Clinical Practice Guideline for the Treatment of Clavicle Fractures (2022)

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.

There is limited evidence on treatment of clavicle fracture using low intensity pulsed ultrasound. One high-quality placebo-controlled trial (Lubbert 2008) was reviewed which investigated use of LIPUS in patients with acute midshaft clavicle fracture. It found that there was no difference in fracture healing, functional outcomes, or pain outcomes between the two groups.

Benefits/Harms of Implementation

There is no obvious benefit of low intensity pulsed ultrasound. However, it can cause unnecessary inconvenience to patients.

Outcome Importance

Clavicle fractures can be treated nonoperatively or surgically based on standard of care. Ultrasound usage is not necessary.

Cost Effectiveness/Resource Utilization

Low intensity pulsed ultrasound adds to significant financial burden to patient. Based on the evidence it doesn’t seem to be cost effective.

Acceptability

There is no issue with acceptability of the outcome.

Feasibility

There is no issue with feasibility of the outcome.

Future Research

Further research is required in this area, as only one high-quality study was identified through the literature review. It’s possible that medium intensity ultrasound may have different outcomes. High quality studies in different age groups could shed some light on the possibility that ultrasound may have different effects in young versus older patients.

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.

One randomized comparative trial (Wang 2020) evaluated the outcomes and complications following operative management of Neer Type II distal clavicle fractures treated with Hook plate versus Lateral Locking plate. Another study found no differences in objective outcomes of healing time, operative time, or blood loss between techniques but lower post-operative complication rates in the locking plate group (OR 5.64, 95% CI 1.37, 23.19) (Wang et al.). Additionally, subjective pain and outcomes scores (Constant, and UCLA) were significantly better in the locking plate techniques compared to the hook plate.

Benefits/Harms of Implementation

The choice of surgical plating technique for Neer Type II distal clavicle fractures appears to demonstrate a benefit with the use of lateral locking plates. A reduction in complications was demonstrated while providing similar rates of bony healing, comparable surgical time, and better patient reported outcomes.

Outcome Importance

Understanding the potential advantages and disadvantages of different surgical techniques for this potentially difficult surgical problem can improve complication rates and patient reported outcomes.

Cost Effectiveness/Resource Utilization

Based on the current evidence there is no recommendation that can be made related to cost/resource effectiveness on this topic. Given a substantial difference in complications between the two techniques the opportunity for cost analysis may be helpful to further analyze the global utility of each treatment.

Acceptability

The use of lateral locking plates requires minimal change to clinical practice as these are common plating techniques used throughout the body. Thus, the findings of this recommendation are likely to be acceptable amongst treating surgeons.

Feasibility

The surgical technique of lateral locked plating requires minimal if any major change in the surgical approach and definitive treatment technique and thus is feasible in most situations. The availability of lateral locking plates may be the only significant deterrent to the feasibility of this recommendation.

Future Research

Additional research is needed on this topic to further support or refute the findings of this study and to evaluate the cost effectiveness and ideal populations for the proposed techniques.

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.

For those with displaced, mid shaft clavicle fractures, the exact amount of displacement and shortening to warrant consideration are not well-defined in the majority of studies. The referral to the guidelines of the COTS study 2007 are often discussed with displacement defined as no cortical contact between the two fragments.  The studies which compared operative treatment with plate fixation versus non-operative treatment found an increased union rate with operative plate fixation (Ban 2021, Tamaoki 2017, COTS 2007). Additional studies that evaluated elastic stable intramedullary nailing (ESIN) also supported operative treatment for displaced midshaft clavicle fractures. The union rate not only was higher for operative treatment, but time to union was also faster (Chen 2011, Smekal 2009, Smekal 2011). There were superior functional outcomes earlier in the operatively treated group. For active patients and those who need to return to work with a displaced, midshaft clavicle fracture, operative fixation should be strongly considered.

Benefits/Harms of Implementation

Plate fixation and intramedullary nailing lead to higher union rates in adult patients.  With any operative treatment, there is increased risk of infection and implant failure.  The infection rates in all of the studies were low. There is increased need for surgery due to nonunion in the non-operatively treated group. There is increased need for reoperation for plate or EISN removal in the operatively treated group due to irritation and/or prominence of implant. Neither operative nor non-operative treatment was found to be superior in terms of cosmesis. At long-term follow-up, similar functional outcomes can be expected.

