From the Guidelines
Surgical treatment is recommended for displaced clavicle fractures in adult patients, as it is associated with higher union rates and better early patient-reported outcomes than nonsurgical treatment. This is based on the most recent and highest quality study, which suggests that surgical treatment of displaced midshaft clavicle fractures in adult patients is associated with higher union rates and better early patient-reported outcomes than nonsurgical treatment 1.
Key Considerations
- The American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures recommends surgical treatment for displaced midshaft clavicle fractures in adult patients, with a strong strength of recommendation 1.
- Surgical treatment may provide a faster functional and radiographic recovery, allowing for earlier return to work, which is particularly relevant given that clavicle fractures typically affect healthy, active adults 1.
- Nonsurgical management of widely displaced fractures often results in malunions, which may have adverse effects on strength and function of the shoulder, in addition to being cosmetically unacceptable 1.
Treatment Approach
- For most cases, treatment usually involves a sling or figure-of-eight brace for 2-6 weeks to immobilize the area while it heals.
- Pain management includes acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for the first 1-2 weeks.
- Ice application for 15-20 minutes several times daily helps reduce swelling and pain.
- Gentle range-of-motion exercises can begin after acute pain subsides, usually around 2 weeks, with gradual return to normal activities as pain allows.
- Full contact sports should be avoided until complete healing occurs, typically 3-4 months post-injury.
Surgical Intervention
- Surgical intervention is more commonly needed for fractures with significant displacement, shortening, or when the bone pierces the skin (open fracture), as these have higher risks of nonunion or malunion if treated conservatively.
- Described surgical techniques include plate osteosynthesis, either with one or two plates and/or with plates positioned superiorly or anteriorly, or intramedullary fixation 1.
From the Research
Clavicle Fracture Overview
- Clavicle fractures are among the most common fractures seen by family physicians, with common mechanisms of injury including a fall on an outstretched hand or direct trauma to the bone 2.
- These fractures can be classified into different types based on their location, with the middle third of the clavicle being the most common site for fractures 2, 3.
Treatment Options
- Nondisplaced fractures are typically treated conservatively with immobilization using a sling or figure-of-8 bandage 2, 4.
- Displaced fractures, especially in young and active patients, may require operative treatment to prevent non-union or malunion 3, 4, 5.
- The treatment approach may vary depending on the location of the fracture, with medial, shaft, and lateral clavicle fractures having different treatment algorithms 4.
Management Considerations
- The history and physical examination remain the primary means of diagnosing clavicle fractures, with plain radiographs helpful in confirming the diagnosis and providing information on fracture classification and treatment options 5.
- Emergency physicians should understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, and be able to identify associated injuries and determine when expert orthopedic consultation or referral is indicated 6.
- Pediatric fractures are generally managed conservatively, while adolescents older than 9 years-old for girls and 12 years-old for boys may be treated using algorithms similar to adults 6.
Referral Guidelines
- Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries 6.
- Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder 6.