What is the best approach to manage a clavicle fracture in an adult patient with recent trauma and impaired renal function due to elevated creatinine level?

Management of Clavicle Fracture in a Patient with Severe Renal Impairment

In a patient with a creatinine of 11 mg/dL, the clavicle fracture treatment must be deferred until the acute kidney injury is stabilized, as this degree of renal dysfunction dramatically increases mortality risk and surgical complications. 1, 2

Immediate Priority: Address the Renal Crisis

Severity Assessment

• A creatinine of 11 mg/dL represents severe acute kidney injury (AKI) or acute kidney disease (AKD), far exceeding the threshold for Stage 3 chronic kidney disease (GFR <30 mL/min/1.73 m²). 1
• This level of renal dysfunction increases mortality risk by approximately 1.83 times for each 1 mg/dL increase in creatinine above baseline, meaning this patient faces exponentially elevated mortality. 2
• Impaired renal function is a strong independent predictor of long-term mortality in acute care patients. 1

Urgent Renal Management

• Initiate aggressive fluid resuscitation immediately to prevent progression to dialysis-dependent renal failure, particularly if rhabdomyolysis is suspected from the trauma mechanism. 1
• Monitor for rhabdomyolysis by checking CPK levels (>1000 IU/L indicates rhabdomyolysis; >75,000 IU/L predicts >80% risk of worsening AKI), plasma myoglobin, and potassium levels. 1
• Maintain urine pH ≥6.5 with bladder catheterization for hourly urine output monitoring. 1
• Volumes of 3-6L per day are required for moderate rhabdomyolysis; >6L for severe cases (CPK >15,000 IU/L). 1
• Nephrology consultation is mandatory for potential renal replacement therapy. 1

Clavicle Fracture Assessment During Stabilization

Determine Surgical Urgency

While renal function is being optimized, assess the fracture for absolute surgical indications:

Immediate surgery required (cannot wait):

• Open fracture with skin compromise 3
• Neurovascular compromise 4, 5
• Impending skin perforation 4
• Floating shoulder (combined clavicle and scapular neck fracture) 4

Surgery can be delayed safely:

• Closed, displaced midshaft fractures (even with >1.5cm shortening) 1, 6
• Displaced lateral fractures with coracoclavicular ligament disruption 6
• Non-displaced fractures 6

Initial Fracture Stabilization

• Apply a simple sling for immobilization (not figure-of-eight brace), which is the preferred method per the American Academy of Orthopaedic Surgeons. 6
• Obtain upright radiographs to assess displacement accurately (superior to supine films). 6
• Document neurovascular status and skin integrity. 4, 3

Surgical Timing Algorithm

If Absolute Surgical Indications Present:

Proceed with surgery only after:

1. Creatinine trending downward for 24-48 hours 1
2. Urine output >0.5 mL/kg/hr established 1
3. Potassium normalized (<5.5 mEq/L) 1
4. Multidisciplinary discussion with nephrology and anesthesia regarding perioperative dialysis planning 1

Surgical approach modifications:

• Use plate fixation rather than intramedullary nailing to minimize operative time and blood loss. 6
• Prefer anterior-inferior plating (lower hardware removal rates). 6
• Minimize nephrotoxic agents (NSAIDs, contrast if imaging needed, aminoglycosides). 1
• Ensure adequate hydration continues perioperatively. 1

If No Absolute Surgical Indications:

Delay definitive treatment 7-14 days minimum until:

• Creatinine returns to within 1.5 times baseline or stabilizes at a new baseline 1
• Patient is medically optimized 1
• AKI/AKD stage is clearly defined and recovery trajectory established 1

During this waiting period:

• Continue sling immobilization 6
• Monitor for compartment syndrome if limb trauma present (check every 30-60 minutes for first 24 hours: pain, pain with passive stretch, paresthesia, paresis). 1
• Initiate VTE prophylaxis with LMWH once hemorrhage controlled and within 36 hours of trauma, adjusting dose for renal function. 1

Definitive Fracture Treatment Selection

For Displaced Midshaft Fractures (>1.5cm shortening):

Surgical treatment is strongly recommended once medically stable, as it provides higher union rates and better early outcomes compared to conservative management. 1, 6

• Plate fixation with anatomically contoured plates (lower removal rates) 6
• Anterior-inferior positioning preferred 6
• Intramedullary nailing is equivalent alternative 6

For Non-displaced or Minimally Displaced Fractures:

Conservative management with sling immobilization is appropriate. 6

• Continue sling for 4-6 weeks 6
• No role for low-intensity pulsed ultrasonography 6

Critical Pitfalls to Avoid

• Never proceed with elective clavicle surgery with creatinine >3 mg/dL without nephrology clearance, as each 1 mg/dL increase adds 2.21 hospital days, 1.09 ventilator days, and $3,088 in costs. 2
• Do not use NSAIDs for pain control in this patient; use opioids or acetaminophen instead. 1
• Avoid contrast-enhanced CT if additional imaging needed; use plain radiographs or non-contrast MRI. 1
• Monitor for hyperkalaemia aggressively if considering surgery, as trauma and tissue injury worsen potassium levels. 1
• Counsel patient that smoking dramatically increases nonunion risk and must be discontinued. 6