Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

involved in high-energy trauma

1st line – advanced trauma life support (ATLS)

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INITIAL
|
involved in high-energy trauma
1st line – 

advanced trauma life support (ATLS)

High-energy trauma (e.g., due to road traffic accidents) is a common cause of clavicle fracture. Assess for underlying and associated serious injuries using an ABCDE primary trauma survey:[21]​

  • Airway with cervical spine precautions

  • Breathing and ventilation

  • Circulation with hemorrhage control

  • Disability (assess neurologic status)

  • Exposure (ensure no injury is missed) and Environmental control.

Arrange an urgent or emergency specialist consultation for patients with suspected open fracture, respiratory or hemodynamic compromise, or signs of neurovascular injury. Signs of vascular injury include a diminished pulse (versus the contralateral uninjured side), pallor, and/or cool or cold tissues in the affected extremity. Hypotension, tachycardia out of proportion to pain, or a decreased or decreasing level of consciousness imply severe blood loss and shock. However, these signs could also be due to other injuries, such as associated tension pneumothorax or intracranial injury, underlining the great importance of a thorough trauma survey and careful evaluation.

Plus – analgesia + immobilization

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INITIAL
|
involved in high-energy trauma
Plus – 

analgesia + immobilization

Treatment recommended for ALL patients in selected patient group

Once the patient has been stabilized, provide adequate analgesia. Parenteral analgesia with an opioid is generally required in patients involved in a high-energy trauma in the emergency setting. Consider opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[44]​ The American Academy of Orthopaedic Surgeons (AAOS) notes in its guideline on managing distal radial fractures that opioid alternatives, both pharmacologic (such as local anesthetics, nonsteroidal anti-inflammatory drugs [NSAIDs], and acetaminophen) and nonpharmacologic (such as ice, elevation, compression, and cognitive therapies) should be considered where possible.[44]​

Primary options

morphine sulfate: children: consult specialist for guidance on dose; adults: 10-30 mg orally (immediate-release) every 4 hours when required, adjust dose according to response; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required

Consider – antibiotics ± tetanus toxoid immunization

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INITIAL
|
involved in high-energy trauma
Consider – 

antibiotics ± tetanus toxoid immunization

Treatment recommended for SOME patients in selected patient group

Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.[45]

The AAOS recommends giving patients with major extremity trauma undergoing surgery 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 (e.g., piperacillin/tazobactam) is preferred.[45]​ 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.[45]

Tetanus toxoid immunization should be administered based on patient vaccination history, date of most recent vaccination, and open wound characteristics (e.g., size, degree of contamination).[47]​

Primary options

cefazolin: children: consult specialist for guidance on dose; adults: 2-3 g intravenously prior to surgery

OR

clindamycin: children: consult specialist for guidance on dose; adults: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: children: consult specialist for guidance on dose; adults: 3.375 to 4.5 g intravenously prior to surgery

More

Consider – orthopedic consultation + appropriate intervention

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INITIAL
|
involved in high-energy trauma
Consider – 

orthopedic consultation + appropriate intervention

Treatment recommended for SOME patients in selected patient group

Arrange an urgent orthopedic consultation, as operative treatment is the preferred approach for most of these injuries.

Arrange vascular surgery consultations for any patient with suspected neurovascular injury.

If open, the fracture will require surgical irrigation and debridement due to the risk of infection, as well as open reduction and internal fixation. Irrigation and debridement should take place in the operating room as soon as possible and ideally less than 24 hours after the injury has occurred.[45]

ACUTE

nonstress fractures

1st line – analgesia + immobilization + supportive care

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ACUTE
|
nonstress fractures
|
closed, nondisplaced
1st line – 

analgesia + immobilization + supportive care

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). Give oral acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and consider an opioid for the acute presentation in the emergency department. Consider opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[44]​ The American Academy of Orthopaedic Surgeons (AAOS) notes in its guideline on managing distal radial fractures that opioid alternatives, both pharmacologic (such as local anesthetics, NSAIDs, and acetaminophen) and nonpharmacologic (such as ice, elevation, compression, and cognitive therapies) should be considered where possible.[44]​

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

Initial immobilization in a shoulder sling is recommended for both adults and children with closed, nondisplaced midshaft, distal (typically Neer type I or III), or medial clavicle fractures, followed by gradual return to range of motion as comfort allows, usually within 2-3 weeks. The sling may be discontinued and activity resumed as pain allows.[3][25]​​[61]​​

In most cases, the consensus is that a sling is preferred for immobilization over a figure-of-eight brace.[35]​​ Figure-of-eight braces have been used for immobilization, but are described as less comfortable and have shown no benefit over a simple shoulder sling.[6][25]​​​

Medial clavicle fractures in children should be differentiated from true sternoclavicular dislocations, especially posterior dislocations which may require emergency surgical intervention.[79]

Repeat physical exam and imaging are often obtained to evaluate for interval displacement and to reassess potential indications for operative management. However, follow-up after initial evaluation may not be necessary in children with isolated, uncomplicated fractures.[69][81]​ See Monitoring.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

codeine sulfate: adults: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

morphine sulfate: children: consult specialist for guidance on dose; adults: 10-30 mg orally (immediate-release) every 4 hours when required, adjust dose according to response; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required

