What is the recommended treatment approach for a patient with a subacute or chronic clavicle fracture, considering factors such as fracture displacement and patient activity level?

Treatment of Subacute and Chronic Clavicle Fractures

For subacute and chronic clavicle fractures, surgical treatment is strongly recommended when symptomatic nonunion or malunion is present, particularly in active patients, as these complications significantly impair shoulder function and strength. 1

Defining the Timeline

• Subacute fractures (typically 3-12 weeks post-injury) that remain displaced with >1.5cm shortening or show signs of delayed union should be considered for surgical intervention 2
• Chronic fractures (>12 weeks) presenting as symptomatic nonunion or malunion are clear indications for delayed surgical reconstruction 1

Treatment Algorithm for Subacute/Chronic Fractures

Step 1: Assess Fracture Union Status

If radiographic union is progressing (callus formation visible):

• Continue conservative management with activity modification 1
• Monitor with serial radiographs every 4-6 weeks 2

If nonunion is present (no progression of healing by 12-16 weeks):

• Proceed to surgical evaluation, especially if symptomatic 1
• The American Academy of Orthopaedic Surgeons reports that nonsurgical treatment of widely displaced fractures results in nonunion rates up to 15% 1

If symptomatic malunion exists:

• Surgical reconstruction should be discussed, particularly in young, active patients 1
• Malunion can adversely affect shoulder strength and function, beyond just cosmetic concerns 1

Step 2: Evaluate Patient Factors

High-priority surgical candidates include:

• Active patients requiring return to work or sport 1
• Those with significant functional impairment or pain 1
• Patients with cosmetically unacceptable deformity causing distress 1
• Smokers (who have higher nonunion rates and inferior outcomes) should be counseled on cessation prior to any intervention 2

Lower-priority surgical candidates:

• Elderly, low-demand patients with asymptomatic nonunion 3
• Those with significant medical comorbidities increasing surgical risk 1

Step 3: Surgical Planning

For symptomatic nonunion or malunion:

• Plate fixation with manufacturer-contoured anatomic clavicle plates is preferred due to lower rates of implant removal or deformation 2
• Anterior inferior plating may result in lower implant removal rates compared with superior plating 2
• Intramedullary nailing provides equivalent long-term outcomes to plate fixation with similar complication rates 2
• Plate fixation may be more beneficial when fracture comminution is present 4

Key Evidence Supporting Surgical Intervention

The American Academy of Orthopaedic Surgeons provides strong evidence that surgical treatment of displaced clavicle fractures results in:

• Higher union rates compared to conservative management 1, 2
• Better early patient-reported outcomes 1
• Faster time to union, allowing earlier return to work or sport 1
• Reduced risk of symptomatic malunion or nonunion 2

However, long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches 1, 2, which is why the decision must weigh the patient's timeline for recovery and activity demands.

Critical Pitfalls to Avoid

Do not assume all nonunions require surgery:

• Asymptomatic nonunion in middle-aged and elderly patients may not adversely affect medium-term functional outcomes 3
• Only 14% of patients with displaced lateral clavicle fractures developed symptoms severe enough to warrant delayed surgery 3

Do not delay surgical consultation for symptomatic cases:

• Patients with persistent pain, functional limitation, or progressive deformity beyond 12 weeks should be referred promptly 1
• Delayed reconstruction becomes more technically challenging as time progresses 1

Do not overlook smoking status:

• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes 2
• Smoking cessation counseling is essential before any treatment decision 2

Special Consideration: Lateral Clavicle Fractures

For displaced lateral clavicle fractures with coracoclavicular ligament disruption, surgical treatment is recommended even in the subacute phase 2. These fractures have higher nonunion rates with conservative management 3.

Rehabilitation Expectations Post-Surgery

• Sling use typically discontinued by 4 weeks for routine activities 2
• Avoid lifting, pushing, or pulling until 4 weeks minimum 2
• Full weight-bearing activities allowed between 8-12 weeks based on radiographic healing 2