AAOS 2023 Recommendations for Orthopedic Referral of Clavicular Fractures

Indications for Surgical Referral in Adults

• Displaced midshaft clavicle fractures in adults should be referred to orthopedic surgery for possible operative fixation because surgery yields significantly higher union rates and lower non‑union risk (≈15 % with non‑operative care) compared with conservative management. Strong recommendation (AAOS). 1
• Fractures with >2 cm shortening are associated with non‑union rates up to 15 % and functional deficits; these patients merit surgical evaluation. Strong recommendation (AAOS). 1
• Unstable distal (lateral) clavicle fractures that involve disruption of the coracoclavicular ligament complex should be considered for operative repair due to inherent instability. Strong recommendation (AAOS). 2

Evidence of Clinical Benefits of Operative Management

• Operative fixation of displaced midshaft fractures provides higher radiographic union rates and reduces the incidence of symptomatic malunion, leading to better early shoulder strength. Strong recommendation (AAOS). 1
• Patients undergoing surgery report superior early patient‑reported outcomes (e.g., DASH and Constant scores) during short‑term follow‑up. Strong recommendation (AAOS). 1
• Surgical treatment enables a faster return to work or sport for active laborers and athletes, offering a functional advantage in the early recovery period. Strong recommendation (AAOS). 1

Patient‑Specific Factors Lowering the Threshold for Referral

• Active laborers or athletes who need rapid return to occupational or athletic activities are advised to consider operative management. Strong recommendation (AAOS). 1
• Individuals who prioritize cosmetic results (to avoid prominent malunion) may benefit from surgical alignment of the clavicle. Strong recommendation (AAOS). 1
• Current tobacco users have an increased risk of non‑union when treated non‑operatively, supporting a lower threshold for surgical referral. Strong recommendation (AAOS). 3
• Patients unable to tolerate a prolonged period of immobilization or delayed functional recovery should be offered operative fixation to expedite rehabilitation. Strong recommendation (AAOS). 1

Imaging and Assessment Pitfalls

• Supine radiographs can underestimate true displacement; upright or stress views are recommended to accurately assess fracture displacement before deciding on management. Strong recommendation (AAOS). 4

Special Considerations for Adolescents (≤ 18 years)

• In adolescents with displaced midshaft clavicle fractures, operative treatment does not demonstrate a clear advantage over non‑operative care; union rates are comparable between the two approaches. Strong recommendation (AAOS). 4
• Surgical management in adolescents carries a notable rate of revision surgery for implant removal, which should be weighed against the lack of functional benefit. Strong recommendation (AAOS). 4
• The same emergent indications that mandate urgent surgical consultation in adults (e.g., open fracture, neurovascular injury, skin tenting) apply to adolescents and should prompt immediate referral. (derived from clinical consensus, not a cited fact)

All facts are derived from the 2023 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines and reflect the strength of evidence as indicated.

Management of Displaced Midshaft Clavicle Fractures in Adults

Anatomical Deformity

Indications for Surgical vs. Non‑Surgical Care

Surgical Techniques

Expected Complications with Conservative Management

Management of Displaced Midshaft Clavicle Fractures

Assessment & Imaging

• Upright (standing) radiographs should be obtained rather than supine views because supine films systematically underestimate true fracture displacement, allowing more accurate classification and treatment planning. 9

• Lateral/distal clavicle fractures frequently involve disruption of the coracoclavicular ligament complex, which influences stability and the need for operative repair. 9

Indications for Surgical Referral (Adults)

• Displaced midshaft fractures: Surgical fixation is strongly recommended for displaced midshaft fractures in adults because it reduces the non‑union rate from roughly 15 % to less than 5 % and yields superior early functional recovery, while long‑term outcomes remain comparable to non‑operative care. (High‑level evidence) 10, 11

• Severe displacement or shortening: Fractures with >100 % displacement (no bony contact) or >2 cm shortening are associated with a ~15 % non‑union risk and functional deficits, supporting operative management. (Evidence level not specified) – citation embedded in the above operative recommendation.

• Unstable lateral fractures: Presence of coracoclavicular ligament disruption in lateral clavicle fractures constitutes an indication for surgical repair. 9

• Patient‑related factors:

  • Active laborers or athletes benefit from surgery because it enables a faster return to work or sport. (Moderate evidence) 11
  • Current tobacco users have a higher risk of non‑union when treated conservatively, favoring operative fixation. (Moderate evidence) 9

Surgical Techniques

• Plate fixation – A single plate placed either superiorly or anteriorly is the standard operative approach and provides long‑term outcomes equivalent to intramedullary nailing. (Level I–II evidence) 9

• Anterior‑inferior plating may lower the need for later implant removal compared with superior plating. (Moderate evidence) 9

• Pre‑contoured anatomic plates are associated with fewer implant‑related complications (removal or deformation) than non‑contoured plates. (Moderate evidence) 9

• Plate fixation is preferred when the fracture exhibits significant comminution, ensuring stable construct. (Moderate evidence) 9

• Intramedullary fixation offers clinical outcomes and complication rates comparable to plate fixation, but is less suitable for highly comminuted fractures. (Moderate evidence) 9

Non‑operative Management

• Immobilization – A simple sling is preferred over a figure‑of‑eight brace for better patient comfort and adherence. (Moderate evidence) 9

• Union expectations – Non‑operative treatment of displaced midshaft fractures carries an approximate 15 % non‑union rate. (Level II evidence) 11

• Recovery timeline – Conservative care results in a slower return to occupational or athletic activities compared with surgical treatment. (Moderate evidence) 11

• Long‑term function – After one year, functional outcomes are similar between operative and non‑operative groups. (High‑level evidence) 10, 11

• Adjunctive therapy – Low‑intensity pulsed ultrasound (LIPUS) should not be used for acute midshaft clavicle fractures because it does not accelerate healing or reduce non‑union rates. (Moderate evidence) 9

Special Population: Adolescents (≤ 18 years)

• In adolescents with displaced midshaft clavicle fractures, surgical treatment provides no clear advantage over non‑operative management; union rates are comparable, while surgery carries a substantial revision rate for implant removal. (Moderate evidence) 9

Adjunctive Care

• Smoking cessation counseling is essential for all patients, as tobacco use increases non‑union risk and leads to inferior clinical outcomes. (Moderate evidence) 9