What is the plan of care for a patient with a clavicle fracture?

Clavicle Fracture Plan of Care

Use a simple sling for immobilization (not a figure-of-eight brace) and pursue nonsurgical management for non-displaced or minimally displaced fractures, but proceed with surgical fixation 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 shortening 1
• Assess for displacement >100% (no cortical contact between fragments), which requires urgent orthopedic follow-up 1
• Evaluate fracture location (midshaft, lateral, or medial third), degree of comminution, and amount of shortening 1

Special consideration for young children: In children under 24 months, determine if a skeletal survey is needed to evaluate for non-accidental trauma—this is necessary if there is no clear fall history or if the mechanism is unclear 2

Nonsurgical Management (First-Line for Most Fractures)

Immobilization:

• Use a sling as the preferred method rather than a figure-of-eight brace, per American Academy of Orthopaedic Surgeons recommendations 1
• Continue sling use for routine activities until 4 weeks, then discontinue for daily activities while avoiding lifting, pushing, or pulling 1

Appropriate candidates for nonsurgical treatment:

• Non-displaced or minimally displaced fractures 1
• Adolescents (≤18 years) with midshaft fractures, as surgery has not shown significant benefits and carries high hardware removal rates 3
• Young children (e.g., 2-year-olds) with simple fractures—these heal well with sling immobilization alone 2

What NOT to use:

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

Surgical Indications (Adults)

Proceed with surgical fixation when:

• Displaced midshaft fractures with shortening exceeding 1.5cm 1
• Displaced lateral fractures with disruption of the coracoclavicular ligament complex 1
• Displacement >100% with no cortical contact between fragments 1
• Open fractures requiring debridement 3
• Polytrauma patients requiring early mobilization 3

Benefits of surgery in appropriate candidates:

• Higher union rates and better early patient-reported outcomes compared to conservative management 1
• Faster recovery and earlier return to work 1
• Reduction in symptomatic malunion/nonunion risk (which can reach 15% with conservative treatment of displaced fractures) 1

Note: Long-term patient-reported outcomes and satisfaction are similar between surgical and nonsurgical approaches, so the decision hinges on early recovery priorities and specific fracture characteristics 1

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
• Consider plate fixation particularly when fracture comminution is present 3

Intramedullary nailing:

• Provides equivalent long-term clinical outcomes to plate fixation with similar complication rates 1, 3

Rehabilitation Timeline

Early phase (0-4 weeks):

• Sling immobilization for comfort and protection 1
• Allow immediate free-shoulder mobilization as tolerated for pain control 1

Intermediate phase (4-8 weeks):

• Discontinue sling for routine activities at 4 weeks 1
• Continue avoiding lifting, pushing, or pulling with the affected arm 1
• Begin muscle strengthening exercises 1

Late phase (8-12 weeks):

• Full weight-bearing activities typically allowed between 8-12 weeks, depending on radiographic evidence of healing and clinical examination 1
• Continue appropriate exercises long-term 1

Risk Factors and Complications to Monitor

Smoking:

• Increases nonunion rates and leads to inferior clinical outcomes—counsel patients on cessation 1

Nonsurgical treatment risks (for widely displaced fractures):

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

Surgical complications:

• Need for hardware removal, particularly with non-precontoured plates 1
• High hardware removal rates in adolescents if surgery is performed 3

Common Pitfalls to Avoid

• Do not use figure-of-eight bracing—slings are preferred and better tolerated 1, 2
• Do not overlook non-accidental trauma in young children—always obtain a clear mechanism of injury 2
• Do not assume all displaced fractures need surgery in adolescents—nonsurgical management is generally preferred as they have excellent long-term outcomes 3
• Do not use supine radiographs alone—upright films are essential for accurate displacement assessment 1