Does a patient with a displaced fracture of the distal left clavicle and inferior displacement of the distal fragments require immediate evaluation in the Emergency Department (ED) for potential relocation?

Displaced Distal Clavicle Fracture: Emergency Department Evaluation

A displaced distal clavicle fracture with inferior displacement does not require immediate ED evaluation for closed reduction, but does require urgent orthopedic follow-up within 1-2 weeks and immediate sling immobilization. 1

Immediate Management in Urgent Care/Office Setting

Immobilization should be initiated immediately with a sling (not a figure-of-eight brace), as recommended by the American Academy of Orthopaedic Surgeons for all acute clavicle fractures. 2, 1

Key Assessment Points

Before deciding on disposition, you must evaluate:

• Neurovascular status: Check distal pulses, capillary refill, and sensation in the affected extremity 3
• Skin integrity: Rule out open fracture 3
• Associated injuries: Assess for pneumothorax, rib fractures, or brachial plexus injury 4

ED Transfer Indications (Emergent)

Send to the ED immediately only if:

• Neurovascular compromise with posterior displacement impinging on brachial plexus or subclavian vessels 4
• Open fracture with skin breach 3
• Associated emergent injuries such as pneumothorax or vascular injury 3

Urgent Orthopedic Referral Indications (Within 1-2 Weeks)

Displaced distal clavicle fractures with coracoclavicular ligament disruption require urgent (not emergent) orthopedic consultation because these are inherently unstable and typically require surgical fixation. 1

The American Academy of Orthopaedic Surgeons specifically recommends surgical treatment for displaced lateral fractures with disruption of the coracoclavicular ligament complex. 2, 1

Why Urgent Rather Than Emergent?

Unlike midshaft fractures with >100% displacement that warrant urgent referral 2, distal clavicle fractures do not require immediate closed reduction in the ED. The decision for surgical versus conservative management depends on:

• Stability assessment: Neer Type II and V fractures (with CC ligament disruption) are unstable and benefit from surgical repair 1
• Radiographic evaluation: Upright radiographs (not supine) should be obtained to accurately assess displacement 2, 1

Critical Imaging Consideration

Obtain upright clavicle radiographs rather than relying on supine chest X-rays, as upright films better demonstrate the true degree of displacement. 2, 1 This is particularly important because minimally displaced fractures on supine imaging may show significant displacement when upright. 5

Outpatient Management Pending Orthopedic Evaluation

• Sling immobilization continuously for comfort 2, 1
• Analgesia: Multimodal pain control with acetaminophen and NSAIDs 3
• Ice application: 20 minutes every 2-3 hours for first 48-72 hours 6
• Elevation: Keep arm elevated when possible 6

Common Pitfall to Avoid

Do not over-triage stable displaced distal clavicle fractures to the ED when adequate immobilization can be achieved and there is no neurovascular compromise. 6 The key distinction is that "relocation" (closed reduction) is not performed for clavicle fractures in the acute setting—the definitive treatment decision (surgical fixation versus conservative management) is made electively by orthopedics based on fracture stability and ligament integrity. 1, 7

Patient Return Precautions

Instruct the patient to return immediately for:

• Increased pain, numbness, or tingling 6
• Color changes in the hand or fingers 6
• Inability to move fingers 6
• Progressive swelling or deformity 3