Outcome Importance

For displaced and shortened clavicle fractures, operative treatment with plate fixation was found to provide the best outcomes in terms of union rate.

Cost Effectiveness/Resource Utilization

Surgical fixation costs more in terms of overall costs and increased costs in the post operative period due to procedure costs for implant removal. With the need for operative conversion in non-operatively treated fractures to promote union, the delay in definitive management may affect the time to return to work and have economic consequences for the patient.

Acceptability

Operative stabilization of displaced and/or comminuted mid shaft clavicle fractures is an acceptable treatment. There are more studies comparing plate fixation, but in comparing operative versus non-operative treatment, regardless of the type of implant, the union rate was superior and time to union was faster compared to non-operative treatment.

Feasibility

Operative treatment with a plate or intramedullary nailing can lead to a high union rate. The familiarity with plate fixation is the most likely reason for the greater number of studies analyzing this technique.

Future Research

Consistency in reporting the definition of displaced clavicle fractures in randomized studies should be sought. Mid- and long-term outcome studies would provide information on value of treatment over time in the adult population. Improved understanding or prediction of which patients are most likely to fail nonoperative or operative treatment will be useful to further tailor clinical decision-making. The determination of when non-operative treatment should be converted to operative stabilization would be useful in shared decision-making processes. It appears functional outcomes are similar at one year with either operative or non-operative treatment.

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.

The literature (prospective and retrospective) generally supports that long-term clinical outcomes (> 1 year) are similar with the use of an intramedullary device versus single plate for fixation of displaced clavicular shaft fractures (Park 2020, Liu 2010, Zhang 2019, Anand 2021, Narsaria 2014). More comminution at the fracture site is however a clinical indication to use a clavicular plate, rather than an intramedullary device. The literature suggests better earlier clinical outcomes with the use of plates, presumably due to better stability early in the recovery phases after surgery (Anand 2021, Fuglesang 2018, van der Meijden 2015). The literature also suggests that hardware irritation/complications may be lower with the use of an intramedullary device when compared to a plate (Fuglesang 2018, Zhang 2019, Zehir 2016).

Benefits/Harms of Implementation

Benefits of these recommendations will potentially help surgeons avoid using an intramedullary device for a comminuted clavicular shaft fracture, when a better therapeutic choice would be a plate for clavicular shaft fracture with comminution. There are not potential clinical harms that could be created by following clinical recommendation of this guideline beyond the expected risks of surgical intervention.

Outcome Importance

Better clinical outcomes might be achieved by following this clinical guideline for the fixation of clavicular shaft fractures depending on fracture pattern simple versus comminuted).

Cost Effectiveness/Resource Utilization

At this time, the direct cost differences between intramedullary devices and plates for clavicular shaft fracture fixation are not known to this group. With respect to resource utilization, orthopedic surgeons would need clinical access to both intramedullary devices and plates for clavicular shaft fracture fixation. This might require more resources as hospitals would need to maintain inventories for both devices.

Acceptability

Clinically active orthopedic surgeons are probably more comfortable with plate fixation of clavicular shaft fractures at this time. Orthopedic surgeons may benefit from clinical training (sawbones, cadaver labs, etc.) to become more familiar with the use of intramedullary devices for clavicular shaft fracture fixation.

Feasibility

Clinical use of both intramedullary devices and plates is very reasonable for orthopedic surgeons who provide clinical surgical care for patients with clavicular shaft fractures.

Future Research

Future research would include more long-term clinical outcome data (need for hardware removal, complications related to surgical procedure, patient reported outcomes, etc.) beyond twelve months.

The non-modifiable risk factors age and sex do not predict patient reported functional outcomes following mid shaft clavicle fracture regardless of treatment modality.

In general, non-modifiable factors and their effect on functional outcome after clavicle facture is not well studied. The effect of non-modifiable factors like age, gender, poly trauma, fall height, and hand dominance, fracture of shortening, and fracture displacement has been reported in the literature but no difference in functional outcome in these studied factors has been found.

One study reported no difference in outcomes based on age, sex, fracture type, and fracture shortening or displacement (Ban 2021). They reported better Constant scores at 6 weeks but no differences at 1 year. Another study did not find any differences in outcomes based on non-modifiable factors including age, sex, fracture shortening, hand dominance, or the diagnosis of diabetes (Chu 2018). Some studies reported no difference in outcome based on sex with either operative or non-operative treatment (Napora 2016, 2018). Finally, one study investigated high vs low energy mechanism, fall from height and the effect of hand dominance on clinical outcomes and found no difference (Nicholson 2020).

