What is the best management plan for a 60-year-old male patient with bilateral shoulder pain, nonunion of a displaced mid-right clavicle fracture, and considerable deformity?

From the Guidelines

The best management plan for this 60-year-old male patient with bilateral shoulder pain, nonunion of a displaced mid-right clavicle fracture, and considerable deformity is surgical intervention with open reduction and internal fixation (ORIF) of the clavicle, as recommended by the most recent guidelines from the American Academy of Orthopaedic Surgeons 1. This approach is supported by recent studies showing that surgical treatment of displaced clavicle fractures results in equivalent or improved short-term patient-reported outcomes and reduced rates of nonunion or symptomatic malunion when compared with nonsurgical treatment 1. The patient's condition, including nonunion, displacement, and significant deformity, are all indications for surgical management rather than continued conservative treatment. The procedure would typically involve plate and screw fixation, possibly with bone grafting to promote healing at the nonunion site. Preoperatively, the patient should undergo comprehensive imaging including plain radiographs and possibly a CT scan to better characterize the nonunion and plan the surgical approach. For pain management before surgery, a regimen of acetaminophen 1000mg every 8 hours and naproxen 500mg twice daily (if not contraindicated) can be prescribed, with tramadol 50mg every 6 hours as needed for breakthrough pain. Postoperatively, the patient will require a structured rehabilitation protocol beginning with immobilization for 1-2 weeks, followed by progressive range of motion exercises and eventually strengthening exercises under physical therapy guidance. Key considerations in the management plan include:

• Surgical intervention to address nonunion and deformity
• Comprehensive preoperative imaging
• Structured postoperative rehabilitation protocol
• Pain management regimen
• Potential for bone grafting to promote healing The goal of this management plan is to improve the patient's quality of life, reduce chronic pain, and prevent secondary shoulder pathologies, as supported by the latest clinical practice guidelines 1.

From the FDA Drug Label

The most common adverse reactions with diclofenac sodium topical solution are application site reactions. The data described below reflect exposure to diclofenac sodium topical solution of 130 patients treated for 4 weeks (mean duration of 28 days) in one Phase 2 controlled trial. The population's mean age was approximately 60 years, 85% of patients were Caucasian, 65% were females, and all patients had primary osteoarthritis. The most common adverse events with diclofenac sodium topical solution were application site skin reactions.

The best management plan for a 60-year-old male patient with bilateral shoulder pain, nonunion of a displaced mid-right clavicle fracture, and considerable deformity includes:

• Pain management: Start Acetaminophen 1-3T TIDPRN and Diclofenac cream to alleviate pain and inflammation.
• Physical therapy: Request physical therapy to improve range of motion and strength in the affected area.
• Medical shoes replacement: Request a replacement for the patient's medical shoes to ensure proper support and comfort. It is essential to monitor the patient's response to treatment and adjust the management plan as needed. 2 2 2

From the Research

Management Plan for a 60-year-old Male Patient with Bilateral Shoulder Pain, Nonunion of a Displaced Mid-right Clavicle Fracture, and Considerable Deformity

The patient's condition requires a comprehensive management plan to address the nonunion of the displaced mid-right clavicle fracture, bilateral shoulder pain, and considerable deformity.

• Pain Management: The use of acetaminophen is recommended for pain management, as it has been shown to have no negative effect on fracture healing 3. In contrast, nonsteroidal anti-inflammatory drugs (NSAIDs) such as celecoxib have been found to impair fracture healing 3, 4. Therefore, the patient's request for acetaminophen is appropriate.
• Physical Therapy: Requesting physical therapy for the patient is a suitable approach to improve range of motion and reduce pain.
• Medical Shoes Replacement: The patient's request for a replacement for his medical shoes should be considered to ensure proper support and comfort.
• Nonunion of a Displaced Mid-right Clavicle Fracture: The nonunion of the displaced mid-right clavicle fracture is a significant concern, as it can lead to considerable deformity and disability. Studies have shown that nonunion of fractures can have a devastating effect on health-related quality of life 5.
• Bisphosphonate Use: Although there is no mention of bisphosphonate use in the patient's history, it is essential to note that long-term bisphosphonate therapy can lead to atypical insufficiency fractures of the femur and delayed union after fracture stabilization 6.
• Patient-Reported Outcome Measurement: The use of Patient-Reported Outcome Measurement Information Systems (PROMIS) can help assess the patient's physical function and pain interference scores, which can be correlated with the progression to nonunion 7.

Treatment Options

The treatment options for the patient's nonunion of a displaced mid-right clavicle fracture should be considered on a case-by-case basis. The patient's age, overall health, and activity level should be taken into account when determining the best course of treatment.

• Surgical Intervention: Surgical intervention may be necessary to address the nonunion of the displaced mid-right clavicle fracture.
• Conservative Management: Conservative management, including physical therapy and pain management, may be suitable for some patients.

Monitoring and Follow-up

Regular monitoring and follow-up are crucial to assess the patient's progress and adjust the management plan as needed.

• Imaging Studies: Imaging studies, such as X-rays, should be used to monitor the patient's fracture healing and detect any potential complications.
• PROMIS Scores: The patient's PROMIS scores should be monitored to assess their physical function and pain interference scores.