1st line – analgesia + immobilization + supportive care

Back
ACUTE
|
nonstress fractures
|
closed, displaced
1st line – 

analgesia + immobilization + supportive care

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). Give oral acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and consider an opioid for the acute presentation in the emergency department. Consider opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[44]​ The American Academy of Orthopaedic Surgeons (AAOS) notes in its guideline on managing distal radial fractures that opioid alternatives, both pharmacologic (such as local anesthetics, NSAIDs, and acetaminophen) and nonpharmacologic (such as ice, elevation, compression, and cognitive therapies) should be considered where possible.[44]

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

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

codeine sulfate: adults: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

morphine sulfate: children: consult specialist for guidance on dose; adults: 10-30 mg orally (immediate-release) every 4 hours when required, adjust dose according to response; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required

Consider – orthopedic referral ± open reduction and internal fixation

Back
ACUTE
|
nonstress fractures
|
closed, displaced
Consider – 

orthopedic referral ± open reduction and internal fixation

Treatment recommended for SOME patients in selected patient group

Midshaft clavicle fractures

Patients with displaced midshaft clavicle fractures should be evaluated by an orthopedic surgeon as soon as possible (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]​

Consider operative or nonoperative 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 nonoperative treatment.[35]​​

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]​​

The indications for urgent surgery (vascular injury, skin tenting, open fracture) generally apply to both adults and children. However, without these injury complications, the higher remodeling potential in children can result in more predictable healing of nonoperatively treated displaced clavicle fractures. Recent studies have demonstrated reliable healing and return to full activity in children with nonoperatively treated clavicle fractures.[12][14][69]

In general, displaced midshaft clavicle fractures in adolescents are managed using the same principles as for adult injuries. The vast majority of clavicle fractures in adolescents are treated nonoperatively. Individualized evaluation and treatment in consultation with an orthopedic/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.[48] 

Distal clavicle fractures

The optimal management of displaced distal clavicle fractures remains controversial. Patients with displaced distal clavicle fractures should be evaluated by an orthopedic surgeon shortly after injury (standard practice would be within 1-2 weeks).

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]​​

In children, significantly displaced distal clavicle fractures would merit operative consideration.

Medial clavicle fractures

Medial clavicle fractures may have anterior or superior displacement.[76]​ If this is suspected to have put vital mediastinal structures at risk, referral for emergency surgical intervention is indicated.

Most medial clavicle injuries in children and adolescents consist of physeal separations. Differentiate these from true sternoclavicular dislocations, especially posterior dislocations which may require emergency surgical intervention.[79]​

1st line – analgesia + immobilization

Back
ACUTE
|
nonstress fractures
|
open
1st line – 

analgesia + immobilization

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). Give oral acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and consider narcotic pain medication for the acute presentation in the emergency department. Consider opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[44]​ The American Academy of Orthopaedic Surgeons (AAOS) notes in its guideline on managing distal radial fractures that opioid alternatives, both pharmacologic (such as local anesthetics, NSAIDs, and acetaminophen) and nonpharmacologic (such as ice, elevation, compression, and cognitive therapies) should be considered where possible.[44]

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

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

codeine sulfate: adults: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

morphine sulfate: children: consult specialist for guidance on dose; adults: 10-30 mg orally (immediate-release) every 4 hours when required, adjust dose according to response; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required

Plus – surgical irrigation and debridement + open reduction and internal fixation

Back
ACUTE
|
nonstress fractures
|
open
Plus – 

surgical irrigation and debridement + open reduction and internal fixation

Treatment recommended for ALL patients in selected patient group

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.[45]

Indications for urgent surgery, such as vascular injury, skin tenting, or open fracture, generally apply to both adults and children.

Plus – antibiotics ± tetanus toxoid immunization

Back
ACUTE
|
nonstress fractures
|
open
Plus – 

antibiotics ± tetanus toxoid immunization

Treatment recommended for ALL patients in selected patient group

Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.[45]

The AAOS recommends giving patients with major extremity trauma undergoing surgery 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 (e.g., piperacillin/tazobactam) is preferred.[45] 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.[45]

Tetanus toxoid immunization should be administered based on patient vaccination history, date of most recent vaccination, and open wound characteristics (size, degree of contamination, etc.).[69]​

Primary options

cefazolin: children: consult specialist for guidance on dose; adults: 2-3 g intravenously prior to surgery

OR

clindamycin: children: consult specialist for guidance on dose; adults: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: children: consult specialist for guidance on dose; adults: 3.375 to 4.5 g intravenously prior to surgery

More

stress fractures

1st line – rest + physical rehabilitation program

Back
ACUTE
|
stress fractures
1st line – 

rest + physical rehabilitation program

Stress fractures of the clavicle are extremely rare, but case reports have described midshaft stress fractures in high-level athletes.[80]

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.

Plus – analgesia

Back
ACUTE
|
stress fractures
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

The type and dose of analgesia will vary with the amount of pain the patient is experiencing and other modifying factors (e.g., age, comorbidities, allergies). In general, use oral acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer