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, and a history of hypertension, currently taking acetaminophen (paracetamol) and naproxen, and requiring amlodipine (amlodipine besylate)?

From the Guidelines

The patient requires an urgent orthopedic consultation to evaluate surgical options for the nonunion of the displaced mid-left clavicle fracture, as surgical intervention is often necessary after 7-8 months to promote healing and alleviate symptoms. The patient's current treatment plan includes naproxen 500 mg twice daily and acetaminophen 1000 mg as needed for pain management, which is appropriate for reducing pain and inflammation at the fracture site 1. The patient's hypertension will be managed with amlodipine 10 mg daily, and regular blood pressure checks are scheduled to ensure the patient's blood pressure is under control.

Key Considerations

• The nonunion of the clavicle fracture is the primary concern, and surgical intervention is likely necessary to promote healing and restore function.
• The patient's pain management plan includes naproxen and acetaminophen, which is a reasonable approach for managing pain and inflammation.
• The patient's hypertension management plan includes amlodipine and regular blood pressure checks, which is a standard approach for managing hypertension.

Treatment Plan

• Orthopedic consultation to evaluate surgical options for the nonunion of the displaced mid-left clavicle fracture.
• Naproxen 500 mg twice daily and acetaminophen 1000 mg as needed for pain management.
• Amlodipine 10 mg daily for hypertension management.
• Regular blood pressure checks to ensure the patient's blood pressure is under control. The patient should be advised that surgical fixation with plates and screws is a likely outcome of the orthopedic consultation, as this is the standard treatment for symptomatic clavicle nonunions to restore function and relieve pain, as recommended by 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 requesting an orthopedic consultation, prescribing naproxen 500 mg twice daily, and continuing acetaminophen 1000 mg as needed.

Clavicle Fracture Management

• Clavicle fractures can lead to complications, particularly nonunions, with a reported rate of 0.1% to 15% 2.
• Contributing factors to nonunion include severe initial trauma, marked initial displacement and shortening, soft tissue interposition, and inadequate initial immobilization 2.
• Treatment options for clavicle fractures include nonsurgical management, salvage procedures, and reconstructive procedures 2, 3, 4.
• Operative treatment has been shown to have superior results compared to conservative management in recent trials of management of displaced fractures 3, 4.

Pain Management and Nonunion Risk

• A study found that minimal pain decrease between 2 and 4 weeks after nonoperative management of a displaced midshaft clavicle fracture is associated with a high risk of symptomatic nonunion 5.
• The study suggests that pain can be a potential proxy variable for the development of symptomatic nonunion after nonoperative treatment of midshaft clavicular fractures 5.

Hypertension Management

• The patient has hypertension and has requested amlodipine 10 mg, which is already on record.
• The treatment plan includes starting the patient on amlodipine 10 mg and referring him to CDP, with BP checks twice a week for two weeks, starting tomorrow.