Midshaft clavicular fractures in adolescents: a comprehensive review of diagnosis and management

Heather L. MacEwen; Michael Morell; Scott Feeley; Nicholas Lopreiato; Chris Renninger; Daniel Song

doi:10.5397/cise.2025.00500

Clin Shoulder Elb > Volume 28(4); 2025 > Article

MacEwen, Morell, Feeley, Lopreiato, Renninger, and Song: Midshaft clavicular fractures in adolescents: a comprehensive review of diagnosis and management

Review

Clinics in Shoulder and Elbow 2025; 28(4): 495-503.

Published online: September 18, 2025

DOI: https://doi.org/10.5397/cise.2025.00500

Midshaft clavicular fractures in adolescents: a comprehensive review of diagnosis and management

Heather L. MacEwen¹

, Michael Morell¹

, Scott Feeley²

, Nicholas Lopreiato²

, Chris Renninger²

, Daniel Song²

¹School of Medicine, Uniformed Services University, Bethesda, MD, USA

²Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA

Corresponding Author: Heather L. MacEwen School of Medicine, Uniformed Services University Bethesda, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
Tel: +1-800-515-5257 E-mail: heather.l.macewen.mil@health.mil

Received: May 7, 2025 Revised: June 27, 2025 Accepted: July 8, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Midshaft clavicular fractures account for approximately 80% of all clavicle fractures in pediatric and adolescent populations and represent up to 15% of all fractures in adolescents. These injuries commonly result from falls, sports-related trauma, or motor vehicle accidents, with adolescent males experiencing fractures at rates up to three times higher than females. This review examines the diagnosis, classification, and management of these fractures, highlighting the nuances between pediatric and adult treatment approaches. Historically, nonoperative management has been favored, leveraging the adolescent clavicle’s remodeling capacity. Recent trends reflect increasing operative interventions, driven by adult studies demonstrating faster recovery and improved functional outcomes in displaced fractures. While nonoperative treatment, using slings or figure-of-8 braces, remains effective for most cases, operative fixation, including open reduction and internal fixation or elastic stable intramedullary nailing, is indicated for open fractures, neurovascular injury, or significant displacement. Studies demonstrate high union rates with both methods, but operative treatment offers quicker return to activity, albeit with higher risks of hardware-related complications. The Function after Adolescent Clavicle Trauma and Surgery study notably supports nonoperative management, showing similar long-term functional outcomes compared to operative treatment. Future research should focus on refining patient-reported outcome measures specific to adolescents and identifying subsets of patients who may benefit from surgery. Shared decision-making remains crucial for optimal patient-centered care.

Key Words: Clavicle fracture; Adolescent; Midshaft fracture; Nonoperative treatment; Patient-reported outcomes

INTRODUCTION

Clavicle fractures account for up to 15% of all fractures in adolescents [1,2]. Of these, midshaft fractures are of the highest prevalence and represent approximately 88% of clavicle fractures [3]. These fractures are commonly traumatic, resulting from falls, sports injuries, or motor vehicle accidents, and are common in active adolescents involved in high-impact activities [2,4]. Understanding the musculoskeletal and clinical differences between children, adolescents, and adults in terms of bone healing, growth potential, and functional capacity is critical to the management of pediatric clavicle fractures [5]. A key distinction between pediatric and adult patients relates to healing patterns through the greater remodeling capacity of skeletally immature patients. Adolescence is a somewhat ambiguous liminal period characterized by rapid musculoskeletal maturation in which the clavicle is not yet skeletally mature. This period ranges from age 10 to 19 years according to the World Health Organization. The American Academy of Pediatrics defines adolescence as ages 11 to 21 years and further subdivides it into early, middle, and late adolescence at 11 to 14, 15 to 17, and 18 to 21 years, respectively. This demographic has greater remodeling potential for fractures. Conversely, adolescents pose a challenge as they begin to approach skeletal maturity as they demonstrate fracture patterns increasingly similar to those of adults despite remaining a unique demographic. As a result, management strategies in this population must carefully balance the benefits of nonoperative care with the potential advantages of surgical intervention, especially in cases of significant displacement or comminution [6,7]. While a specific consensus on displacement criterion in the adolescent literature has not been described, a >2-cm threshold for displacement has been consistently studied in operative management6. Historically, midshaft clavicle fractures have primarily been treated nonoperatively. However, there has been an increasing trend toward operative treatment [8,9]. This shift has been driven by emerging evidence from adult populations indicating that surgical intervention may lead to faster recovery, improved functional outcomes, and a quicker return to sports and physical activities, all of which are often key concerns for active adolescents [10]. Surgical treatment is not without risks, and complications such as hardware prominence, infection, and need for revision surgery must be carefully weighed against the potential benefits [7]. This review aims to provide a comprehensive overview of the current literature on the diagnosis, classification, and management of midshaft clavicle fractures in adolescents, focusing on the advantages of nonoperative and operative approaches.

