What is the appropriate treatment for a patient with a fractured clavicle?

Treatment of Clavicle Fractures

Use a sling for immobilization and determine whether surgical intervention is needed based on fracture location, displacement, and patient age. 1

Initial Assessment and Imaging

• Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and shortening 1
• Classify the fracture by location: midshaft (80% of cases), distal/lateral, or proximal/medial 1, 2
• Measure displacement and shortening on upright films to guide treatment decisions 1

Immobilization Method

• A simple sling is the preferred immobilization method for most acute clavicle fractures, not a figure-of-eight brace 1
• This recommendation applies across all age groups, from young children to adults 1, 3

Nonsurgical Management Indications

Treat conservatively with sling immobilization for: 1

• Non-displaced or minimally displaced fractures of any location 1
• Pediatric patients under 18 years (unless absolute surgical indications exist) 4
• Stable lateral fractures without coracoclavicular ligament disruption 1
• Stable proximal fractures without significant displacement 1

Expected outcomes with nonsurgical treatment: 1

• Excellent healing in non-displaced fractures
• Long-term patient satisfaction similar to surgical treatment (beyond 1 year) 1
• However, displaced fractures carry 15% nonunion risk and 11.3% symptomatic malunion risk with conservative treatment 1

Surgical Indications

Emergent Orthopedic Consultation Required: 2

• Open fractures requiring debridement 4
• Posteriorly displaced proximal fractures (risk of neurovascular compromise) 2
• Associated neurovascular injuries 2

Urgent Orthopedic Referral (Within Days): 1

• Midshaft fractures with >1.5cm shortening 1
• Displacement >100% (no cortical contact between fragments) 1, 2
• Displaced lateral fractures with coracoclavicular ligament complex disruption 1
• Comminuted fractures with significant instability 2
• Polytrauma patients requiring early mobilization 4

Delayed Surgical Consultation: 1

• Symptomatic nonunion or malunion beyond 12 weeks 1
• Persistent pain or functional limitation in active patients 1
• Progressive deformity affecting shoulder strength 1

Surgical Options When Indicated

Plate fixation and intramedullary nailing provide equivalent long-term outcomes with similar complication rates. 1

• Manufacturer-contoured anatomic clavicle plates are preferred over non-contoured plates due to lower implant removal rates 1
• Anterior inferior plating may result in lower hardware removal rates compared to superior plating 1
• Plate fixation may be more beneficial when significant comminution is present 4
• Intramedullary nailing is an equivalent alternative with similar functional outcomes 1

Age-Specific Considerations

Children Under 2 Years: 3

• First determine if skeletal survey is needed to evaluate for non-accidental trauma 3
• Skeletal survey required if: no trauma history, fracture attributed to being hit by toy/object, or uncertain mechanism 3
• Skeletal survey NOT needed if clear fall history exists 3
• Treat with simple sling; surgery not indicated 3
• Refer if displacement >100% 3

Adolescents (≤18 Years): 4

• Nonsurgical management is generally preferred as primary treatment 4
• Surgery has not demonstrated significant benefits over conservative management in this age group 4
• High rates of subsequent hardware removal procedures occur when surgery is performed 4
• Consider surgery only for: open fractures, polytrauma, or severely displaced fractures (>1.5cm shortening) 4

Adults: 1

• Surgical treatment of displaced midshaft fractures provides higher union rates (97% vs 85%) and better early patient-reported outcomes 1
• Faster return to work with surgical treatment 1
• Long-term outcomes (>1 year) are similar between surgical and nonsurgical approaches 1

Critical Pitfalls to Avoid

• Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management—it does not accelerate healing or reduce nonunion rates 1
• Counsel smoking cessation aggressively, as smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Do not overlook non-accidental trauma in young children—always obtain clear mechanism of injury 3
• Do not use supine radiographs for displacement assessment—they underestimate true displacement 1
• Recognize that widely displaced fractures treated conservatively have 15% nonunion risk and 11.6% symptomatic nonunion rate 1

Postoperative Management (If Surgery Performed)

• Apply cryotherapy immediately and continue through first week 1
• Discontinue sling by 4 weeks for routine activities, but avoid lifting/pushing/pulling 1
• Begin isometric shoulder strengthening at 4-6 weeks 1
• Progress to neuromuscular control exercises by 6-12 weeks 1
• Allow full weight-bearing activities at 8-12 weeks based on radiographic healing 1
• Confirm >90% strength symmetry and full pain-free range of motion before return to heavy labor or contact sports 1