In a 65-year-old man with a left clavicular fracture who experiences nighttime pain and numbness after sleeping on the affected side but can perform activities of daily living, what is the next step in management?

Management of Clavicular Fracture with Nighttime Pain and Numbness

The next step is to obtain urgent imaging (X-rays to assess fracture displacement/healing, and consider CT if needed) and perform a thorough neurovascular examination to evaluate for brachial plexus injury or thoracic outlet syndrome, followed by orthopedic referral for surgical evaluation if the fracture is displaced.

Immediate Assessment Required

The combination of nighttime pain and numbness after sleeping on the affected side raises serious red flags for two complications:

1. Brachial Plexus Injury

• Numbness following clavicular fracture suggests possible brachial plexus compression, which occurs in <1% of cases but is a serious complication 1
• This can result from direct compression by fracture fragments or from callus formation during healing 2, 3
• Key examination findings to assess:
  • Sensory distribution of numbness (which dermatomes are affected)
  • Motor strength testing of shoulder, elbow, wrist, and hand (grade 0-5)
  • Reflexes (biceps, triceps, brachioradialis)
  • Specific nerve root testing (C5-T1 distribution)

2. Thoracic Outlet Syndrome (TOS)

• The clavicle borders the thoracic outlet, and fracture displacement, callus formation, or malunion can compress the brachial plexus or subclavian vessels 2
• TOS most frequently occurs in middle-aged adults (40-64 years), making your 65-year-old patient at risk
• Specific symptoms to evaluate:
  • Swelling or discoloration of the arm
  • Chronic pain with specific arm positions
  • Paresthesias in specific patterns
  • Vascular symptoms (coldness, color changes)

Diagnostic Workup

Obtain immediately:

• New X-rays to assess:
  • Degree of fracture displacement (if not already documented)
  • Callus formation
  • Fracture alignment and shortening
  • Signs of malunion

Consider additional imaging:

• CT angiography if vascular TOS suspected (swelling, discoloration)
• MRI if significant neurological deficits present
• Nerve conduction studies/EMG if brachial plexus injury confirmed clinically 4, 3

Treatment Decision Algorithm

If Fracture is Displaced:

Surgical treatment is strongly recommended 5

The 2023 AAOS guidelines provide a strong recommendation that surgical treatment of displaced midshaft clavicle fractures results in:

• Higher union rates (85-100% vs. 85% with up to 15% nonunion conservatively)
• Better early patient-reported outcomes
• Faster functional recovery
• Lower rates of symptomatic malunion 5

This is particularly important in your patient because:

• Displaced fractures have higher nonunion rates (up to 15%) with conservative treatment 5
• The neurological symptoms suggest possible nerve compression that may worsen with continued displacement
• Surgical fixation can decompress neural structures and prevent progressive callus formation

If Brachial Plexus Injury Confirmed:

• Urgent orthopedic referral for consideration of surgical decompression
• If fracture is displaced, open reduction and internal fixation (ORIF) can address both the fracture and decompress the plexus 1, 4
• Conservative management with structured rehabilitation may be appropriate for incomplete injuries if fracture is stabilized 4, 3

If TOS Suspected:

• May require hardware removal and first-rib resection if symptoms persist after fracture healing 2
• Risk factors that increase TOS likelihood: obesity, tobacco use, hypercoagulable states, cervical ribs 2

Critical Pitfalls to Avoid

1. Do not assume numbness is "normal" post-fracture pain - this requires immediate neurovascular assessment 1
2. Do not delay re-evaluation - neurological deficits can progress rapidly and require prompt intervention 1
3. Do not continue conservative management without reassessing fracture displacement - the patient's symptoms may indicate fracture displacement or callus compression 2, 3
4. Monitor patients within days after injury to check for onset of neurological deficits, especially if using figure-eight bandage or sling 1

Surgical Considerations if Indicated

If surgery is pursued:

• Plate fixation vs. intramedullary nailing: Both have equivalent long-term outcomes, though plate fixation may be preferred if comminution present 5
• Surgery provides faster return to work and activities, which may be relevant for this patient's quality of life 5
• Long-term outcomes are similar between surgical and nonsurgical treatment, but surgery reduces early complications 5

Bottom line: The numbness is not a benign symptom and mandates urgent evaluation for neurovascular compromise, with strong consideration for surgical intervention if the fracture is displaced.