Benefits/Harms of Implementation

Nonmodifiable factors do not seem to affect patient reported outcomes therefore there is no significant benefit or harm of this recommendation.

Outcome Importance

Outcome does not go against standard of care. Surgical treatment of clavicle fracture is the preferred treatment in majority of significantly displaced fractures. Non-operative management could be a reasonable option in high-risk patients.

Cost Effectiveness/Resource Utilization

This recommendation does not have any effect on the financial aspect of clavicle fracture treatment.

Acceptability

Fracture treatment should be acceptable as it does not change the current standard of care.

Feasibility

Operative and non-operative treatment are feasible. There is no additional barrier as a result of this recommendation.

Future Research

Research is lacking in this field. As non-modifiable factors cannot be changed, treatment methods should be calibrated based on relevant factors to achieve better outcomes. Well powered randomized controlled studies to identify factors that negatively impact functional outcomes are needed to help surgeons select an appropriate treatment strategy.

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

Five low quality studies were examined, identifying smoking as the most common modifiable risk factor associated with poor outcomes (nonunion in surgical or non-surgical fixation).  One study showed that non-union is an uncommon outcome in non-surgical treatment, however the risk of non-union was greatly increased by smoking (Liu 2015).  Another non-surgical treatment study showed that smoking was the strongest risk factor for non-union (Murray 2013). 

In two studies that analyzed both surgical and non-surgical treatment of clavicle fractures, ASES scores were assessed, demonstrating that smokers in each group had significantly lower ASES scores than those that did not smoke (Napora 2016, 2018).  Smoking and unemployment led to overall poorer outcome in each of these studies as well.  The final study also linked clavicle fracture non-union to smoking (Chu 2018).

Benefits/Harms of Implementation

Recognition of the risks of smoking on outcome following clavicle fracture may benefit surgeons as they counsel patients regarding expected outcomes.

Outcome Importance

Smoking is a modifiable risk factor that can be directly correlated to outcomes following a clavicle fracture which is critical to patient counseling and treatment decision making.

Cost Effectiveness/Resource Utilization

Not applicable to this recommendation.

Acceptability

No change to treatment is recommended.

Feasibility

As no change to treatment is recommended, feasibility is not applicable.

Future Research

Further research regarding other modifiable risk factors that may impact clavicle fracture treatment is needed.

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.

There were three low quality studies evaluating single versus dual plate fixation of midshaft clavicle fractures (Chen 2017, DeBaun 2020, Lee 2020). The studies evaluated differing aspects of clavicle fracture fixation. They compared results between dual mini fragment plates of multiple sizes (DeBaun 2020), dual plating with mini fragment and small fragment plates (Chen 2017), and finally two orthogonal mini-fragment plates (Lee 2020) compared to a single small fragment plate. The small fragment plate type, position, and fixation strategy (lag/neutralize/bridge/compression) was at the discretion of the operating surgeon in the studies with not all details reported (Chen 2017, DeBaun 2020), and not delineated (Lee 2020).

Lee (2020) did not find a significant difference in the need for hardware removal, but 8/89 small fragment plates were removed while no mini fragment plates were removed. Thus, the study favored mini fragment fixation regarding implant removal. This may not be applicable in the non-military population.

In Chen (2017) ten patients elected to undergo plate removal, with 7/10 being small fragment superior placement, favoring mini fragment dual plate fixation in terms of implant removal.  DeBaun (2020) did not find a significant difference in hardware removal.

Benefits/Harms of Implementation

Any reoperation is considered a risk and the reoperation rate varied due to implant type and position. The use of multiple smaller plates rather than a single larger 3.5mm plate may benefit patients by providing similar union rates with a reduced rate of secondary procedures.

Outcome Importance

Dual plate fixation is an acceptable treatment for mid shaft clavicle fractures. There could be selection bias depending upon fracture type.

Cost Effectiveness/Resource Utilization

Higher rates of reoperation were noted for single implant fixation, leading to increased cost. In the one study that reported total operative time, those patients undergoing dual plate fixation took almost an hour longer in the operating room leading to increased cost. Formal cost analysis was not performed in any of the included studies.

