Nonoperative treatment

Most clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial management typically requires temporary immobilization for comfort followed by gradual increase in activity.

There is insufficient evidence that a figure of 8 bandage obtains better results than a simple splint which is easier to use and has less discomfort.

The patient should sleep on his/her back or on the non-injured side, wearing the sling.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

When sleeping on the back, the injured side can be supported by placing a pillow underneath the arm, but the patient can assume any position of comfort. Some even find it more comfortable sleeping in a sitting or semi reclined position.

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

Loose fitting clothing and button-up shirts are ideal. The non-affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder motion, and/or the fracture shows early evidence of healing radiographically.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The phases of nonoperative treatment are thus

• Temporary immobilization
• Passive/assisted range of motion
• Active range of motion
• Progressive resistance exercises

Usually immobilization is maintained for 3-4 weeks.

This is followed by gentle range of motion exercises.

Non-weight-bearing of the affected upper limb is required for approximately 6 weeks or until radiographic and clinical evidence of progressive healing.

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms. All sporting activity and work requiring forceful use of the arm is withheld until there is evidence of clinical and radiographic union. The clavicle should unite in 8-12 weeks.

After clavicular injury, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended.

• Straightening and flexion of the elbow
• Open and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion
• Movement of an open hand from side to side

• Squeezing the shoulder blades together, while shoulders remain relaxed

Pendular exercises can be started when pain starts to subside.

Gradual progression to passive and assisted range of motion exercises are started as tolerated when the fracture begins to move as a unit, and there is no significant displacement visible on the x-ray. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

Activated assisted range of motion exercises are started with:

• External rotation
• Internal rotation

• Flexion with arms on table
• Flexion with ball on wall

Sub-maximal isometric exercises with:

• Internal rotation
• External rotation (1)
• Abduction (2)
• Extension

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.