Clinical feature and management of clavicle fracture in children and adults
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clavicle fracture adults children management clinical features guideline AAOS pediatric orthopedic
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https://orthoinfo.aaos.org/en/diseases--conditions/clavicle-…
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AP radiograph displaced midshaft clavicle fracture adult
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Clavicle fracture: clinical features and management
Most clavicle fractures involve the midshaft. The usual mechanism is a fall onto the lateral shoulder, direct blow, sports injury, or road traffic trauma. In infants, it may result from birth trauma.
Clinical features
| Feature | Children | Adults |
|---|---|---|
| Symptoms | Pain, crying or reluctance to use the arm; older child supports the arm | Pain over collarbone, worse with shoulder/arm or neck movement; arm held close to body |
| Signs | Local tenderness, swelling, bruising, deformity; occasionally palpable callus appears about 7-10 days after an occult neonatal fracture | Tenderness, swelling/ecchymosis, visible or palpable step/deformity, crepitus, shoulder droop and shortening |
| Common site | Midshaft, usually with substantial remodeling capacity | Midshaft most common; distal fractures have higher nonunion risk |
| Neurovascular issues | Uncommon but must be assessed, especially if displaced | Check radial pulse, capillary refill, motor/sensory function, and brachial plexus/subclavian vessel injury |
| Important special injuries | Birth fracture may coexist with brachial plexus palsy; sternoclavicular physeal injury can mimic dislocation | Posterior sternoclavicular injury can threaten trachea, esophagus, and mediastinal vessels |
The clinical diagnosis is usually confirmed with plain clavicle radiographs. Obtain additional views or CT when a medial-end/sternoclavicular injury is suspected, particularly when posterior displacement is possible. A focused neurovascular examination is mandatory because of the nearby brachial plexus and subclavian vessels. Miller's Review of Orthopaedics, p. 932.
Red flags requiring urgent orthopaedic or emergency assessment
- Open fracture or threatened skin, especially skin tenting/blanching
- Absent or weak pulse, altered sensation, motor deficit, expanding hematoma
- Suspected posterior sternoclavicular displacement, dyspnea, stridor, dysphagia, hoarseness, or chest symptoms
- Associated scapular-neck fracture or multiple rib fractures, suggesting a floating shoulder
- Polytrauma, pneumothorax, or severe chest injury
- Marked displacement/comminution, especially in adults and near skeletal maturity
Management in children
Usual treatment: nonoperative
Children have a high healing and remodeling potential. Most are treated with:
- Analgesia: paracetamol/acetaminophen or an NSAID when appropriate.
- Immobilization for comfort: a broad-arm sling, often with swathe, is standard.
- Early movement: finger, wrist, and elbow motion immediately; gentle shoulder range of motion after pain settles.
- Follow-up: assess clinical union, symptoms, function, and radiographic healing when indicated.
- Return to sport/contact activity: only when painless, with near-full shoulder movement and clinical/radiographic union. A common practical timeframe is about 6-8 weeks, but it depends on age, fracture pattern, and sport.
For uncomplicated pediatric fractures, sling support is commonly used for about 2-4 weeks followed by range-of-motion progression. Pediatric nonunion is rare. The POSNA pediatric guidance describes nonoperative care as the mainstay.
Neonatal clavicle fracture
Usually needs no active immobilization beyond gentle handling and pain relief. Evaluate arm movement to exclude associated brachial plexus palsy. Miller's Review of Orthopaedics, p. 932.
When to consider surgery in children/adolescents
Surgery is uncommon and should be decided by pediatric orthopaedics. Indications include:
- Open fracture
- Neurovascular compromise
- Skin at risk of breakdown
- Floating shoulder
- Symptomatic nonunion or problematic malunion
- Selected older adolescents with marked displacement/shortening, comminution, or high functional demands
In adolescents, the benefit of routine fixation for a displaced midshaft fracture remains debated. Adults' surgical thresholds should not be applied automatically to younger children. The pediatric literature notes that suggested thresholds such as complete displacement or 15-20 mm shortening have not been firmly validated in skeletally immature patients. POSNA review
Avoid prolonged figure-of-eight bandaging in children: it can be uncomfortable and may cause brachial plexus compression; a sling is generally preferred. Tintinalli's Emergency Medicine, p. 3303.
Management in adults
Nonoperative management
Appropriate for most nondisplaced or minimally displaced fractures and for many displaced fractures after shared decision-making.
- Sling for comfort, typically for the early painful period
- Ice and analgesics
- Hand, wrist, and elbow exercises immediately
- Pendulum and gentle shoulder range-of-motion exercises once pain permits
- Gradual strengthening after clinical/radiographic union
- Serial review and radiographs to ensure maintained alignment and union
A sling is usually favored over a figure-of-eight brace because it is simpler and better tolerated. The AAOS patient guidance also recommends progressive motion and strengthening as healing advances.
Operative management
Open reduction and internal fixation (ORIF), usually plate-and-screw fixation, is considered when the expected benefit outweighs surgical risks.
Strong indications
- Open fracture
- Neurovascular injury or compromise
- Threatened skin or skin tenting
- Floating shoulder
- Symptomatic established nonunion
- Posterior sternoclavicular injury with mediastinal risk, requiring specialist urgent management
Relative/selective indications
- Completely displaced and substantially shortened midshaft fracture
- Marked comminution
- Distal clavicle fracture with unstable pattern and high risk of nonunion
- Polytrauma where earlier upper-limb function assists mobilization
- Patient-specific needs, such as selected high-demand athletes or manual workers
Surgery can improve alignment and may reduce nonunion risk in selected displaced adult midshaft fractures, but it carries risks: infection, wound problems, numbness below the clavicle, implant irritation/removal, neurovascular injury, lung injury, and failure of fixation. The AAOS overview outlines these operative and nonoperative considerations.
Complications
- Malunion with visible bump or shortening
- Delayed union/nonunion, more relevant in adults, smokers, markedly displaced/comminuted fractures, and some distal fractures
- Shoulder stiffness
- Chronic pain or reduced endurance
- Brachial plexus or subclavian vessel injury
- Pneumothorax
- Rarely, thoracic outlet symptoms
- Implant irritation or need for hardware removal after fixation
In children, nonunion and clinically important malunion are rare; the likelihood rises with increasing age. Miller's Review of Orthopaedics, p. 932.
Recent-evidence note
A recent systematic review found that conclusions across clavicle-fracture randomized trials have statistical fragility, so treatment should remain individualized rather than based on a single displacement cutoff alone (PMID 39970459).
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