Acceptability

These studies represent low quality studies with inconsistent operative details and outcomes. Consideration of dual plating techniques is likely acceptable to most orthopedic surgeons treating clavicle fractures as it within the current standards of care for treatment.

Feasibility

These studies may be useful when planning fixation for specific groups of patients in terms of counseling regarding hardware removal and union rate. Implementation of dual plating techniques in appropriate patients is likely feasible for most orthopedic surgeons as these implants are readily available in most hospitals similar to the single larger plates.

Future Research

Future studies are warranted on single versus dual plate fixation with controlled variables including type of plate, fracture type and positioning of plates. Details regarding duration of surgery and including patient reported outcome measures would be helpful. Large studies of diverse populations are necessary to assist in developing best practices on this topic.

Anterior inferior plating of midshaft clavicle fractures in adults may lead to lower implant removal rates compared to superior plating.

A single low-quality retrospective observational study (Serrano 2017) was included. There were 510 patients with mid-shaft clavicle fractures treated with either anterior-inferior (AI) plating or superior plating at the surgeon’s discretion. The minimum follow up was 24 months. Regarding union rate and time to union, there was no difference between treatment groups. Similarly, regarding infection rate, there was no difference between treatment groups. Regarding implant removal for plate irritation, AI plating was preferred with superior plating carrying a 5 times greater odds ratio. Due to the decreased risk for a secondary intervention, this could be inferred to decrease the financial burden for the patient.

Benefits/Harms of Implementation

There is increased patient satisfaction assumed due to the decreased need for plate removal. Additionally, there are risks to a second operation so reducing the risk of a secondary operation is likely beneficial to patients.

Outcome Importance

There is no difference in union rate or time to union dependent upon plate position for mid shaft clavicle fixation. In addition, the infection rate is not different depending upon plate placement. However, rates of implant removal may vary depending on plate position and surgeons should be aware of this. The plate position for fixation should be at the discretion of the treating surgeon.

Cost Effectiveness/Resource Utilization

Due to decreased need for plate removal with anterior inferior plating, there is decreased burden on the health care system.

Acceptability

Either treatment is acceptable. The patient can be counseled regarding a low-quality study finding a lower need for plate removal and assumed increased patient satisfaction. Many orthopedic surgeons treating clavicle fractures likely already use both plate positions depending on fracture pattern and patient characteristics.

Feasibility

Either plate position should be feasible for most orthopedic surgeons treating clavicle fractures.

Future Research

Future research is needed to increase the number of studies with these two treatment interventions in direct comparison. Research should also focus on patient reported outcome measures to understand the relationship between satisfaction and plate removal.

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.

Two low quality studies were reviewed comparing pre-contoured and non-contoured plates for the treatment of clavicle fractures (Fang 2020, Rongguang 2016). Both studies demonstrated no significant differences in the rates of patient reports outcomes, or adverse events. Fang (2020) found pre-contoured plates offered a lower rate of implant deformity (0 vs. 11.3%) however implant removal rates, and clinical outcomes were similar between groups. Rongguang (2016) reported lower rates of hardware removal in the pre-contoured plate groups and those with high BMI.

Benefits/Harms of Implementation

Both pre-contoured and non-contoured plates offered similar functional outcomes across both studies. Rongguang (2016) suggested a reduced rate of implant removal which may provide the benefit of reduced incidence of revision surgery with no specific downside. Additionally, anatomically pre-contoured plates may be less likely to undergo deformity however the clinical significance of this was not demonstrated in either clinical study.

Outcome Importance

Further understanding of the utility of pre-contoured plates may provide insight into cost effective ways to manage this common pathology.

Cost Effectiveness/Resource Utilization

No evidence was presented in either study specific to cost effectiveness or resource utilization; however, given the higher rate of plate removal reported by Rongguang (2016). This is a future area of research need.

Acceptability

Both plate types (pre-contoured and non-contoured) use similar surgical techniques and would not require significant changes to established practices.

Feasibility

Anatomically pre-contoured plates are generally more expensive than non-pre-contoured plates. The availability of pre-contoured plates may be a significant deterrent to the feasibility of this recommendation in areas without access to such instrumentation.

Future Research

Further high-quality studies evaluating the clinical, radiographic, and functional outcomes of patients treated with clavicle fractures are needed. Additionally, a cost effectiveness study would help to stratify the utility of these techniques.

