What is the initial management for a 20-year-old patient with a clavicle fracture?

Management of Clavicle Fracture in a 20-Year-Old

Immobilize the fracture with a simple sling and determine whether surgical intervention is needed based on the degree of displacement, shortening, and fracture location. 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, or proximal third 2, 3
• Assess for displacement (>100% means no cortical contact between fragments), shortening (measure if >1.5cm), and comminution 1

Decision Algorithm: Conservative vs. Surgical Management

Proceed with Conservative (Non-Operative) Management if:

• Non-displaced or minimally displaced fractures 1
• Displacement <100% with cortical contact maintained 1
• Shortening <1.5cm 1

Conservative treatment consists of:

• Simple sling immobilization (NOT figure-of-eight brace, which the American Academy of Orthopaedic Surgeons specifically recommends against) 1
• Multimodal analgesia including NSAIDs and ice application 4
• Discontinue sling by 4 weeks for routine activities, but avoid lifting/pushing/pulling 1
• Full weight-bearing activities allowed at 8-12 weeks based on radiographic healing 1

Refer for Urgent Orthopedic Consultation if:

• Displacement >100% (no cortical contact between fragments) 1
• Shortening >1.5cm in midshaft fractures 1
• Displaced lateral fractures with coracoclavicular ligament disruption 1
• Comminuted fractures 2
• Open fractures 5
• Associated neurovascular compromise 6

Surgical Options When Indicated

The American Academy of Orthopaedic Surgeons provides clear guidance on surgical techniques:

• Plate fixation using manufacturer-contoured anatomic clavicle plates (lower rates of implant removal/deformation) 1
• Anterior inferior plating may result in lower implant removal rates compared to superior plating 1
• Intramedullary nailing provides equivalent long-term outcomes to plate fixation with similar complication rates 1

Evidence Supporting Surgical Intervention in Young Adults

For a 20-year-old with a displaced midshaft fracture, the American Academy of Orthopaedic Surgeons reports that surgical treatment provides higher union rates and better early patient-reported outcomes compared to conservative management 1. Specifically:

• Conservative management of widely displaced fractures results in nonunion rates up to 15% 1
• Symptomatic malunion rates: 11.3% conservative vs. 1.2% surgical 1
• Symptomatic nonunion rates: 11.6% conservative vs. 3% surgical 1
• Faster return to work with surgical treatment 1

However, long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches 1, so the decision hinges on early functional recovery priorities and fracture characteristics.

Critical Pitfalls to Avoid

• Do not use figure-of-eight bracing – the American Academy of Orthopaedic Surgeons specifically recommends slings instead 1
• Do not use low-intensity pulsed ultrasonography (LIPUS) – it does not accelerate healing or reduce nonunion rates 1
• Counsel about smoking cessation – smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Do not miss urgent surgical indications – fractures with >100% displacement require prompt orthopedic referral 1

Pain Management Considerations

While the elderly trauma guidelines emphasize regional anesthesia techniques 4, for a healthy 20-year-old with an isolated clavicle fracture, standard multimodal analgesia with NSAIDs, acetaminophen, and ice application is appropriate 4. Reserve opioids for severe pain in the first few days only.