ANATOMY

The clavicle is an S-shaped bone that connects to the axial skeleton medially through the sternoclavicular joint, while its lateral end articulates with the scapula at the acromioclavicular joint. Developmentally, the clavicle is the first bone to ossify, beginning at 5 weeks of gestation with two primary ossification centers that fuse midshaft through intramembranous ossification. By 7 weeks of gestation, cartilaginous growth areas develop at the acromial and sternal ends, initiating endochondral ossification. The clavicle is not only the first bone to ossify, but it is also the last bone to completely fuse, typically closing between 21 and 24 years [11,12]. This early, prolonged, and unique developmental process influences clavicle growth and remodeling potential and contributes to its vulnerability to fractures at different stages of life, beginning with birth-related trauma.

EPIDEMIOLOGY

Clavicle fractures are the most common birth-related fracture, often occurring due to shoulder dystocia during vaginal delivery [13]. In preambulatory infants, clavicle fractures are uncommon outside the perinatal period and should raise concern for non-accidental trauma, particularly in the absence of a clear mechanism. Children aged 10 years or younger are more likely to experience middle-third fractures or nondisplaced fractures, often as a result of low-energy trauma, such as falls from height or playground injuries [3]. In contrast, adolescents—particularly early and middle aged adolescents 10 to 17 years of age—exhibit a higher frequency of more severe, displaced fractures, often resulting from high-energy mechanisms in activities such as contact sports (e.g., football, lacrosse, hockey), biking, or motor vehicle accidents [2]. Increased sports participation significantly contributes to the higher incidence of clavicle fractures in adolescents. While the adolescent clavicle retains significant remodeling potential, it is less pronounced than in younger children and depends on skeletal maturity. The clavicle reaches approximately 80% of its length by 9 years in girls and 12 years in boys [5]. Above the age of 12 years, the growth rate averages 5.4 mm per year for males and 2.6 mm per year for females [5].

Clavicle fractures are among the most common fractures in the pediatric population, with a significant portion occurring in the midshaft region. In pediatric and adolescent trauma, clavicle fractures make up approximately 10%–15% of all fractures, with incidence varying depending on age, activity level, and activity of choice [1,2,14]. These fractures are particularly frequent in adolescents and are often associated with a direct blow to the shoulder during sports participation [2]. The incidence and presentation of clavicle fractures change notably as children mature, reflecting differences in bone composition, activity levels, and the potential for fracture healing and remodeling. The overall incidence of clavicle fractures in children shows a marked increase with age, peaking during adolescence. Karl et al. [15] reported that the incidence of clavicle fractures was bimodal, with the highest rates in the younger than 18 and older than 65 year age groups (10.2 and 5.1 per 10,000 person-years, respectively).

The most common type of clavicle fracture is midshaft fracture, representing approximately 70%–80% of all clavicle fractures in pediatric and adolescent populations. The prevalence of midclavicular fractures specifically decreases with age, accounting for up to 88.2% of clavicle fractures within the first decade of life [3]. Boys, who traditionally engage more frequently in contact sports, exhibit a higher rate of clavicle fractures compared to girls, with some studies reporting a male-to-female ratio of up to 3:1 in certain populations. Ellis et al. [2] found that 545 patients (79% male) with diaphyseal clavicle fractures had a mean age of 14.1±2.1 years, with 82% of fractures occurring between 11 and 16 years. The timing of peak fracture incidence is also closely associated with periods of rapid growth, where bone strength may temporarily lag behind increases in size and weight.