Upright radiographs may be superior for demonstrating the degree of displacement in midshaft clavicle fractures when compared to supine radiographs.

Two low quality studies were reviewed demonstrating more displacement of midshaft clavicle fractures with upright compared to supine radiographs (Herman 2019, Malik 2017). Herman et al. found a higher proportion of displacement greater than 100% in the group with upright radiographs (52.1% vs 33.5%). Malik (2017) specifically measured the change in vertical and horizontal displacement on supine and upright radiographs taken within 2 weeks and found significantly more displacement in both planes in the upright group. The mean displacement ranged from 3.34 to 6.3 mm with use of upright films when compared to supine radiographs. Additionally, Herman et al. noted upright films more frequently lead to a change in treatment as a result of displacement when compared to supine imaging. Upright clavicle radiographs may provide more information regarding displacement compared to supine radiographs alone.

Benefits/Harms of Implementation

Patient positioning for upright versus supine radiographs is unlikely to cause notable harm or benefit to the patient. Upright radiographs are likely to show more displacement and may lead to changes in treatment secondary to displacement compared to supine radiographs.

Outcome Importance

Understanding the impact of positioning on displacement is important for the treating surgeon so that appropriate treatment and injury stratification can be determined.

Cost Effectiveness/Resource Utilization

No evidence related to cost or resource utilization is available on this topic. It is unlikely that there is a substantial difference between upright and supine radiographs as this is only a difference in patient positioning.

Acceptability

Little needed change in practice pattern makes this recommendation likely to be acceptable to most.

Feasibility

Alterations in position are feasible in most x-ray settings. Obtaining upright radiographs, once patient is able, can be performed in a subacute manner without clinically relevant changes in treatment.

Future Research

Continued understanding of the impact of displacement on clinical outcomes is necessary.

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.

Four low quality observational studies examined the impact of various factors on the rate of nonunion for non-operatively treated midshaft clavicle fractures. Two studies found that comminution and displacement had a significant impact increasing the rate of nonunion (Liu 2015, Robinson 2004). One study found that comminution predicted delays in union at 6 and 12 weeks, but not by 24 weeks (Robinson 2004). Finally, one study found that comminution did not impact union rates (Rugpolmuang 2016). Based on the available evidence it is likely that comminution and displacement increase the risk of nonunion of a non-operatively treated midshaft clavicle fracture.

Benefits/Harms of Implementation

Understanding predictors of nonunion will benefit patients by providing the surgeon with more predictive information to help guide treatment. This can help minimize treatment delays and inappropriate treatment for patients.

Outcome Importance

Understanding predictors of nonunion with non-operative treatment of clavicle fractures is critical to patient counseling and treatment decision making.

Cost Effectiveness/Resource Utilization

Understanding predictors of nonunion can help lead to optimizing treatment for a patient earlier to reduce time off work while balancing complications.  

Acceptability

Surgeons are likely to accept that there may be a higher risk of nonunion based on certain fracture characteristics, although this clinical practice guideline is not making treatment recommendations.

Feasibility

 Guidelines regarding risk provide surgeons with information to help counsel patients and guide treatment but no treatment recommendations are provided here.

Future Research

Further research regarding outcomes is needed so that surgeons can make treatment decisions based on the risk of nonunion.

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.

Two low-quality studies (Swarup 2011, Riiser 2021) comparing operative and non-operative treatment of clavicle fracture in adolescent patients (≤ 18 years old) met inclusion criteria. Both studies found no significant difference in patient reported outcomes between operative and non-operatively treated patients. Swarup (2021) found no significant difference between groups in QuickDASH, Numerical Rating Scales for pain, UCLA Activity Scale, PROMIS Pain Interference, and PROMIS Physical Function Upper Extremity, and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Eight of forty-three operatively treated patients required implant removal (Swarup 2011). Conducting a similar comparison, Riiser (2021) found no significant difference in QuickDASH or Oxford Shoulder Score. However, they did find that non-operative treatment was favored for cosmetic outcomes, pain, and patient satisfaction (Riiser 2021). 

Benefits/Harms of Implementation

The decision for surgery in an adolescent patient should be based upon a shared decision-making model with the understanding that there is no difference in outcome measures once the fracture has healed. Surgery should be reserved for select cases in the older adolescents.

