Executive Editor: Joseph Schatzker General Editor: Jonas Andermahr, Michael McKee, Diane Nam

Clavicle 15.3 A1 Undisplaced lateral, extra articular - Nonoperative treatment

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Glossary

1 Introduction top

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

The nonoperative management of distal clavicle fractures is similar to that of mid-shaft fractures.

Although the rate of radiographic non-union with displaced distal clavicle fractures is higher than in the mid-shaft, most elderly patients function well without a need for surgical reconstruction.

2 Activities of daily living top

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Sleeping

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.


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When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder.

It may be more comfortable to sleep in a sitting or semi reclined position.


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Hygiene

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.


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Dressing

Loose fitting clothing and button-up shirts are ideal. The 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.


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Progressive exercises

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, 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 approximately for 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.

3 Phases of nonoperative treatment top

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Phase I: Day one to three weeks after injury

After distal 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:

  • Open and closure of the hand
  • Squeezing of a soft ball

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  • Straightening and flexion of the elbow


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


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Phase II: Three to six weeks after injury

Pendular exercises can be started when pain starts to subside.


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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 change in 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

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


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Sub-maximal isometric exercises with:

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

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Phase III: Six to twelve weeks after injury

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

Radiographic union of distal clavicle fractures is often delayed compared to similar midshaft fractures. Especially in low demand patients, this should not interfere with the progression of rehabilitation, as most of these patients will obtain nearly full function and minimal pain despite radiographic evidence of delayed or non-union.

Return to full activities and/or contact sports is permitted typically beyond 6 months post injury after full healing of the fracture, however, this may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

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