Most clavicle shaft fractures in children are nondisplaced, minimally shortened or angulated, and are well treated with nonoperative management. Indications for operative fixation include open fractures and impending open fractures. Relative indications for operative fixation include fractures in multi-trauma patients, floating shoulder injuries, comminuted fractures, and shortened fractures in older adolescents. Controversies exist in preferred methods of fixation and include superior or anteroinferior plating, locked or unlocked plating, and intramedullary fixation. Retrospective studies of operative fixation in children show the feasibility and safety of fixation and are helping to define operative indications, but stronger evidence and reliable outcomes’ measures for the pediatric upper extremity are still needed. Both nonoperative and operative treatment should be considered when making recommendations for treatment of significantly displaced or shortened midshaft clavicle fractures. The advantages and disadvantages of both should be clearly presented to the patient and family so that they may also participate in the decision-making process.