Outcome Importance

It is important to understand surgical treatment with a plate or intramedullary nail does not confer an advantage in functional outcomes. Displaced, midshaft clavicle fractures in adolescents heal regardless of what treatment method is chosen as no non-unions were reported in the two studies (Swarup 2021, Riiser 2021).

Cost Effectiveness/Resource Utilization

Operative treatment has a higher need for implant removal, thus increasing health care costs and the risks associated with additional surgery.

Acceptability

Families and patients need to be counseled they can expect similar functional results with surgery or without surgery and the studies favor a trend toward non-operative treatment providing a more favorable cosmetic result.

Feasibility

Guidelines regarding treatment risks and outcomes provide surgeons with information to help counsel patients and their families. No specific treatment recommendations are provided as similar outcomes are demonstrated regardless of how they are treated.

Future Research

Due to the low number of studies on this topic, there is need for future research to provide best evidence to guide decision making. Research should be directed towards the older adolescents, age 14 –18.

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.

A systematic review of literature yielded no studies that met inclusion criteria for this topic. Sling immobilization has been the mainstay of non-operative treatment in most studies evaluating non-operative treatment of clavicle fractures (Ahrens 2017, Smekal 2009, COT 2007, Ban 2021, Woltz 2018). Other modalities have included Collar and Cuff (Robinson 2013) and Figure-of-Eight bandage (Naveen 2017, Tamaoki 2017). However, these have been less studied overall compared to ORIF. A randomized trial for mid-shaft clavicle fractures treated non-operatively, demonstrated no improvement in function, reduced pain, and improved patient comfort/compliance with sling when compared to Figure-of-Eight (Ersen 2015). Simple Sling immobilization is easily applied, well tolerated, and cost effective.

Benefits/Harms of Implementation

Sling immobilization offers a simple, cost-effective technique for non-operative care. The risks, or harms of implementation are minimal for this specific intervention. The technique is ubiquitous with minimal opportunity for the generation of health disparities or access to treatment.

Outcome Importance

Identifying optimal immobilization strategies for patient comfort while maximizing outcomes is critical for patient satisfaction and improving the success of non-operative management when indicated

Cost Effectiveness/Resource Utilization

Sling immobilization is simple, and low cost with few significant risks compared to more complex or expensive immobilization methods

Acceptability

Surgeons and patients are likely to accept that sling immobilization may be optimal for non-operative management given its prevalence, simplicity of use and low cost.

Feasibility

Recommendations, even those with consensus only support, inform and help counsel patients regarding treatment. The use of sling immobilization is inexpensive and can be applied broadly across health care settings and environments.

Future Research

Further research regarding the optimal immobilization method(s) including sling, collar and cuff or figure of eight sling, is needed so that surgeons can make evidence-based treatment decisions to optimize patient comfort, and outcome.

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.

A systematic literature review yielded no studies that met inclusion criteria for this clinical practice guideline. Outside the inclusion criteria, limited reliable evidence exists to guide surgeons on the optimal treatment of lateral clavicle fractures. Overall multiple surgical techniques have been described with newer techniques associated with improved outcomes and reduced re-operation. The work group is of the opinion that given the available evidence supporting modern techniques of fixation and the established high risks of non-union, surgical management may be appropriate in selected patients with displaced lateral clavicle fractures.

Benefits/Harms of Implementation

Surgical management of lateral clavicle fracture with coracoclavicular ligament injury may reduce the risk of non-union and improve patient outcomes. However, given the lack of supportive literature at the current time careful consideration must be made to avoid unnecessary operative interventions in this patient population.

Outcome Importance

Further understanding of the utility of surgical management of the displaced lateral clavicle fracture with Coracoclavicular ligament disruption may provide insight into the clinical effectiveness and cost effectiveness of the technique

Cost Effectiveness/Resource Utilization

No evidence related to cost or resource utilization is available on this topic. This would be an important area of further research to guide thoughtful health policy and treatment decisions.

Acceptability

Little change is required to implement this recommendation; thus, it is likely to be acceptable to most.

Feasibility

Implementation of this recommendation requires little additional surgical change however, public health resources and the associated cost of treatment may make this less feasible in some health care settings. Additionally, novel treatment techniques described to address this injury may require additional expertise or knowledge prior to implementation.

Future Research

Continued understanding of the impact of displacement, and the role of treatment on clinical outcomes is necessary.