Multimodal Pain Management for Displaced Clavicle Fracture in a 17-Year-Old at Home
For a 17-year-old with a displaced clavicle fracture managed at home, use a combination of scheduled NSAIDs (if no contraindications), acetaminophen, ice application, and sling immobilization, with short-acting opioids reserved only for breakthrough pain in the first 3-5 days. 1, 2
Initial Pain Control Strategy
First-Line Pharmacologic Management
- Start with scheduled NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) as the foundation of pain control, as they address both pain and inflammation 2
- Add scheduled acetaminophen (650-1000mg every 6 hours, not exceeding 4g/24 hours) to provide additive analgesia through a different mechanism 2
- Consider short-acting opioids (e.g., oxycodone 5-10mg every 4-6 hours as needed) for breakthrough pain during the first 3-5 days only, then taper rapidly 2
Non-Pharmacologic Interventions
- Apply ice to the fracture site for 15-20 minutes every 2-3 hours during the first 48-72 hours to reduce swelling and provide local analgesia 2
- Immobilize with a simple sling (not a figure-of-eight brace), as this is the preferred method recommended by the American Academy of Orthopaedic Surgeons for acute clavicle fractures 1
- Elevate the arm when resting to minimize swelling 2
Pain Management Timeline
Days 1-3 (Acute Phase)
- Scheduled NSAIDs + acetaminophen around the clock 2
- Ice application every 2-3 hours while awake 2
- Opioids available for severe breakthrough pain 2
- Continuous sling use except for hygiene 1
Days 4-14 (Subacute Phase)
- Continue scheduled NSAIDs, transition acetaminophen to as-needed 2
- Discontinue opioids if possible 2
- Reduce ice application frequency to 3-4 times daily 2
- Maintain sling use for comfort 1
Weeks 2-4
- Transition all medications to as-needed basis 2
- Begin gentle pendulum exercises if pain allows 1
- Gradual weaning from sling for light activities 1
Critical Considerations for Adolescents
This 17-year-old should be managed with nonsurgical treatment as the primary approach, as the American Academy of Orthopaedic Surgeons recommends conservative management for adolescents (18 years and younger) with midshaft clavicular fractures 3. Surgical treatment in this age group has not demonstrated significant benefits and is associated with high rates of hardware removal procedures 3.
Red Flags Requiring Urgent Orthopedic Referral
- Displacement >100% (no cortical contact between fragments) 1
- Shortening >1.5cm 1
- Open fracture 3
- Neurovascular compromise 2
- Skin tenting or impending open fracture 2
Common Pitfalls to Avoid
- Do not use figure-of-eight braces despite their historical popularity—slings are preferred and better tolerated 1
- Avoid NSAIDs if the patient smokes, as smoking already increases nonunion risk significantly; counsel on smoking cessation 1, 4
- Do not prescribe prolonged opioid courses—most patients should not need opioids beyond 5-7 days 2
- Ensure upright radiographs were obtained for proper displacement assessment, as supine films underestimate displacement 1, 3
Alternative Pain Control Options
If standard oral medications provide inadequate relief, consider discussing with orthopedics:
- Hematoma block can be performed in the emergency department or clinic setting for significant pain relief without systemic medication side effects 5
- Clavipectoral plane block offers complete clavicular analgesia with minimal adverse effects, though requires ultrasound guidance and procedural expertise 6
Patient Education Points
- Pain typically peaks at 24-48 hours and should steadily improve over 7-10 days 2
- Sleeping semi-upright (in a recliner or propped with pillows) often provides better comfort 2
- Avoid lifting, pushing, or pulling with the affected arm for at least 4 weeks 1
- Follow-up radiographs at 2 weeks to assess healing and ensure no displacement progression 1
- Long-term functional outcomes are typically excellent with nonsurgical management in adolescents 3