Treatment of Clavicle Fractures

Publication Date: December 2, 2022
Last Updated: January 31, 2023

Summary of Recommendations

BONE STIMULATOR

Low-intensity pulsed ultrasound (LIPUS) should not be used for nonoperative management of acute mid-shaft clavicle fracture as it does not result in accelerated healing or lower rates of non-union. (Moderate)
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HOOK PLATE VS. LATERAL LOCKING PLATE FOR LATERAL FRACTURE

Moderate evidence demonstrates that lateral locking plates may have fewer complications and better functional outcomes than hook plates for the treatment of lateral (Neer Type II) clavicle fractures in adults. (Moderate)
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ISOLATED DISPLACED MIDSHAFT FRACTURE: OPERATIVE VS. NON-OPERATIVE TREATMENT [ADULT]

Operative treatment of displaced midshaft clavicle fractures in adult patients is associated with higher union rates and better early patient-reported outcomes than non-operative treatment. However, practitioners may consider either operative or non-operative treatment as both are associated with similar long-term patient-reported outcomes and patient satisfaction. (Strong)
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NAILING vs. SINGLE PLATE

Surgical treatment of clavicle shaft fractures with an intramedullary nail or a single plate results in equivalent long-term clinical outcomes with similar complication rates. Plate fixation may be of benefit in the presence of fracture comminution. (Moderate)
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NON-MODIFIABLE RISK FACTORS: AGE AND SEX

The non-modifiable risk factors age and sex do not predict patient reported functional outcomes following mid shaft clavicle fracture regardless of treatment modality. (Limited)
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MODIFIABLE RISK FACTORS: SMOKING

Limited evidence suggests that smoking tobacco increases the rate of nonunion in clavicle fractures and leads to inferior clinical outcomes. (Limited)
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DUAL PLATING

Dual plating of midshaft clavicle fractures in adults utilizing one 2.7-mm plate and a 2.7-mm or smaller plate may result in similar union rates and lower implant removal and secondary procedure rates than those seen with use of single 3.5-mm plates. (Limited)
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ANTERIOR vs. SUPERIOR PLATING

Anterior inferior plating of midshaft clavicle fractures in adults may lead to lower implant removal rates compared to superior plating. (Limited)
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PRE-CONTOURED PLATE vs. NON-PRE-CONTOURED PLATE

Surgeons may use manufacturer-contoured anatomic clavicle plates for treatment of midshaft clavicle fractures in adults as they have lower rates of implant removal or deformation compared to other plates. (Limited)
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RADIOGRAPH: SUPINE vs. UPRIGHT

Upright radiographs may be superior for demonstrating the degree of displacement in midshaft clavicle fractures when compared to supine radiographs. (Limited)
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PREDICTORS OF NON-UNION FOLLOWING NON-OPERATIVELY TREATED CLAVICLE FRACTURE

Increasing displacement and/or comminution in mid-shaft clavicle fractures may be associated with higher rates of non-union following non-operative treatment in adults. (Limited)
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ISOLATED DISPLACED MIDSHAFT FRACTURE: OPERATIVE VS. NON-OPERATIVE TREATMENT [ADOLESCENT = 18 YEARS O

In adolescent patients with displaced midshaft clavicle fractures, operative treatment may offer no benefit compared to non-operative treatment. Operative treatment is associated with similar union rates and substantial reoperation rates for implant removal. (Limited)
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IMMOBILIZATION METHOD

In the absence of reliable evidence, it is the opinion of the work group that sling is preferred in most cases for immobilization of acute clavicle fractures as opposed to figure-of-eight brace. (Consensus)
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LATERAL CLAVICLE FRACTURE: OPERATIVE vs. NON-OPERATIVE TREATMENT

In the absence of reliable evidence, it is the opinion of the work group that displaced lateral fractures with disruption of the coracoclavicular ligament complex may benefit from operative repair. (Consensus)
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Recommendation Grading

Overview

Title

Treatment of Clavicle Fractures

Authoring Organization

Publication Month/Year

December 2, 2022

Last Updated Month/Year

August 9, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

The purpose of this clinical practice guideline is to evaluate the current best evidence associated with the treatment of isolated clavicle fractures. Evidence-based medicine (EBM) standards advocate for use of empirical evidence by physicians in their clinical decision making. To assist with access to the large resources of information, a systematic review of clavicle fracture literature was conducted between November 2021 and July 2022. This clinical practice guideline highlights where there is good evidence, where evidence is lacking, and what topics future research will need to target in order to help facilitate evidence-based decision making in the treatment of clavicle fractures. AAOS staff methodologists assisted the physician/clinician work group in evaluating the existing literature so that they could formulate the following recommendations based on a rigorous systematic process. Musculoskeletal care is provided in many different settings and by a variety of health care professionals. This guideline is an educational tool to guide qualified physicians and clinicians in making treatment decisions that improve the quality and efficacy of care. This guideline does not include all possible methods of care and does not intend to exclude other acceptable interventions similarly directed at obtaining favorable outcomes. The final decision to use a specific treatment is at the discretion of the treating health care professional and must be made after assessing all concerns presented by the patient, available diagnostic information, and consideration of locality-specific resources.

Target Patient Population

Patients with an isolated clavicle fracture that has been diagnosed by a trained healthcare professional

Target Provider Population

Orthopaedic surgeons and allied providers caring for patients with confirmed clavicle fractures

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment

Diseases/Conditions (MeSH)

D002968 - Clavicle, D050723 - Fractures, Bone

Keywords

fracture, Clavicle Fractures, Clavicle

Source Citation

American Academy of Orthopaedic Surgeons Treatment of Clavicle Fractures Evidence-Based Clinical Practice Guideline. www.aaos/org/claviclecpg Published 12/02/2022

Supplemental Methodology Resources

Data Supplement, Data Supplement

Methodology

Number of Source Documents
67
Literature Search Start Date
November 1, 2021
Literature Search End Date
July 1, 2022