What is the recommended initial evaluation and management for a hemodynamically stable patient with a minimally displaced right clavicle fracture and no neurovascular compromise?

Initial Evaluation and Management of Minimally Displaced Right Clavicle Fracture

For a hemodynamically stable patient with a minimally displaced right clavicle fracture and no neurovascular compromise, obtain upright radiographs in three views (AP internal/external rotation and axillary or scapula-Y), immobilize in a simple sling, and initiate conservative management with multimodal analgesia. 1, 2

Initial Imaging Protocol

Obtain upright radiographs rather than supine films to accurately assess true displacement and shortening, as supine positioning underrepresents the degree of malalignment. 1, 2 The standard trauma shoulder series must include:

• Anteroposterior views in both internal and external rotation 3
• Axillary or scapula-Y view (vital to avoid misclassifying acromioclavicular or glenohumeral dislocations that can appear aligned on AP views alone) 3

Critical pitfall: Initial supine chest radiographs obtained during trauma evaluation frequently underestimate displacement. In high-energy trauma patients, 60% of fractures appearing minimally displaced on supine chest X-rays progress to >100% displacement on follow-up. 4 Therefore, dedicated upright clavicle radiographs should be obtained on the day of presentation, not just supine trauma films. 4

Radiographic Assessment for Treatment Decision

Measure and document the following on upright films:

• Displacement: Minimally displaced means cortical contact is maintained between fragments (<100% displacement) 1, 2
• Shortening: Measure if >1.5cm, as this threshold indicates surgical consideration 1, 2
• Comminution: Document presence, as this affects prognosis 5

For minimally displaced fractures with maintained cortical contact and shortening <1.5cm, conservative management is appropriate. 1, 2

Conservative Management Protocol

Immobilization:

• Use a simple sling, not a figure-of-eight brace, as the American Academy of Orthopaedic Surgeons recommends slings as the preferred immobilization method 1, 2
• Discontinue sling by 4 weeks for routine activities, but continue avoiding lifting, pushing, or pulling with the affected arm 1
• Allow full weight-bearing activities at 8-12 weeks based on radiographic healing 1, 2

Pain Management:

• Multimodal analgesia with NSAIDs and acetaminophen 2
• Ice application in the acute phase 1, 2

Follow-up Schedule

Early follow-up within 2 weeks is critical, particularly after high-energy mechanisms, as fractures can displace secondarily. 4 Schedule:

• 1-2 weeks: Repeat radiographs to assess for interval displacement 1
• 4 weeks: Clinical and radiographic assessment 1
• 3 months and 6 months: Monitor for healing and complications 1

Red Flags Requiring Urgent Orthopedic Consultation

Refer immediately if any of the following develop:

• Displacement progresses to >100% (no cortical contact between fragments) 1
• Shortening exceeds 1.5cm 1
• Open fracture 6
• Neurovascular compromise develops 3
• Polytrauma requiring early mobilization 6

Expected Outcomes and Patient Counseling

For minimally displaced fractures treated conservatively:

• Union rates are excellent when displacement is minimal 3, 1
• Long-term patient-reported outcomes at >1 year are similar to surgical treatment 3, 1

However, counsel patients that if displacement is actually greater than initially appreciated:

• Nonunion rates can reach 15% with widely displaced fractures treated conservatively 1, 2
• Symptomatic malunion occurs in 11.3% versus 1.2% with surgery 1, 2
• Time to return to work is longer with conservative management 3, 1

Risk factors that worsen outcomes:

• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes 1
• Displacement >1 bone width is the strongest predictor of persistent symptoms at 6 months 5
• Higher age and comminution increase risk of symptoms remaining at 6 months 5

Rehabilitation Progression

• Weeks 0-4: Sling immobilization, gentle pendulum exercises as tolerated 1
• Weeks 4-6: Begin isometric strengthening exercises for shoulder girdle muscles (non-weight-bearing) 1
• Weeks 6-12: Progress to combined strength training with neuromuscular control exercises 1
• Before return to heavy labor or contact sports: Confirm full range of motion without pain and shoulder strength >90% symmetry compared to contralateral side 1