CLINICAL PRESENTATION AND DIAGNOSIS

Adolescents with midshaft clavicle fractures typically present with localized pain, deformity, swelling, and tenderness over the fracture site following injury. Tenting of the skin can be observed in markedly displaced fractures due to sharp fragment angulation piercing through the deltotrapezial fascia. Patients often report shoulder motion pain, particularly at abduction and forward elevation. Ecchymosis may present across the upper chest and shoulder from soft tissue trauma. Due to the proximity of the brachial plexus and subclavian vessels to the clavicle, traumatic injury and fracture can compromise these surrounding structures, necessitating neurovascular examination on presentation. While direct vascular injury is rare, blunt trauma can cause subclavian vessel spasm or thrombosis, leading to distal vascular compromise with diminished pulses or skin discoloration secondary to poor perfusion. Focal neurologic deficits distal to a clavicle fracture should raise suspicion for brachial plexus injury. Notably, the ulnar nerve is at the highest risk of injury because of its location adjacent to the middle-third of the clavicle [16]. Ulnar nerve injury due to clavicular fracture may present with sensory deficits of the dorsal fourth and fifth fingers as well as the hypothenar eminence. In contrast, motor deficits could lead to flexion impairment in the ring and small fingers as well as impaired interossei and lumbrical muscle functions.

Imaging Evaluation

Radiographic assessment is the gold standard for diagnosing and classifying clavicle fractures, particularly in adolescent patients. It can also be helpful in assessing concomitant injuries such as shoulder dislocations. Standard imaging includes anteroposterior and 15° to 45° cephalad tilted views to assess fracture location, displacement, angulation, and shortening at time of injury. Anteroposterior plain radiographic imaging of the bilateral clavicles has been used in follow-up to further characterize shortening and remodeling at large study centers. However, this modality is largely unable to capture sagittal plane deformities and subtle side-to-side differences, hindering the clinical utility of bilateral reimaging in the pediatric population [17]. While plain radiographs should be used primarily in most cases, computed tomography (CT) with or without three-dimensional reconstruction of the clavicle remains the more precise technique. Advanced imaging may be considered when there is concern for neurovascular injury, posterior sternoclavicular joint dislocation, or scapulothoracic dissociation [18]. Due to the significantly higher radiation doses associated with CT scans than plain films, their use remains controversial, particularly in radiosensitive pediatric and adolescent populations [19].

MANAGEMENT STRATEGIES

Nonoperative Treatment

Historically, midshaft clavicle fractures in adolescents have been managed nonoperatively, even in cases of significant displacement. This approach was largely influenced by early studies [20], which reported nonunion rates as low as 0.1% with adequate remodeling despite substantial shortening and angulation, which is a testament to the remodeling capacity of the clavicle in the pediatric skeleton. The rarity of nonunion has been demonstrated in a more recent study at 0.4%, although malunion continued to be observed radiographically without significant functional impairment [2]. Adult populations were similarly managed nonoperatively in the majority. However, recent studies in adult populations have challenged this belief by showing that nonoperative treatment of displaced fractures may result in higher nonunion rates [21,22].

Nonoperative treatment remains the primary treatment for acute nondisplaced midclavicular fractures in the pediatric population. Given the clavicle’s strong healing potential following mid-diaphyseal fractures in younger patients, even completely displaced or comminuted fractures have traditionally been allowed to heal successfully without surgical intervention, relying on the bone’s natural remodeling capacity. Nonoperative management remains the preferred clinical approach for all clavicle fracture patterns, as demonstrated by a 2011 computer-based survey study of 188 Pediatric Orthopaedic Society of North America members. More than 90% of these doctors favoring nonoperative treatment for nondisplaced and angulated midshaft clavicle fractures in the 12–19-year-old adolescent population [23].

