Clavicle Fracture Management

Treatment Options

The American Academy of Orthopaedic Surgeons recommends a sling as the preferred immobilization method for most acute clavicle fractures, rather than a figure-of-eight brace 1, 2
Nonsurgical management is appropriate for non-displaced fractures, with the American Academy of Orthopaedic Surgeons citing its effectiveness 2, 3
The American Academy of Orthopaedic Surgeons suggests that upright radiographs are recommended for assessment as they better demonstrate the degree of displacement compared to supine radiographs 1, 4
Low-intensity pulsed ultrasonography (LIPUS) should not be used for nonsurgical management of acute midshaft clavicle fractures, as it does not accelerate healing or reduce nonunion rates, according to the American Academy of Orthopaedic Surgeons 5

Surgical Indications

Surgical treatment is indicated for displaced midshaft fractures in adults with shortening exceeding 1.5cm, as recommended by the American Academy of Orthopaedic Surgeons 2
The American Academy of Orthopaedic Surgeons indicates that surgical treatment is also recommended for displaced lateral fractures with disruption of the coracoclavicular ligament complex 1, 5

Surgical Options

Plate fixation is a surgical option, with manufacturer-contoured anatomic clavicle plates preferred due to lower rates of implant removal or deformation, according to the American Academy of Orthopaedic Surgeons 1, 6
Anterior inferior plating may lead to lower implant removal rates compared with superior plating, as suggested by the American Academy of Orthopaedic Surgeons 7, 6
Intramedullary nailing provides equivalent long-term clinical outcomes to plate fixation with similar complication rates, according to the American Academy of Orthopaedic Surgeons 5, 2

Special Considerations

Smoking increases the rate of nonunion in clavicle fractures and leads to inferior clinical outcomes, as reported by the American Academy of Orthopaedic Surgeons 7, 4
For adults with displaced midshaft clavicle fractures, surgical treatment provides higher union rates and better early patient-reported outcomes, according to the American Academy of Orthopaedic Surgeons 2, 3
Long-term patient-reported outcomes and satisfaction are similar between surgical and nonsurgical approaches, as found by the American Academy of Orthopaedic Surgeons 8, 2

Rehabilitation

Rehabilitation should include muscle strengthening exercises, long-term continuation of appropriate exercises, patient education about pain management strategies, and monitoring for signs of complications requiring medical attention, although a non-preferred source 9

Potential Complications

Nonsurgical treatment of widely displaced fractures may result in higher nonunion rates, symptomatic malunion affecting shoulder strength and function, cosmetic concerns, and longer time to return to work, as reported by the American Academy of Orthopaedic Surgeons 3
Surgical complications may include need for hardware removal, particularly with non-precontoured plates, according to the American Academy of Orthopaedic Surgeons 1, 6

Duration of Sling Use and Weight-bearing Restrictions After ORIF for Clavicle Fracture

Rehabilitation and Weight-bearing

By 4 weeks, most patients can discontinue sling use entirely for routine activities but should continue to avoid lifting, pushing, or pulling with the affected arm, as recommended by the American Academy of Orthopaedic Surgeons 10, 11
Full weight-bearing activities are typically allowed between 8-12 weeks, depending on radiographic evidence of healing and clinical examination, according to the American Academy of Orthopaedic Surgeons 10, 11

Clavicle Fracture Management

Disposition Criteria

The American Academy of Orthopaedic Surgeons recommends urgent orthopedic follow-up for fractures with displacement >100% (no cortical contact between fragments) 12
Surgical treatment of displaced midshaft fractures provides higher union rates and better early patient-reported outcomes compared to conservative management, with a reduction in the risk of symptomatic malunion or nonunion, which can reach 15% with conservative treatment of displaced fractures 13
Nondisplaced or minimally displaced fractures can be managed successfully without surgery, particularly those with minimal displacement 13
The American Academy of Orthopaedic Surgeons suggests that surgery may provide faster recovery and earlier return to work, although long-term outcomes are similar between surgical and nonsurgical treatment 14

Treatment of Subacute and Chronic Clavicle Fractures

Introduction to Treatment Guidelines

The American Academy of Orthopaedic Surgeons strongly recommends surgical treatment for subacute and chronic clavicle fractures with symptomatic nonunion or malunion, particularly in active patients, as these complications significantly impair shoulder function and strength 15

