Approach

​Physical examination and radiographic assessments are the main factors that guide the management of clavicle fractures. The goals of treatment are:

  • Optimisation of fracture healing, whether via surgical or conservative management

  • Restoration of shoulder function, strength, and range of motion.

Neurovascular injury can be caused by the fracture fragments themselves, by traction injury, or even via direct blunt trauma to the shoulder or upper extremity from the inciting injury. A difference in blood pressure or pulses between the injured and contralateral (uninjured) upper extremity should prompt expeditious evaluation with arteriography (e.g., CT angiogram) or duplex ultrasound.[42]​ Indications for emergency surgical evaluation include open fracture, respiratory or haemodynamic compromise, and signs of neurovascular injury of the involved upper extremity.

For all clavicle fractures, provide adequate analgesia. The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). In adults or children, give oral paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), and consider an opioid for the acute presentation in the accident and emergency department. Parenteral morphine sulfate is generally required in patients involved in a high-energy trauma. Consider opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for non-medical use).[43]​ The American Academy of Orthopaedic Surgeons (AAOS) notes in its guideline on managing distal radial fractures that opioid alternatives, both pharmacological (such as local anaesthetics, NSAIDs, and paracetamol) and non-pharmacological (such as ice, elevation, compression, and cognitive therapies) should be considered where possible.[43]​

Acute fractures are typically associated with a few days of moderate to severe pain. Fracture pain should decrease with time and initial sling immobilisation.

Open fractures

Open fractures have an associated skin injury, usually a small skin perforation or more significant abrasions (e.g., ‘road rash’) in which probing of the wound demonstrates communication of the wound with the fracture site. Open fractures require surgical irrigation and debridement due to the risk of infection, as well as open reduction and internal fixation. The AAOS recommends that patients with open fractures are brought to the operating room for irrigation and debridement as soon as possible, and ideally less than 24 hours after the injury has occurred.[44]​ A thorough neurovascular examination pre- and post-operatively is essential. 

The patient should receive prophylactic antibiotics as soon as possible.[44][45]​​​ Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.[44]​ The AAOS recommends giving antibiotic prophylaxis for patients undergoing surgery with systemic cefazolin or clindamycin, except for type III (and possibly type II) open fractures (according to the Gustilo-Anderson classification), for which additional gram-negative coverage is preferred.[44]​ However, local sensitivities and protocols should be followed for antibiotic selection. In patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial, when available.[44]​

Tetanus toxoid immunisation should be administered based on patient vaccination history, date of most recent vaccination, and open wound characteristics (e.g., size, degree of contamination).[46]​ 

Midshaft clavicle fractures

The majority (80%) of clavicle fractures are midshaft fractures.[9][47]​​ Other than urgent factors such as an open fracture, any respiratory or haemodynamic compromise, or neurovascular injury, the main considerations guiding non-operative versus operative management of a clavicle fracture are:

  • Fracture location

  • Displacement

    • Displacement is common in midshaft clavicle fractures, due to the force of the sternocleidomastoid on the medial fragment opposing the forces of the pectoralis major and deltoid muscles on the lateral fracture fragment.[48]​ The net effect is displacement of the ends of the fracture, with the lateral fragment lower than the medial fragment. 

  • Shortening

    • Shortening is caused by the pectoralis major, anterior deltoid, the trapezius, and latissimus dorsi muscles pulling the shoulder girdle, and these effects can be exacerbated by a loss of bony length due to comminution (multiple smaller fracture fragments) or fracture pattern obliquity.[49]

  • Patient goals and activity levels

  • Any contraindications to surgery.

Non-displaced fractures

Non-displaced fractures are typically treated conservatively, with oral analgesia as required, a shoulder sling for comfort, and limitations on initial activity and weight bearing. Initial immobilisation in a shoulder sling for 2 to 3 weeks is recommended, followed by gradual return to range of motion.[25]​ In most cases, the consensus is that a sling is preferred for immobilisation over a figure-of-eight brace.[35]​​ Figure-of-eight braces have been used for immobilisation, but are described as less comfortable and have shown no benefit over a simple shoulder sling.[6][25]​​​​ 

Repeat physical exam and imaging are often obtained to evaluate for interval displacement and to reassess potential indications for operative management.