Common nonoperative treatment options in adolescents include 2 to 4 weeks of shoulder immobilization with a simple sling or a figure-8 brace [6]. While no study has directly compared a simple sling with figure-8 brace exclusively in adolescent patients, the evidence has demonstrated no significant difference in functional or cosmetic outcomes between these two immobilization methods in pediatrics and late adolescence into adulthood. In a randomized controlled trial, Ersen et al. [24] compared the broad arm sling and the figure-8 bandage for midshaft clavicle fractures in patients older than 15 years, evaluating pain, functional outcomes (Constant and American Shoulder and Elbow Surgeons scores), and radiographic union. The study found that the two methods yielded similar functional and radiographic outcomes, although the broad arm sling was associated with significantly lower pain levels during the first three days of treatment [24]. Furthermore, the figure-8 bandage was more difficult to apply and caused greater initial discomfort, resulting in preference for the broad arm sling due to patient management factors, such as ease of use and improved early pain control. Similarly, figure-8 bracing was not superior to simple slinging in pediatric patients aged 2 to 9 years, sustaining the use of broad arm sling for nonoperative management [25]. Meta analysis has also failed to definitively prove the benefit of one specific modality in adolescent patients 14 years or older [26]. It is our recommendation that a simple broad arm sling be used for nonoperative immobilization and management of adolescent clavicle fracture due to comparative simplicity and pain reduction. Following immobilization, return to sports in pediatrics and all age range adolescents is typically recommended 6 to 8 weeks post-injury provided that the fracture site is non-tender and radiographic healing is evident [18]. Specific return to sport timelines are correlated heavily to the initial fracture pattern, with greater displacement, comminution, and angulation all delaying return [27]. Patients and parents should be informed that, while fracture healing is rapid, a palpable bump will develop over the fracture site due to callus formation, which will gradually remodel over several months and is not of functional concern (Fig. 1).

Much of adolescent management has been formed through evidence in skeletally mature adults. However, recent investigation into this unique population has begun to address this disparity. The Function after Adolescent Clavicle Trauma and Surgery (FACTS) prospective, multicenter cohort study is a landmark adolescent study that evaluated 545 patients aged 10 to 18 years with clavicle fractures within tertiary care pediatric trauma centers. FACTS included all patients with traumatic diaphyseal fractures. Of the 545 cases, 83% (451 fractures) were managed nonoperatively, closely resembling conservative management trends in adults between the ages of 18 to 65 years [2]. Notably, nearly one-third of completely displaced fractures in this population were radiographically indicated for surgery based on a commonly used criterion of >2 cm shortening, demonstrating the persistent use of nonoperative management in the adolescent population in contradistinction to adults.

A separate analysis of the FACTS multicenter study performed by Heyworth et al. [8] examined 416 adolescents aged 10 to 18 years from the previous study. This study included only patients with completely displaced midshaft clavicle fractures without extension into ligamentous insertions. A subpopulation of 282 patients (68%) that provided 2-year patient-reported outcomes (PRO) was subsequently studied. PROs were analyzed statistically via two-sided Fisher exact test, where propensity score matching analysis for age, shortening, displacement, and comminution appropriately matched confounders. Eighty-eight (31%) operative patients were identified and compared to the remaining nonoperative group on demographic, radiographic, clinical variability, and functional scoring differences. This adjusted analysis found no significant differences in any functional PRO parameters between operative and nonoperative groups. Additionally, combined analysis found that overall nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were rare, with no significant difference between operative and nonoperative groups [8]. Separately, a 10-year review across nine pediatric hospitals identified only 25 adolescent patients with clavicle nonunions, all requiring surgical fixation [7]. Together, these studies support the rarity of clavicle nonunions in adolescents. In contrast, adult literature consistently reports higher rates of nonunion and symptomatic malunion, which have been key indications for operative fixation. A meta-analysis by McKee et al. [21] reviewed randomized clinical trials comparing operative versus nonoperative treatment and found nonunion in 15% of nonoperative patients, significantly higher than the 1% rate in operative patients (P=0.001).

