Progressive ROM may be initiated after 3 weeks of immobilization

TREATMENT distal calvicle

Nonoperative

sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

indications

stable fractures (Neer Type I, III, IV)

pediatric distal clavicle fractures (skeletally immature)

Operative

open reduction internal fixation

indications absolute

open or impending open fractures

subclavian artery or vein injury

floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement)

symptomatic nonunion

relative

unstable fracture patterns (Neer Type IIA, IIB, V)

brachial plexus injury (questionable because 66% have spontaneous return)

closed head injury

seizure disorder

polytrauma patient

TREATMENT Mid clavicle

Nonoperative

indications

< 2cm shortening and displacement

< 1cm displacement of the superior shoulder suspensory complex

closed and no neurovascular injury

low demand patient

modalities: sling, figure-of-8 strap

elevate and extend shoulder to bring distal fragment to the proximal fragment

outcomes

figure-of-8 associated with more pain, shortening, and lower compliance than sling

no difference in functional or cosmetic outcomes between sling and figure-of-eight braces

Operative

indications

absolute

open fractures

displaced fracture with skin tenting

subclavian artery or vein injury

floating shoulder (clavicle and scapular neck fracture)

relative and controversial indications

displaced with > 2cm shortening

bilateral displaced clavicle fractures

brachial plexus injury (questionable because 66% have spontaneous return)

closed head injury

Clinical recommendation	Evidence rating	References
Nonoperative treatment is preferred for nearly all acute, nondisplaced midshaft clavicle fractures.	B	¹²
Treatment with an arm sling is preferred over a figure-of-eight dressing for acute midshaft clavicle fractures because it is better tolerated and leads to similar outcomes.	B	¹⁰, ¹¹
Displaced midshaft clavicle fractures may be managed nonoperatively, but plate fixation should be considered.	B	¹², ¹³, ¹⁵
Nonoperative treatment is preferred for distal clavicle fractures because outcomes are the same whether or not bony union is achieved.	B	²⁵, ²⁶

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