The sling may be discontinued and activity resumed as pain allows.

Displaced fractures

Consider operative or non-operative treatment for displaced midshaft clavicle fractures in adult patients, as the long-term patient-reported outcomes and patient satisfaction levels are similar for both.[35]​​ However, surgical treatment in adults is associated with higher union rates and better early patient-reported outcomes than non-operative treatment.[35]​​ Fractures with initial shortening greater than 2 cm have been associated with a higher risk of non-union or delayed union and worse clinical outcomes, including reduced shoulder endurance, reduced functional scores, ongoing pain, decreased external rotation and abduction strength, and long-term weakness in the affected shoulder in some studies.[6][7]​​​​[48][50][51][52][53][54][55]​​​​ 

Operative treatment of displaced midshaft clavicle fractures can lead to improved short-term functional outcomes, increased patient satisfaction, lower non-union rates, and earlier healing and return to sports, as compared with conservative treatment.[25][47]​ However, long-term functional outcomes and patient reported satisfaction have been reported to be similar when comparing operative and non-operative treatment.[7][56][57][58][59]​

Patients with displaced midshaft clavicle fractures should be evaluated by an orthopaedic surgeon as soon as possible (in the author’s opinion, standard practice would be within 1-2 weeks) to review treatment options. Base the treatment decisions on patient factors, such as functional goals and activity levels as well as clinical aspects, such as the injury characteristics.[9]

Open reduction and internal fixation with plates and screws are generally considered standard surgical methods for treatment of displaced midshaft clavicle fractures, with other options including intramedullary devices.[25][35]​​ Contemporary fixation with two mini-fragment locking plates in orthogonal planes (i.e., anterior and superior) allows for rigid fixation, early motion, and low risk of symptomatic hardware in the future.

Intramedullary fixation is often reserved for simple fracture patterns: transverse (the plane of fracture is orthogonal to the long axis of the clavicle), displaced, and length stable, with no comminution and no significant obliquity to the fracture lines.

In general, adults should delay return to contact sports for 4-5 months to allow for fracture healing, however successful return to high level contact sports has been described in about 2 months for operatively treated clavicle fractures, and 3 months for non-operative injuries.[60][61][62]

Children

In children, midshaft clavicle fractures are common injuries occuring due to a fall on an outstretched hand or direct trauma to the anterior shoulder. In children, the periosteal sleeve is thick and protects the bony cortex of the clavicle.[63]​ The bone is also more pliable in younger patients, leading to low incidence of fracture displacement in young children, with increasing incidence of fracture displacement in older children. The evaluating physician should be aware that clavicle fractures in younger patients may appear unimpressive radiographically due to the lack of bony ossification, but still have significant clinical deformity on examination, due to periosteal sleeve avulsion. Children have a lower incidence of neurovascular complications associated with clavicle fractures than adults.[64]​​ 

In children, clavicle fractures are managed with initial immobilisation in a sling, followed by return to active range of motion of the affected shoulder as comfort allows, usually within 2-3 weeks. Clavicle fractures in children up to 15 years of age, whether displaced or non-displaced, heal clinically when managed non-operatively, with resolution of pain and return of full function expected at a mean of 6 weeks.​[64] 

In general, clavicle fractures in adolescents (<18 years) are managed using the same principles as for adult injuries, with surgical fixation considered for displaced fractures.[35][65][66]​​​ A systematic review and meta-analysis investigating operative versus non-operative management of displaced midshaft clavicle fractures in paediatric and adolescent patients found that both operative and non-operative management provided excellent rates of union and patient-reported outcome measures.[67]​ Operative management led to a faster return to activity compared to non-operative management; however it also had higher complication rates.[67]​ 

The indications for urgent surgery previously described (vascular injury, skin tenting, open fracture) generally apply to both adults and children. However, without these injury complications, the higher remodelling potential in children can result in more predictable healing of non-operatively treated displaced clavicle fractures. Studies have demonstrated reliable healing and return to full activity in children with non-operatively treated clavicle fractures.[12][14][68]

The vast majority of clavicle fractures in adolescents are treated non-operatively. Individualised evaluation and treatment in consultation with an orthopaedic/sports medicine specialist is advised for significantly displaced/shortened fractures. Choose treatment options on an individual patient basis, considering the benefits and harms, and patient preference.[47]

Distal clavicle fractures

Distal clavicle fractures comprise 20% to 30% of all clavicle fractures, but this fracture pattern has been associated with non-union rates of 10% to 44%.[69]​

The Neer classification divides distal clavicle fractures into three types based on the relationship of the fracture line to the coracoclavicular ligaments and acromioclavicular joint.[2]​ Type I and III fractures occur distal to the coracoclavicular ligaments, while type II fractures occur proximal to or between the two coracoclavicular ligaments. See Classification. 

