Mid Clavicular Fracture Treatment
Use a simple sling for immobilization and pursue nonsurgical management for non-displaced or minimally displaced fractures, but proceed with surgical fixation for displaced midshaft fractures with shortening exceeding 1.5cm in adults. 1
Initial Assessment and Immobilization
A sling is the preferred immobilization method for most acute clavicle fractures, not a figure-of-eight brace. 1 This recommendation is based on better patient tolerance and equivalent outcomes, with research confirming significantly higher pain scores on the first day with figure-of-eight bandages (VAS 6.8 vs 5.6, p=0.034). 2
Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and are essential for treatment planning. 1
Treatment Algorithm Based on Fracture Characteristics
Non-displaced or Minimally Displaced Fractures
- Proceed with nonsurgical management using sling immobilization. 1
- These fractures have very low nonunion rates and excellent outcomes with conservative treatment. 3
- This approach is appropriate across all age groups, from young children to adults. 1, 4
Displaced Midshaft Fractures in Adults
- Surgical treatment is indicated when shortening exceeds 1.5cm. 1
- Surgery 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 intervention results in faster recovery and earlier return to work, though long-term outcomes at final follow-up are similar between surgical and nonsurgical approaches. 1
Fractures Requiring Urgent Orthopedic Referral
- Displacement >100% (no cortical contact between fragments) requires urgent orthopedic consultation. 1
- Open fractures requiring debridement and stabilization. 4
- Polytrauma patients where early mobilization is critical. 4
Surgical Options When Indicated
Plate fixation and intramedullary nailing provide equivalent long-term clinical outcomes with similar complication rates. 1
For 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 with superior plating. 1
Plate fixation may be more beneficial when fracture comminution is present. 4
Post-Treatment Management and Timeline
Discontinue sling use by 4 weeks for routine activities, but continue avoiding lifting, pushing, or pulling with the affected arm. 1
Full weight-bearing activities are typically allowed between 8-12 weeks, depending on radiographic healing evidence and clinical examination. 1
Special Population Considerations
Adolescents (18 years and younger)
- Nonsurgical management is generally preferred as the primary treatment approach. 4
- Surgical treatment has not demonstrated significant benefits over conservative management in this age group and is associated with high rates of subsequent hardware removal surgeries. 4
- Reserve surgery only for open fractures, polytrauma, or severely displaced fractures with significant shortening. 4
Young Children (under 2 years)
- Use simple sling immobilization; surgical intervention is not indicated. 5
- Critical pitfall: Always determine mechanism of injury, as clavicle fractures outside the neonatal period in children under 24 months raise concern for non-accidental trauma unless there is clear fall history. 5
Important Risk Factors and Complications
Smoking increases nonunion rates and leads to inferior clinical outcomes; counsel patients on cessation. 1
Nonsurgical treatment of widely displaced fractures may result in higher nonunion rates, symptomatic malunion affecting shoulder strength and function, cosmetic concerns, and longer time to return to work. 1
Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management, as it does not accelerate healing or reduce nonunion rates. 1