skip to main content

Displaced midshaft clavicle fracture with skin tenting/ischaemia — MSRA MCQ

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

HardShoulder InjuriesDisplaced midshaft clavicle fracture with skin tenting/ischaemiaMSRA

A 15-year-old boy is reviewed in general practice the morning after a rugby injury. Emergency-department radiographs showed a comminuted midshaft fracture of the right clavicle with 15 mm shortening. He was discharged in a broad-arm sling with virtual fracture-clinic follow-up planned in 4 days. Since discharge, swelling has increased and his mother has noticed that the skin over the medial fracture fragment is becoming progressively stretched. Examination shows a 1 cm area of tightly tented, pale skin directly over the palpable fragment. The skin is intact, but does not blanch normally. There is no chest pain, dyspnoea, dysphagia or haemoptysis. Radial pulse, capillary refill, hand power and sensation are normal. What is the most appropriate management now?

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

Reveal the answer and explanation

Correct answer: E — Contact the on-call orthopaedic team and arrange same-day emergency-department assessment with the arm supported in a sling

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

This is skin tenting with evolving skin ischaemia over a displaced clavicle fracture. The decisive feature is not the degree of shortening or comminution, but the tightly stretched, pale, poorly blanching skin over the fracture fragment. This represents threatened skin viability and requires acute orthopaedic assessment, despite an intact distal neurovascular examination. The arm should remain supported and the patient should be sent to the emergency department after direct orthopaedic contact. A is inappropriate because routine virtual follow-up applies to uncomplicated fractures; skin compromise is an exception. B is insufficient because repeat imaging and a next-day clinic review delay specialist assessment of threatened soft tissue. D wrongly waits for conversion to an open fracture or neurovascular deterioration. E overstates the immediate risk: there is no evidence of haemodynamic instability, vascular compromise, respiratory compromise or mediastinal injury requiring emergency ambulance transfer. Marked displacement alone may justify fracture-clinic consideration in an adolescent, but skin tenting/ischaemia changes both the priority and referral route.

Reference: Emergency Department Medical Guidelines: Clavicle Fracture Guidelines (Implemented August 2023; section reviewed April 2023) — https://www.sheffieldchildrens.nhs.uk/download/1721/acute-injury-and-orthopaedics/64209/4-15-clavicle-fracture.pdf