primary approach for midshaft fractures in adolescents 3
• Surgery has not demonstrated significant benefits over conservative management in this age group and is associated with high rates of hardware removal procedures 3
• Surgical intervention in adolescents should be reserved only for: open fractures requiring debridement, polytrauma patients needing early mobilization, or severely displaced fractures with >1.5cm shortening 3

Surgical Options (When Indicated)

Plate fixation:

• Use manufacturer-contoured anatomic clavicle plates due to lower rates of implant removal or deformation 1
• Anterior inferior plating may result in lower implant removal rates compared to superior plating 1
• Plate fixation may be more beneficial when fracture comminution is present 3

Intramedullary nailing:

• Provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 1

Immobilization Method

• Use a sling rather than figure-of-eight brace for all acute clavicle fractures, as recommended by the American Academy of Orthopaedic Surgeons 1, 3, 2

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

Rehabilitation Timeline (Post-Surgical)

• By 4 weeks: discontinue sling for routine activities but avoid lifting, pushing, or pulling with the affected arm 1
• Full weight-bearing activities typically allowed between 8-12 weeks based on radiographic healing evidence 1

Critical Risk Factors

• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes; counsel patients on cessation 1, 2
• Fractures with displacement >100% (no cortical contact) require urgent orthopedic follow-up 1

Potential Complications

Nonsurgical treatment of widely displaced fractures:

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

Surgical complications:

• Hardware removal needs, particularly with non-precontoured plates 1
• Hardware irritation occurs in approximately 24% of surgical patients 4