What is the appropriate management for an acute clavicle fracture in an otherwise healthy adult?

Management of Acute Clavicle Fractures in Adults

For most acute clavicle fractures in healthy adults, initial treatment with simple sling immobilization is appropriate, but surgical fixation should be strongly considered for displaced midshaft fractures with >1.5cm shortening or >100% displacement (no cortical contact), as these provide higher union rates and better early functional outcomes. 1, 2

Initial Assessment and Imaging

• Obtain upright radiographs (not supine) with at least three views: anteroposterior in internal and external rotation plus an axillary or scapula-Y view, as upright films better demonstrate true displacement and shortening 3, 1, 2
• Measure specific fracture characteristics: displacement (>100% means no cortical contact between fragments), shortening (>1.5cm is significant), and presence of comminution 1, 2
• Assess for open fracture, neurovascular compromise, or polytrauma requiring early mobilization 4

Treatment Algorithm Based on Fracture Pattern

Non-displaced or Minimally Displaced Fractures

Conservative management is appropriate and effective for these fractures. 1, 2

• Use a simple sling (not figure-of-eight brace) as the preferred immobilization method 1
• Provide multimodal analgesia with NSAIDs, acetaminophen, and ice application 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

Displaced Midshaft Fractures (Shortening >1.5cm or >100% Displacement)

Surgical treatment should be strongly recommended for these fractures in healthy, active adults. 1, 2

The evidence supporting surgery is compelling:

• Union rates: 97% with surgery vs. 85% with conservative treatment 1, 2
• Symptomatic nonunion: 3% with surgery vs. 11.6% with conservative treatment 1, 2
• Symptomatic malunion: 1.2% with surgery vs. 11.3% with conservative treatment 1, 2
• Better early patient-reported outcomes and faster return to work with surgery 1, 2

Displaced Lateral Fractures

• Surgical treatment is recommended when there is disruption of the coracoclavicular ligament complex 1

Surgical Options When Indicated

Plate fixation and intramedullary nailing provide equivalent long-term outcomes with similar complication rates. 1, 4

Plate Fixation

• Use manufacturer-contoured anatomic clavicle plates (lower rates of implant removal or deformation compared to non-contoured plates) 1, 4
• Anterior inferior plating may result in lower implant removal rates compared to superior plating 1, 4
• Plate fixation may be more beneficial when significant comminution is present 4

Intramedullary Nailing

• Provides equivalent outcomes to plating with similar complication rates 1, 4

Critical Caveats and Pitfalls

• Do NOT use low-intensity pulsed ultrasonography (LIPUS) for nonsurgical management—it does not accelerate healing or reduce nonunion rates 1
• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes; counsel patients on cessation 1
• Long-term outcomes (>1 year) are similar between surgical and nonsurgical approaches, though surgery provides faster recovery and earlier return to function 1, 2
• Arrange urgent orthopedic follow-up for fractures with >100% displacement (no cortical contact) 1

Special Populations

Adolescents (≤18 years)

• Nonsurgical management is generally preferred as the primary approach, as surgical treatment has not demonstrated significant benefits and is associated with high rates of hardware removal 4
• Surgery is reserved for open fractures, polytrauma requiring early mobilization, or severely displaced fractures with >1.5cm shortening 4

Neonates and Infants

• For infants ≤10 days old with acute clavicle fracture and no trauma history, skeletal survey appropriateness is uncertain due to possible birth injury 3
• Outside the neonatal period (<24 months), skeletal survey is necessary except in children 12-23 months with a reported fall history 3