What is the appropriate management for a 40-year-old male patient with a nonunion of a displaced mid-left clavicle fracture, presenting with pain and visible deformation?

From the Guidelines

The patient with a nonunion of a displaced mid-left clavicle fracture should be considered for surgical intervention, as it is associated with higher union rates and better early patient-reported outcomes, according to the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1. The patient's current situation, with a nonunion of a displaced mid-left clavicle fracture that occurred approximately 7-8 months ago, causing pain and visible deformation, warrants an orthopedic consultation to discuss the possibility of surgical intervention.

• The patient's pain management plan should include naproxen 500 mg twice daily to reduce inflammation and provide pain relief, and acetaminophen 1000 mg twice daily as needed for additional pain control, as these medications work through different mechanisms to provide comprehensive pain management.
• While waiting for the orthopedic consultation, the patient should avoid activities that exacerbate pain, apply ice for 15-20 minutes several times daily to reduce inflammation, and consider using a sling for comfort and support if movement causes significant discomfort.
• The patient should be advised that clavicle nonunions often require surgical fixation with plates and screws to achieve proper healing, especially when displacement and deformity are present, as this approach can lead to improved functional outcomes and reduced rates of nonunion or symptomatic malunion 1.
• The decision to proceed with surgical intervention should be made in consultation with an orthopedic specialist, taking into account the patient's individual circumstances and the potential benefits and risks of surgery, as outlined in the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1.

From the Research

Patient Assessment and Treatment

• The patient is a 40-year-old male with a nonunion of a displaced mid-left clavicle fracture, which occurred seven to eight months ago 2.
• The patient reports pain in the area and a visible deformation can be observed.
• The treatment plan includes a consult with orthopedics, prescribing naproxen 500 mg BID, and continuing acetaminophen 1000 mg BID PRN.

Clavicle Fracture Management

• Clavicle fractures are common, accounting for 2.6% to 4% of all fractures, with 80% of them located in the middle third of the clavicle 3.
• The treatment of middle third clavicle fractures is usually non-surgical, but displaced fractures may be considered for surgical treatment due to the greater risk of non-union 3.
• Surgical treatment of acute middle third clavicle fractures may not improve upper arm function at follow-up of one year or longer, but may reduce the risk of treatment failure 3.

Surgical vs. Conservative Treatment

• Low-quality evidence suggests that surgical treatment has no additional benefits in terms of function, pain, and quality of life compared with conservative treatment, but may result in fewer treatment failures overall 3.
• Very low-quality evidence means that we are very uncertain of the findings of a slightly better cosmetic result after surgery and of no difference between surgical and conservative treatment in the risk of adverse events 3.
• Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences 3.

Regional Anesthetic and Analgesic Techniques

• Regional anesthetic and analgesic techniques can be used to manage pain in patients with clavicle fractures or undergoing clavicle surgery 4.
• Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block 4.
• Cervical plexus block can provide motor-sparing analgesia following clavicle surgery, and promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique 4.