Relative indications often used for referral discussion
Completely displaced midshaft fracture in adult
Higher nonunion risk compared with nondisplaced
Shared decision-making based on goals
Significant shortening in adult midshaft fracture
Functional deficit risk discussion
Cosmetic concern discussion
Floating shoulder pattern
Clavicle fracture plus scapular neck fracture
Stability and alignment considerations
Guideline framing
Displaced midshaft fractures in adults may benefit from operative fixation with improved union and early function (AAOS strong recommendation; Class I)
Long-term functional differences smaller
Surgical complication trade-offs
Nondisplaced fractures typically managed nonoperatively (AAOS strong recommendation; Class I)
High union rates
Lower complication burden
Special Populations
Pregnancy
Pregnancy
Imaging strategy
Radiographs acceptable when clinically indicated
Abdominal shielding when feasible without compromising study
Analgesia
Acetaminophen preferred
NSAID avoidance in later pregnancy
Disposition
Low threshold for obstetric assessment if trauma mechanism significant
Fetal monitoring considerations per gestational age and local protocol
Geriatric
Geriatric
Injury context
Low-energy falls common
Osteoporosis risk
Complications and recovery
Higher baseline frailty affecting rehab
Higher risk of delayed union and functional decline
Medication safety
Opioid fall risk
NSAID renal and GI risk
Disposition planning
Home supports and mobility aids
PT and OT referral considerations
Pediatrics
Pediatrics
Pattern recognition
Greenstick and buckle patterns common
Distal clavicle physeal injury can mimic AC separation
Management differences
Nonoperative care favored for most fractures
Shorter immobilization period often sufficient
Red flags for urgent referral
Open fracture
Skin tenting with threatened viability
Neurovascular compromise
Safeguarding considerations
Non-ambulatory infant with fracture as potential sentinel injury
Inconsistent mechanism history
Background
Epidemiology
Epidemiology
Common fracture type in trauma presentations
Frequent in falls and sports injuries
Frequent in bicycle and motor vehicle collisions
Anatomic distribution
Midshaft most common location
Distal and medial less common
Prognosis patterns
High union rate with nonoperative care for nondisplaced fractures
Higher nonunion risk with marked displacement in adults
Pathophysiology
Pathophysiology
Typical deforming forces
Sternocleidomastoid elevates medial fragment
Shoulder weight depresses lateral fragment
Nearby structure risk
Subclavian vessels posterior to medial and midshaft clavicle
Brachial plexus proximity
Apex of lung proximity
Complication mechanisms
Nonunion driven by displacement, comminution, and patient factors
Malunion driven by shortening and overlap
Skin compromise driven by sharp fragment tenting
Therapeutic Considerations
Therapeutic Considerations
Nonoperative strategy rationale
Sling comfort and soft tissue rest
Early elbow and hand motion prevents stiffness
Operative strategy rationale
Improved alignment and length restoration
Reduced nonunion risk in selected displaced adult fractures
Shared decision-making domains
Athletic or occupational overhead demands
Cosmetic concerns
Tolerance for surgical risks and hardware
Evidence framing for ED documentation
Guideline-based counseling for displaced adult midshaft fractures
Clear documentation of skin and neurovascular status
Patient Discharge Instructions
copy discharge instructions
copy discharge instructions
Diagnosis and expected course
Clavicle fracture
Pain and swelling typically improve over 1-2 weeks
Immobilization and activity
Sling use for comfort
Remove sling for elbow, wrist, and hand motion several times daily
Avoid lifting, pushing, pulling with injured arm
Avoid contact sports until cleared
Pain control
Acetaminophen as directed
Ibuprofen or naproxen as directed if safe
Opioid only for severe breakthrough pain if prescribed
Ice and positioning
Ice 15-20 minutes at a time
Sleep semi-upright if more comfortable
Follow-up
Orthopedics or fracture clinic appointment within 1 week
Earlier follow-up if significant displacement or high-demand activity
Return to emergency department now if
New numbness, tingling, or weakness in arm or hand
Hand becomes cold, pale, or pulseless
Worsening swelling at base of neck or above collarbone
Skin over fracture becomes very tight, white, or breaks open
Shortness of breath or chest pain
Fever or drainage from wound
References
Clinical guidelines and evidence sources
Clinical guidelines and evidence sources
AAOS Clinical Practice Guideline: Treatment of Clavicle Fractures (published 2022)
Recommendations on operative vs nonoperative management of isolated clavicle fractures
PubMed summary of AAOS clavicle fracture guideline (published 2023)
Overview of recommendations and options
Radiopaedia: clavicle AP cephalic angulation view and clavicle series
Standard radiographic projections used for clavicle evaluation
UpToDate: clavicle fractures
Skin tenting as marker of significant displacement
Literature on adolescent displaced midshaft fractures and shortening thresholds
Relative indications discussed for operative referral context
Evidence grading conventions used in this document
Evidence grading conventions used in this document
AAOS strength labels used when referencing guideline positions
Strong recommendation
Moderate recommendation
Class I, Class IIa, Class IIb labels used as action-strength shorthand
Class I for standard-of-care and strong guideline support
Class IIa for generally favored strategies with conditional evidence
Class IIb for selective use based on context and clinician judgment
ACEP Level A, Level B, Level C labels used as ED evidence shorthand when applicable
Level C used for expert consensus ED practice elements
Condition-specific ACEP guideline not available for isolated clavicle fracture
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