Neer type II distal clavicle fractures are inherently less stable than types I and III. Neer type I and III fractures are typically non-displaced and ultimately result in appropriate bony healing with non-surgical management. Neer type II fractures are often displaced.[2]​ Non-operative management of these fractures tends to lead to a higher rate of non-union compared to when operative management is performed. Non-union, defined by Neer as lack of bony bridging for more than 12 months after injury, following non-surgical management of type II fractures has been reported to occur in 28% to 44% of patients, but the clinical significance of this has been questioned.[69]​ Studies have followed cohorts of patients with displaced distal clavicle fractures initially treated non-operatively, and have noted that some patients with non-union have symptoms severe enough to warrant delayed surgical intervention, while others with non-union remain asymptomatic without significant effects on functional outcome or strength.[70][71][72][73]​ As a result, the optimal management of displaced distal clavicle fractures remains controversial. The consensus of the work group for the 2022 "Treatment of clavicle fractures" clinical practice guideline is that displaced lateral fractures with disruption of the coracoclavicular ligament complex may benefit from operative repair.[35]​​

Multiple surgical techniques have been described for operative treatment of displaced distal clavicle fractures, including fixation with a hook plate, a tension band construct, a modified Weaver-Dunn procedure, and arthroscopic assisted coracoclavicular fixation with or without coracoclavicular ligament repair or reconstruction.[9][69]​​​​ In the setting of distal clavicle fractures, if a hole is drilled into the coracoid, the smaller the hole the better, as drilling a hole into the coracoid is associated with a higher risk of coracoid fracture. Some of these surgical treatment techniques require hardware removal after the initial stages of healing, while others do not. Where wires are used, there is a risk of hardware migration into the adjacent vital soft tissue structures.[60]

As with midshaft clavicle fractures, patients with displaced distal clavicle fractures should be evaluated by an orthopaedic surgeon shortly after injury (in the author’s opinion, standard practice would be within 1-2 weeks).

Non-displaced distal clavicle fractures in children and adolescents are treated conservatively. Significantly displaced fractures would merit operative consideration.

Medial clavicle fractures

Medial clavicle fractures are rare injuries. They were originally thought to comprise about 3% of all clavicle fractures; however the incidence could be as high as 10%.[11][74][75]​​​​ These are almost always treated non-operatively, with initial sling immobilisation for comfort followed by early range of motion as pain allows.[3][25]​​[60]

Medial clavicle fractures usually have anterior or superior displacement.[75]​ If the fracture displaces posteriorly, it may put vital mediastinal structures at risk, and referral for emergency surgical intervention is indicated. Indications for operative fixation of displaced medial clavicle fractures have been described as open fracture, extensive soft tissue damage, neurovascular impairment, and symptomatic mal- and non-unions.[60]

Various techniques, using plates and sutures, have been described for surgical fixation of medial clavicle fractures, with some methods requiring a second operation for hardware removal.[60][75][76]

Children and young people

The clavicle is the last bone in the human body to complete fusion, and the medial epiphysis of the clavicle does not ossify until 20 years of age, with ossification centres rarely fusing before 25 years.[77]​ For this reason, most medial clavicle injuries in children and adolescents consist of physeal separations. These have high remodelling potential and are treated non-operatively, but should be differentiated from true sternoclavicular dislocations, especially posterior dislocations, which may require emergency surgical intervention.[78]

Stress fractures

Stress fractures of the midshaft clavicle are extremely rare, but case reports have described their occurrence in high-level athletes.[79]​ No surgical intervention is indicated for these injuries, and they are expected to completely resolve with a period of rest and cessation of any aggravating activities.

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