Operative Treatment

While nonoperative management remains the standard of care for most adolescent midshaft clavicle fractures, operative intervention is indicated in select cases, including open fractures, skin tenting or compromise, and major vascular injury. Additional relative indications for surgical repair include refracture, displacement greater than 2 cm, end-to-end shortening greater than 1.5–2.5 cm, symptomatic nonunion or malunion, and comminution [6,7,28]. In recent years, expanded surgical indications have been debated, largely influenced by adult studies demonstrating improved functional outcomes with operative fixation in displaced fractures. A multicenter randomized controlled trial in adults by the Canadian Orthopaedic Trauma Society found that surgically managed displaced midshaft clavicle fractures had faster time to union (16.4 vs. 28.4 weeks, P=0.001), lower rates of nonunion (1% vs. 15%, P=0.042) and malunion (0% vs. 18%, P=0.001), and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (P=0.001) compared to nonoperative treatment [29]. This landmark study has influenced the adult management of clavicle fracture; however, the study excluded patients younger than 16 years, and its findings may not be valid in the early adolescent population.

Operatively managed midshaft clavicle fractures in the pediatric population are treated in a similar manner to the adult population, primarily with open reduction and internal fixation (ORIF) despite incomplete development [30]. As the middle-third of the clavicle has the highest bone density in both the skeletally mature and immature [31], ORIF is a viable surgical technique for midshaft operative management in adolescents. Naimark et al. [32] found that patients aged 10 to 19 years accounted for 26% of all clavicle ORIFs. ORIF can be performed in beach chair or supine position with conventional plates and screws or through elastic stable intramedullary nailing (ESIN). Dynamic compression plates or reconstruction plates are generally favored, although pre-contoured plates have also been successfully used with the added benefit of ease of placement. Semi-tubular and locked plates may be inappropriate due to inadequate rigidity and significant cost, respectively. A 3.5-mm dynamic compression plate or plate of similar strength with screws crossing at least six cortices on each side of the fracture are recommended. Plate placement can be superior or anterior. However, superior positioning may lead to symptomatic hardware. While dual superior and anterior plating with smaller plates is posited to enhance stability in adult populations and reduce hardware prominence, this has not demonstrated superior clinical outcomes in adults. Furthermore, dual plating has not been studied in adolescent populations.

ESIN fixation exists as an alternative technique to plating that may be favored by subspecialists in adolescent populations due to its less invasive nature. The ESIN technique is relatively contraindicated in multifragmentary, comminuted, pathologic, or open fracture. Indications for ESIN are otherwise similar to those for operative plating, comprising full displacement and shortening >2 cm. For ESIN fixation, the entry site is accessed through a smaller incision over the medial clavicle for insertion into the medullary canal. After open reduction through the small incision, the nail is advanced across the fracture site. The potential advantage of ESIN over plate fixation lies in the smaller incisions, reduced hardware prominence over the fracture site, and decreased soft tissue trauma. ESIN has also been recently shown to have similar functional outcomes to plating in adolescents with shorter operative times [33]. However, ESIN is generally followed with planned implant removal, incurring the risk of additional surgical treatment. Additionally, ESIN adds potential complications of nail migration, hardware deformation or breakage, and skin irritation at the insertion site, especially prior to planned implant removal [34]. While cosmetic results may favor ESIN, conventional plating is generally favored in practice for its familiarity, relative simplicity, effectiveness with comminution, strong fixation, and good functional result [30].

Postoperatively, the shoulder is often immobilized in a sling for 4–6 weeks. Cortical plates generally remain in place after union. The decision regarding hardware removal following fixation is multifactorial, where removal can be performed to relieve pain or discomfort from hardware prominence or protrusion and to limit impacts in the skeletally immature adolescent. Implant removal has been reported in 17%–40% of primary plating and is generally elective. However, some institutions routinely plan for hardware removal in adolescents. Implant removal carries additional risks that cannot be disregarded. An ideal timeframe for removal is a matter of debate, although some sites perform removal as early as 6 months while others wait up to 1 year to minimize the risk of refracture [35]. The decision to remove hardware lacks consensus and is more clinically based on individual patient characteristics and activity levels [30,36,37].

