Clavicle Fracture Treatment
For displaced midshaft clavicle fractures in adults with shortening exceeding 1.5cm, surgical treatment is recommended as it provides higher union rates and better early patient-reported outcomes, while non-displaced or minimally displaced fractures should be managed nonsurgically with sling immobilization. 1, 2
Initial Assessment
Radiographic Evaluation
- Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and shortening 2
- Assess for displacement >100% (no cortical contact between fragments), which requires urgent orthopedic referral 2
- Measure shortening—displacement exceeding 1.5cm is a surgical indication 2
Fracture Location Classification
- Midshaft fractures (middle third): Account for 69-81% of all clavicle fractures 3
- Lateral fractures (distal third): Require assessment of coracoclavicular ligament integrity 2
- Medial fractures (proximal third): Less common, require evaluation for sternoclavicular involvement 4
Treatment Algorithm
Nonsurgical Management Indications
- Non-displaced or minimally displaced fractures are appropriate for conservative treatment 2
- Immobilize with a sling (preferred over figure-of-eight brace) 2
- Figure-of-eight braces are no longer recommended as the primary immobilization method 2
Avoid this pitfall: Do NOT use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management—it does not accelerate healing or reduce nonunion rates 2
Surgical Management Indications
Absolute Indications
- Midshaft fractures with shortening >1.5cm 2
- Displaced lateral fractures with coracoclavicular ligament disruption 2
- Open fractures requiring debridement 5
- Polytrauma patients requiring early mobilization 5
Evidence Supporting Surgery
The AAOS 2023 guideline provides a strong recommendation for surgical treatment of displaced clavicle fractures in adults based on high-quality evidence showing:
- Higher union rates compared to nonsurgical treatment 1
- Better early patient-reported outcomes 1, 2
- Faster time to union, relevant for patients needing quick return to work or sport 1
Important nuance: Long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches, so both remain valid options when weighing individual patient factors 1, 2
Surgical Technique Options
Plate Fixation
- Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal or deformation 2
- Anterior inferior plating may result in lower implant removal rates compared to superior plating 2
- Plate fixation may be more beneficial when fracture comminution is present 5
Intramedullary Nailing
- Provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 2, 5
- Both techniques are acceptable surgical options 2
Risk Factors and Complications
Patient Risk Factors
- Smoking increases nonunion rates and leads to inferior clinical outcomes 2
- Counsel patients on smoking cessation prior to treatment
Nonsurgical Treatment Complications
- Higher nonunion rates with widely displaced fractures (up to 15%) 2
- Symptomatic malunion affecting shoulder strength and function 2
- Cosmetic concerns from deformity 2
- Longer time to return to work 2
Surgical Treatment Complications
- Need for hardware removal, particularly with non-precontoured plates 2
- Standard surgical risks (infection, neurovascular injury) 6
Postoperative Rehabilitation (If Surgery Performed)
- Discontinue sling use by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 2
- Full weight-bearing activities typically allowed between 8-12 weeks based on radiographic healing 2
Special Population Considerations
Adolescents (≤18 years)
- Nonsurgical management is generally preferred as primary treatment 5
- Surgical treatment has not demonstrated significant benefits over conservative management in this age group 5
- Surgery associated with high rates of subsequent hardware removal procedures 5