Although the management of clavicle fractures now clearly requires the consideration of surgical indications, most clavicle fractures can be managed successfully with nonoperative treatment. Options for nonoperative management include a simple sling or figure-of-8 bandage. Neither has been shown to be effective in reducing displaced fractures and a comparative study revealed greater patient satisfaction and fewer complications with sling immobilization (6). Figure-of-8 bandages have been associated with pressure sores and neurovascular compression, particularly when overtightened in hopes of obtaining a closed reduction. Most authors recommend use of the sling full-time for a minimum of 10 to 14 days to allow resolution of acute pain before introducing range of motion exercises. Typically, patients gradually progress their range of motion such that the sling is discontinued by 4 to 6 weeks, and overhead activities are permitted. A return to full noncontact activities is allowed once progression toward radiographic union begins and when full motion has returned which is typically 6 to 8 weeks. A return to contact sports and repetitive overhead activities typically is delayed until 12 weeks. It should be noted that radiographic union often lags behind clinical improvement and that a combination of these factors must be considered in deciding upon the return to activity.

In rare situations, clavicle fractures require urgent or emergent surgical treatment. These include open fractures and impending open fracture from displaced fragments threatening the skin or neurovascular compromise. In these circumstances, rapid evaluation and operative treatment are required to prevent serious complications such as chronic infection, skin necrosis, or permanent impairment of the distal upper extremity. Additional indications for early operative management include multiply injured patients where fixation of the clavicle facilitates mobilization and the rare case of concomitant ipsilateral fractures of the clavicle and scapula. This double disruption of the superior shoulder suspensory complex can be addressed by stabilizing either or both of the clavicular and scapular fractures.

More commonly, treatment decisions are guided by optimizing functional outcome. Inherent in the assessment are the principle goals of minimizing the risk of nonunion and symptomatic malunion, which are the primary adverse events associated with isolated clavicle fractures. The available literature and classification systems provide a guide for predicting, which fractures are at greatest risk of developing these late complications (7,8). Indications for surgery are summarized in Table 29.2.