OUTCOMES AND COMPLICATIONS

Nonoperative

Complications following midshaft clavicle fractures in adolescents vary depending on treatment, with both operative and nonoperative management carrying specific risks. While nonunion and symptomatic malunion are rare in pediatric patients, growth disturbances and hardware-related complications remain concerns. Schulz et al. [38] found that, at 2 years post-injury in patients 11 to 17 years, nonoperative management of completely displaced, shortened midshaft clavicle fractures resulted in a 100% union rate without significant loss of range of motion. Strength was comparable to that of the uninjured limb, except for an 8% decrease in maximal shoulder external rotation strength (P=0.04) and an 11% loss of shoulder abduction endurance strength (P=0.04) [38]. Despite this strength difference and an accompanying significant shortening compared to the uninjured clavicle (P≤0.001), functional outcomes including Single Assessment Numeric Evaluation, a short-form version of the DASH (QuickDASH) score, and Constant scores were similar between sides. Additionally, all patients returned to the same or higher level of preinjury activity, drawing question to the clinical significance of these strength differences. As mentioned previously, the FACTS study found a low overall rate of complications, including nonunion, delayed union, symptomatic malunion, and refracture, in this cohort. Among these, refracture was the most common, occurring in six patients (2.1%) in the nonoperative group, all healed with additional nonoperative treatment [8]. That study found no significant difference in PROs between operative and nonoperative treatment of displaced midshaft clavicle fractures in adolescents. Despite greater fracture severity in operative patients (comminution and increased shortening), PRO scores, including DASH, remained similar even after adjusting for confounders [8]. Last, Strauss et al. [39] analyzed 537 pediatric clavicle fractures at a single institution of patients between ages 0 and 17 years with an older peak of the bimodal distribution during middle adolescence at 10–17 years. That study found an overall complication rate of 3.7%, with only 2.5% of fractures treated nonoperatively experiencing complications. These data all contribute to the favoring of nonoperative management in adolescent clavicle fractures, as conservative treatment yields similar functional outcomes while mitigating surgical risk.

Operative

Surgical intervention carries inherent risks, including infection and need for removal of hardware due to implant-related issues. Kamaci et al. [40] evaluated the functional and cosmetic outcomes of adolescent contact sports athletes (age, 11–19 years) who underwent surgical fixation for midshaft clavicle fractures. All patients achieved radiographic union by 6 weeks postoperatively and returned to competitive sports at preinjury level within a mean 45.9±16 days [40]. Another study directly compared the outcomes of operative and nonoperative treatment for displaced pediatric midshaft clavicle fractures in children and early and middle adolescents aged 8 to 16 years, specifically examining mean time to union and time to return to activity. They found that operative treatment resulted in a significant decrease in time to union (7.3 weeks vs. 10.4 weeks, P<0.001) and an earlier return to activity (9.2 weeks vs. 16.6 weeks for the nonoperative group, P<0.001) [41]. Vander Have et al. [6] conducted a retrospective study of 42 patients comparing operative versus nonoperative fixation of midshaft clavicle fractures in adolescents aged 12 to 17 years (mean age, 15.4 years). The operative group had a greater degree of shortening on presentation (27.5 mm vs. 12.5 mm). The mean time to radiographic union for displaced fractures was 8.7 weeks in the nonoperative group and 7.4 weeks in the operative group (P=0.02), although no nonunions were reported in either group [6]. Notably, five patients treated nonoperatively developed symptomatic malunion. The most common complaint from this study population was implant prominence and irritation in six patients (40%), subsequently requiring implant removal in three patients (18.8%). A consideration unique to operative treatment is implant viability and removal. Some institutions routinely remove plates after union in adolescent patients for complication prevention, however this practice is not universally performed due to inadequate evidence and inherent risk during reoperation. For instance, Mehlman et al. [37] retrospectively reviewed 24 patients aged 7 to 16 years (mean age, 12 years 8 months) who underwent plate fixation for displaced clavicles. Although all fractures healed and 87% of patients returned to unrestricted sports (the remaining 13% not returning due to parental concern for reinjury rather than functional concern), some hospital centers may strongly recommend secondary operation for hardware removal in the skeletally immature [37]. Revision surgery for hardware removal also carries fundamental risks to which the nonoperative patient would not be exposed such as tissue damage and infection. Additionally, it remains unclear if hardware removal predisposes an adolescent to refracture. Refracture following implant removal, particularly in high-impact sports, is rare and occurs at similar rates to refracture adjacent to retained hardware [42].