Defining the Timeline and Treatment Algorithm

Chronic fractures (>12 weeks) presenting as symptomatic nonunion or malunion are clear indications for delayed surgical reconstruction 15
The American Academy of Orthopaedic Surgeons reports that nonsurgical treatment of widely displaced fractures results in nonunion rates up to 15% 15

Evaluating Patient Factors for Surgery

Active patients requiring return to work or sport are considered high-priority surgical candidates 16
Patients with significant functional impairment or pain are also considered high-priority surgical candidates 15
The American Academy of Orthopaedic Surgeons provides strong evidence that surgical treatment of displaced clavicle fractures results in higher union rates compared to conservative management 16

Key Evidence Supporting Surgical Intervention

Surgical treatment of displaced clavicle fractures results in better early patient-reported outcomes 16
Surgical treatment of displaced clavicle fractures results in faster time to union, allowing earlier return to work or sport 16
However, long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches 16

Critical Considerations for Surgical Consultation

Patients with persistent pain, functional limitation, or progressive deformity beyond 12 weeks should be referred promptly for surgical consultation 15
Delayed reconstruction becomes more technically challenging as time progresses 15

Postoperative Management of Clavicle Fractures

Pain Management and Rehabilitation

Apply cryotherapy immediately postoperatively and continue through the first week, as recommended by the British Journal of Sports Medicine guidelines 17
Begin isometric strengthening exercises for the shoulder girdle muscles by 4-6 weeks, starting with non-weight-bearing exercises, according to the British Journal of Sports Medicine 17
Combine strength training with neuromuscular control exercises by 6-12 weeks, as suggested by the British Journal of Sports Medicine 17
Assess shoulder strength with isokinetic testing showing >90% symmetry before return to heavy labor or contact sports, as recommended by the British Journal of Sports Medicine 17
Confirm full range of motion without pain or compensatory patterns before return to activity, as advised by the British Journal of Sports Medicine 17

Treatment for Displaced Clavicle Fracture

Evidence Supporting Treatment Options

Conservative management is appropriate for non-displaced or minimally displaced fractures, according to the American Academy of Orthopaedic Surgeons 18
Symptomatic malunion rates are higher with conservative treatment (11.3%) compared to surgery (1.2%) 18
Symptomatic nonunion rates are higher with conservative treatment (11.6%) compared to surgery (approximately 3%) 18
Longer time to return to work is associated with conservative treatment compared to surgery 18

Imaging and Assessment Guidelines for Acute Clavicle Fractures in Adults and Children

Radiographic Evaluation in Adults

The American College of Radiology recommends obtaining upright radiographs (not supine) with at least three views—anteroposterior in internal rotation, anteroposterior in external rotation, and either an axillary or scapula‑Y view—because upright films more accurately demonstrate true displacement and shortening of the fracture. 19

Imaging Considerations in Infants and Young Children

The American Academy of Pediatrics notes that for infants ≤10 days old with an acute clavicle fracture and no history of trauma, the need for a skeletal survey is uncertain due to the possibility of a birth‑related injury. 20
For children younger than 24 months, a skeletal survey is generally required, except in the subgroup aged 12–23 months when the injury is clearly related to a reported fall, in which case the survey may be omitted. 20

Skeletal Survey Indications for Clavicle Fractures in Toddlers (Ages 1–3 Years)

Abuse Screening Recommendations

In toddlers aged 12–23 months who present with an isolated clavicle fracture and a clear history of a fall, a skeletal survey is not required because the mechanism adequately explains the injury【21, 22, 23】.
In toddlers aged 12–23 months with an isolated clavicle fracture without a clear trauma history, a skeletal survey must be performed to evaluate for occult fractures that may indicate non‑accidental trauma【21, 22, 23】.
In children younger than 12 months, a skeletal survey is mandatory for any clavicle fracture, regardless of the reported mechanism, except for rare neonatal birth‑injury scenarios【21, 22, 23】.

Failure to obtain a skeletal survey when indicated is a common pitfall; therefore, any clavicle fracture in a child 12–23 months old without a clear fall history, or in any child under 12 months, should trigger a skeletal survey【23】.