What is the recommended treatment for a patient with a displaced clavicle fracture?

Treatment for Displaced Clavicle Fracture

For adults with displaced midshaft clavicle fractures, surgical treatment is recommended when shortening exceeds 1.5cm or displacement is greater than 100% (no cortical contact), as this approach provides higher union rates, better early functional outcomes, and reduces the risk of symptomatic nonunion from 15% to approximately 3%. 1

Initial Assessment and Decision Algorithm

Obtain upright radiographs to accurately assess displacement, as supine films underestimate the true degree of displacement. 1

Key Decision Points:

Surgical indications include: 1

• Shortening exceeding 1.5cm
• Displacement >100% with no cortical contact between fragments
• Displaced lateral fractures with coracoclavicular ligament disruption

Conservative management is appropriate for: 1

• Non-displaced or minimally displaced fractures
• Fractures without significant shortening

Surgical Treatment Options

When surgery is indicated, you have two equivalent options:

Plate fixation: 1

• Use manufacturer-contoured anatomic clavicle plates (lower rates of implant removal/deformation)
• Anterior inferior plating preferred over superior plating (lower hardware removal rates)
• Better for comminuted fractures

Intramedullary nailing: 1

• Provides equivalent long-term outcomes to plate fixation
• Similar complication rates
• Suitable for simple fracture patterns

Conservative Management Protocol

For non-displaced fractures: 1

• Use a simple sling (NOT figure-of-eight brace)
• Slings are the preferred immobilization method per AAOS guidelines

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

Evidence Supporting Surgical Intervention

The shift toward surgery for displaced fractures is based on:

• Nonunion rates: Conservative treatment of widely displaced fractures results in nonunion rates up to 15%, compared to approximately 3% with surgery 2, 1
• Early functional recovery: Surgery provides better patient-reported outcomes in the first year and faster return to work 2, 1
• Symptomatic malunion: Conservative treatment leads to malunion rates of 11.3% versus 1.2% with surgery 3

Important caveat: Long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches, so the primary benefit of surgery is faster recovery and reduced risk of nonunion/symptomatic malunion. 1

Special Populations

Adolescents (≤18 years): 4

• Nonsurgical management is generally preferred as primary treatment
• Surgery has not demonstrated significant benefits over conservative management in this age group
• High rates of subsequent hardware removal procedures
• Surgical indications limited to: open fractures, polytrauma requiring early mobilization, or severely displaced fractures with >1.5cm shortening

Young children (under 2 years): 5

• Simple sling immobilization
• Surgery not indicated
• Must evaluate for non-accidental trauma if no clear fall history

Risk Factors for Poor Outcomes

Smoking significantly increases nonunion rates and leads to inferior clinical outcomes - counsel patients on cessation. 1

Postoperative Management

Sling use and progression: 1

• Discontinue sling by 4 weeks for routine activities
• Avoid lifting, pushing, or pulling until 4 weeks
• Full weight-bearing activities allowed at 8-12 weeks based on radiographic healing

Rehabilitation protocol: 1

• Cryotherapy immediately postoperatively through first week
• Isometric strengthening at 4-6 weeks (non-weight-bearing)
• Combined strength and neuromuscular control exercises at 6-12 weeks
• Confirm >90% strength symmetry and full pain-free ROM before return to heavy labor or contact sports

Common Pitfalls

Surgical complications to anticipate: 1, 3

• Hardware removal for discomfort (10.2% of surgical patients)
• Infection (3.2% in surgical group only)
• Wound dehiscence

Conservative treatment complications: 1, 3

• Symptomatic malunion (11.3%)
• Symptomatic nonunion (11.6%)
• Cosmetic deformity
• Longer time to return to work

Urgent Orthopedic Referral Criteria

Refer urgently for: 1

• Displacement >100% (no cortical contact)
• Open fractures
• Neurovascular compromise
• Polytrauma patients