Indications for Surgery in Clavicular Fracture
Surgery is indicated for displaced midshaft clavicle fractures with shortening exceeding 1.5cm and for displaced lateral fractures with disruption of the coracoclavicular ligament complex. 1
Absolute Surgical Indications
The following represent clear-cut indications where surgical intervention should be pursued:
- Neurovascular compromise due to posterior displacement with impingement on the brachial plexus, subclavian vessels, or carotid artery 2
- Open fractures requiring debridement and stabilization 3
- Displaced lateral (distal third) fractures with disruption of the coracoclavicular ligament complex 1, 2
- Polytrauma patients where early mobilization is critical for overall management 3
Relative Surgical Indications
These situations warrant strong consideration for operative management based on improved outcomes:
- Displaced midshaft fractures with >1.5cm shortening - this is the key threshold recommended by the American Academy of Orthopaedic Surgeons 1
- Complete displacement with >100% displacement (no cortical contact between fragments) requiring urgent orthopedic follow-up 1
- Severe comminution of midshaft fractures, particularly in active adults 2, 4
- Inability to tolerate prolonged immobilization due to Parkinson's disease, seizure disorders, or other neuromuscular conditions 2
- Symptomatic nonunion following failed conservative treatment (can be considered as early as 3 months post-injury) 5
Evidence Supporting Surgical Management
The shift toward increased surgical intervention is supported by substantial evidence:
- Nonsurgical treatment of widely displaced fractures results in nonunion rates up to 15%, compared to 5% with surgical treatment 6, 1
- Surgical treatment provides higher union rates and better early patient-reported outcomes compared to conservative management 1, 7
- Faster return to work and sport with operative intervention, particularly relevant for active adults 7, 8
- Reduced symptomatic malunion which can adversely affect shoulder strength and function 6, 1
When Conservative Management is Appropriate
Surgery should be avoided in these scenarios:
- Non-displaced or minimally displaced fractures can be managed successfully without surgery with low nonunion rates 6, 1
- Adolescents (≤18 years) - nonsurgical management is generally preferred as primary treatment, with excellent long-term outcomes 3
- Patients who accept cosmetic deformity and understand the slightly longer recovery time 8
Critical Assessment Steps
Before deciding on surgical intervention:
- Obtain upright radiographs rather than supine films, as they better demonstrate true displacement 1, 3
- Measure shortening accurately - the 1.5cm threshold is the key decision point 1
- Assess coracoclavicular ligament integrity in lateral fractures 1
- Consider patient factors including activity level, occupation demands, and smoking status (smoking increases nonunion risk and leads to inferior outcomes) 1
Important Caveats
- Long-term outcomes (>1 year) are similar between surgical and nonsurgical approaches, though surgery provides faster early recovery 1, 8
- Surgical complications include hardware removal needs (particularly with non-precontoured plates) and infection risk 1
- In adolescents, surgery has not demonstrated significant benefits and is associated with high rates of subsequent hardware removal procedures 3