skip to main content

Displaced midshaft clavicle fracture with threatened skin integrity — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardShoulder InjuriesDisplaced midshaft clavicle fracture with threatened skin integrityMSRA

A 31-year-old self-employed electrician is seen in general practice the day after falling directly onto his left shoulder from an e-scooter. In the emergency department, radiographs showed a comminuted midshaft clavicle fracture with complete displacement and 22 mm shortening. He was discharged in a shoulder immobiliser with a virtual fracture-clinic appointment in 10 days. Today he reports increasing focal pressure beneath the fracture. Examination shows a sharp bony prominence with tightly stretched, blanched and non-mobile skin directly over it. The skin is intact. Radial pulse, capillary refill, motor function and sensation in the arm are normal. There is no dyspnoea, chest pain or other injury. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Arrange same-day emergency orthopaedic assessment for a clavicle fracture with threatened skin integrity

Explanation lettering: E = shown as B · B = shown as C · C = shown as E

This fracture has become skin-compromised: the important discriminators are progressive pressure, a sharp prominence, and skin that is blanched, tightly stretched and non-mobile over the fragment. This represents threatened skin integrity and requires same-day assessment by emergency/on-call orthopaedics. Intact distal neurovascular findings do not offset the risk of conversion to an open fracture. B is inappropriate because the original routine pathway is superseded by evolving skin compromise. C is initially plausible because complete displacement and more than 2 cm shortening are features that warrant specialist review, particularly in an active adult; however, an appointment within a week is inadequate where the skin is threatened. D delays definitive assessment and does not alter the clinically evident need for urgent orthopaedic review. E is inappropriate in an unstable, markedly displaced acute fracture and may worsen pain or skin pressure; mobilisation advice is considered only after urgent complications have been excluded and a definitive plan made.

Reference: ED/MIU Adult (>16 yrs) Orthopaedic referral pathway (2025) — https://rightdecisions.scot.nhs.uk/media/t1uki5fm/orthopaedic-referral-pathway.pdf The emergency medicine management of clavicle fractures (2021) — https://pubmed.ncbi.nlm.nih.gov/34217972/