How should I manage an isolated minimally displaced mid‑shaft clavicle fracture with intact neurovascular status seen on a shoulder X‑ray?

Management of Minimally Displaced Mid-Shaft Clavicle Fracture

For an isolated minimally displaced mid-shaft clavicle fracture with intact neurovascular status, treat with a simple sling for immobilization and pursue nonsurgical management. 1

Initial Imaging and Assessment

• Obtain upright radiographs (anteroposterior views in internal and external rotation plus axillary or scapula-Y view) as they better demonstrate the true degree of displacement compared to supine films. 2, 1
• Measure fracture displacement and shortening carefully on upright films to guide treatment decisions. 1
• Confirm neurovascular status is intact clinically before proceeding with conservative management. 2

Immobilization Method

• Use a simple sling rather than a figure-of-eight brace as the preferred immobilization method for acute clavicle fractures. 1
• The American Academy of Orthopaedic Surgeons specifically recommends against figure-of-eight bracing in favor of sling immobilization. 1

When Nonsurgical Management is Appropriate

Nonsurgical management is the correct choice for minimally displaced fractures because:

• Non-displaced or minimally displaced fractures can be managed successfully without surgery. 1
• The nonunion rate for minimally displaced fractures treated conservatively is very low. 3
• Long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches for fractures without significant displacement. 1

Red Flags Requiring Orthopedic Referral

You must refer urgently for orthopedic consultation if any of these features are present:

• Displacement >100% (no cortical contact between fragments). 1
• Shortening exceeding 1.5 cm, which is an indication for surgical treatment in adults. 1
• Open fracture. 4
• Vascular compromise on examination. 2
• Polytrauma requiring early mobilization. 4

Common Pitfall to Avoid

Do not use supine radiographs alone to assess displacement, as they underrepresent the degree of malalignment and shortening. 2, 1 Always obtain upright films for accurate assessment, as this directly impacts the decision between conservative and surgical management.

Additional Considerations

• Do not use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management, as it does not accelerate healing or reduce nonunion rates. 1
• Counsel patients who smoke that smoking increases nonunion rates and leads to inferior clinical outcomes. 1
• For minimally displaced fractures managed conservatively, the risk of symptomatic nonunion or malunion remains low, unlike significantly displaced fractures where these complications can reach 15%. 1

Follow-up Protocol

• Schedule orthopedic follow-up within 1-2 weeks to reassess fracture position and ensure appropriate healing trajectory. 1
• Monitor for signs of nonunion or symptomatic malunion (persistent pain, functional limitation, progressive deformity beyond 12 weeks). 1
• Most patients can discontinue sling use by 4 weeks for routine activities while avoiding lifting, pushing, or pulling. 1