Despite these findings, nonoperative treatment has been associated with similar long-term functional outcomes compared to operative fixation in adolescents, with no significant differences in shoulder endurance or strength after 2 years. In contrast, adult literature suggests that operative treatment results in lower nonunion and malunion rates, but these findings have not been consistently replicated in adolescent populations. These distinctions between adults and early to middle adolescents warrant the establishment of distinct and definitive guidelines. Overall, while surgical treatment may offer an earlier return to activity and correction of significant displacement, it carries a higher risk of complications, particularly hardware-related issues that often necessitate removal. Nonoperative treatment remains a viable option for most midshaft clavicle fractures in adolescents, given their strong remodeling potential and low risk of long-term functional impairment.

FUTURE DIRECTIONS AND RESEARCH

The FACTS study remains the most robust evidence for management strategy, highlighting that the number of nonoperative treatments in the adolescent population greatly surpasses operative cases, with similar long-term healing and functional outcomes. Nonetheless, that study highlights the need for further large-scale, prospective studies of the older adolescent athlete and the worst fracture patterns to determine if there is a subset of patients that would benefit from operative management. Additionally, randomized trials assessing aspects of operative or nonoperative intervention separately may further identify ways to optimize return to activity and overall short- and long-term outcomes. Additionally, more robust patient-reporting measures specific to adolescents should be utilized to assess the true impact of clavicle fractures and their treatment. DASH/QuickDASH scores were created to evaluate functional outcomes within adults and, while QuickDASH is reliable in adolescents older than 8 years, there is evident need for validated pediatric-formatted questionnaires [43]. Specific scoring systems, such as the pediatric/adolescent shoulder survey (PASS), which was developed as a pediatric analog to the DASH score, may more accurately represent pediatric levels of pain and activity through more applicable phrasing relating to functional and athletic outcomes [44]. The PASS and similar adolescent-focused scoring systems can aid in the practical value of continued research toward establishing a definitive benefit between modalities.

CONCLUSIONS

An understanding of the remodeling and healing potential of the clavicle is necessary to manage midshaft clavicle fractures in the adolescent population in distinction to adults. A thorough review of the current literature supports both nonoperative and operative management. Consistently high union rates and similar long-term functional outcomes have been repeatedly demonstrated through comparison of nonoperative versus operative management, with operative having the benefit of faster return to activity timelines. Ultimately, treatment decisions should be driven through patient-centered discussion by shared medical decision-making.

As this review article is based solely on previously published studies and does not involve direct human subjects research, it was deemed exempt from institutional review board review and approval.

NOTES

Author contributions

Conceptualization: SF, DS. Formal analysis: HLM. Supervision: SF, DS. Writing– original draft: HLM, MM. Writing – review & editing: SF, NL, CR, DS. All authors read and agreed to the published version of the manuscript.

Conflict of interest

None.

Funding

None.

Data availability

None.

Acknowledgments

None.

Fig. 1.

A 14-year-old male with a sports-related right midshaft clavicle fracture. (A) Initial injury radiograph demonstrated a minimally displaced fracture with apex cranial angulation and no associated soft tissue swelling or pneumothorax. (B) Six-week follow-up radiograph demonstrated interval healing with early callus formation and persistent cranial angulation. (C) Radiograph at 3 months post-injury demonstrated osseous union with restoration of clavicular length and contour.

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