What is the recommended management for an isolated mid‑shaft clavicle fracture in an otherwise healthy adult?

Management of Isolated Mid-Shaft Clavicle Fracture in Adults

Initial Assessment and Imaging

Obtain upright radiographs (not supine films) to accurately assess displacement and shortening, as upright views better demonstrate the true degree of fracture severity 1, 2.

Measure and document the following critical parameters:

• Displacement: >100% displacement means no cortical contact between fragments 2
• Shortening: Measure if >1.5 cm present 1, 2
• Comminution: Document presence and severity 2

Treatment Algorithm: Conservative vs. Surgical Decision-Making

Conservative Management Indications

Proceed with nonsurgical treatment for 1, 2:

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

Conservative treatment consists of simple sling immobilization (NOT figure-of-eight brace), as the American Academy of Orthopaedic Surgeons specifically recommends slings over figure-of-eight braces 1, 2.

Conservative Management Protocol:

• Apply sling immediately with multimodal analgesia (NSAIDs, acetaminophen, ice) 2
• Discontinue sling by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 1
• Allow full weight-bearing activities at 8-12 weeks based on radiographic healing 1, 2
• Do NOT use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing or reduce nonunion rates 1

Critical Caveat for Conservative Management:

Be aware that conservative management of widely displaced fractures carries significant risks 1, 2:

• Nonunion rates up to 15% (vs. 3% with surgery)
• Symptomatic malunion rates of 11.3% (vs. 1.2% with surgery)
• Symptomatic nonunion rates of 11.6% (vs. 3% with surgery)
• Longer time to return to work

Monitor pain trajectory closely: if pain shows minimal or no decrease from week 2 to week 4 (VASratio >0.6), this indicates an 18-fold increased risk of symptomatic nonunion and warrants surgical consultation 3.

Surgical Management Indications

Surgical treatment is indicated for 1, 2:

• Displacement >100% (no cortical contact between fragments)
• Shortening exceeding 1.5 cm
• Open fractures
• Polytrauma patients requiring early mobilization
• Displaced lateral fractures with coracoclavicular ligament disruption

Evidence Supporting Surgery in Appropriate Cases:

For displaced midshaft fractures meeting surgical criteria, operative treatment provides higher union rates and better early patient-reported outcomes compared to conservative management 1, 2. However, long-term outcomes (beyond 1 year) are similar between approaches 1.

Surgical Options

When surgery is indicated, choose between 1, 2:

Plate Fixation:

• Use manufacturer-contoured anatomic clavicle plates (lower implant removal/deformation rates) 1
• Anterior inferior plating preferred over superior plating (lower implant removal rates) 1
• Better option when significant comminution present 4

Intramedullary Nailing:

• Provides equivalent long-term outcomes to plate fixation with similar complication rates 1, 4

Special Considerations and Risk Factors

Smoking significantly increases nonunion rates and leads to inferior clinical outcomes—counsel patients strongly on cessation 1.

Common Pitfalls to Avoid

• Do NOT use figure-of-eight braces (slings are superior) 1, 2
• Do NOT obtain only supine radiographs (upright views are essential) 1, 2
• Do NOT ignore minimal pain improvement at 4 weeks (strong predictor of nonunion requiring surgical intervention) 3
• Do NOT use LIPUS therapy (ineffective and not recommended) 1
• Do NOT underestimate nonunion risk in displaced fractures (up to 15% with conservative treatment) 1, 2