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Threatened open displaced midshaft clavicle fracture — MSRA MCQ

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ModerateShoulder InjuriesThreatened open displaced midshaft clavicle fractureMSRA

A 31-year-old man attends your GP surgery 3 days after falling from an electric scooter onto his left shoulder. Emergency-department radiographs showed a completely displaced, comminuted midshaft clavicle fracture. He was discharged in a sling with virtual fracture-clinic follow-up planned in 5 days. Since this morning, the prominence over the fracture has increased. The skin over the medial fracture end is tightly tented, pale and does not blanch normally, although it has not broken down. Pain is controlled with paracetamol and ibuprofen. The left hand is warm with normal capillary refill, radial pulse, power and sensation. He has no chest pain, breathlessness or haemoptysis. What is the most appropriate management now?

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

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Correct answer: B — Arrange immediate transfer to the emergency department for same-day orthopaedic assessment

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

This is a displaced clavicle fracture with threatened skin viability: the increasingly prominent fracture end is tightly tenting pale, non-blanching skin. This raises concern for progression to an open fracture and requires same-day emergency orthopaedic assessment, even though distal neurovascular findings are currently normal. The absence of chest symptoms makes an intrathoracic complication less likely, but does not make threatened skin safe for routine follow-up. B is appropriate for many uncomplicated clavicle fractures, but not where skin is threatened. C may have a role in selected soft-tissue diagnostic uncertainty, but would delay necessary specialist assessment and does not alter the immediate decision. D is insufficiently prompt because skin compromise can evolve before an outpatient appointment. E is inappropriate while there is an unstable displaced fracture with threatened skin; rehabilitation advice is considered after urgent complications have been excluded and the fracture-management plan is established.

Reference: Broken collarbone (Page last reviewed 2 August 2023) — https://www.nhs.uk/conditions/broken-collarbone/ Skin Tenting in Displaced Midshaft Clavicle Fractures (2021) — https://pubmed.ncbi.nlm.nih.gov/34423090/ The emergency medicine management of clavicle fractures (2021) — https://pubmed.ncbi.nlm.nih.gov/34217972/