How should I evaluate and manage acute clavicular pain following trauma?

Evaluation and Management of Acute Clavicular Pain Following Trauma

Obtain standard three-view shoulder radiographs immediately as the mandatory first imaging step for all patients with acute post-traumatic clavicular pain, including anteroposterior views in internal and external rotation plus an axillary or scapular-Y view. 1, 2

Initial Diagnostic Workup

Essential History Elements

• Document the exact mechanism of injury: how the fall or trauma occurred, height of fall, landing position (direct blow to shoulder versus fall on outstretched hand), and whether work-related 3
• Record the precise time of injury and symptom evolution since onset 3
• Identify any prior clavicular fractures, AC joint injuries, or shoulder dislocations 3
• Assess pain location: superior shoulder pain specifically implicates AC joint pathology, while anterior pain may suggest associated rotator cuff involvement 3, 2

Physical Examination Priorities

• Palpate the radial and ulnar arterial pulses; absence of a pulse requires immediate vascular imaging (duplex ultrasound or CT angiography) after high-energy trauma or shoulder dislocation 3
• Document neurovascular status at each encounter to ensure no compromise from the injury 1
• Inspect for visible deformity, swelling, or tenting of the skin over the clavicle 4
• Palpate the entire length of the clavicle for focal tenderness, crepitus, or step-off deformity 4
• Examine the AC joint specifically for tenderness, widening, or superior displacement of the distal clavicle 5, 6
• Test active shoulder range of motion, particularly abduction and forward flexion, noting any limitations or pain patterns 3

Imaging Strategy

First-Line Imaging

• Standard three-view radiographs are mandatory and effectively demonstrate clavicle fractures, AC joint separations, dislocations, and associated arthritis 1, 2
• Required views: AP in internal rotation, AP in external rotation, and axillary or scapular-Y view 1, 2

Advanced Imaging Indications

• CT without contrast should be obtained if fracture characterization is needed or to better delineate comminution and displacement, particularly for surgical planning 1
• CT is less useful than MRI for soft tissue evaluation but superior for bony detail 1

Classification and Treatment Algorithm

Clavicle Fractures

• Most clavicular fractures (middle third, minimally displaced) are successfully treated conservatively with sling immobilization for 2-4 weeks followed by progressive physical therapy 7, 4
• Surgical fixation should be considered for significantly displaced fractures (>2 cm shortening), comminuted fractures, or open fractures to reduce rates of nonunion and malunion 7
• Type II distal clavicle fractures (those disrupting the coracoclavicular ligaments) are prone to nonunion and should be considered for operative fixation 5

AC Joint Injuries

• Type I and II AC separations are treated non-operatively with initial sling immobilization (3-7 days) followed by early functional rehabilitation, with excellent outcomes expected 5, 6, 8
• Type III AC separations remain controversial, but studies show no distinct advantage for surgical reconstruction over nonoperative treatment in most patients 5
• Types IV, V, and VI AC injuries require operative reduction and fixation due to severe displacement and acute soft tissue injury 5, 6, 8

Conservative Management Protocol

Initial Phase (First 2-4 Weeks)

• Sling immobilization for comfort, typically 3-7 days for AC sprains and 2-4 weeks for clavicle fractures 6, 8, 4
• Ice application and NSAIDs for acute pain management 2
• Acetaminophen as first-line analgesic (maximum 4 grams daily) 2

Rehabilitation Phase

• Implement range of motion exercises focusing on external rotation and abduction once adequate healing has occurred 1
• Avoid overhead pulleys initially, as uncontrolled abduction may stress the injury site 1, 3
• Progress to scapular stabilization exercises and rotator cuff strengthening 2
• Consider functional electrical stimulation to improve shoulder lateral rotation 3, 2

Red Flags Requiring Urgent Specialist Referral

• Absent peripheral pulses indicating vascular compromise 3
• Open fractures or skin tenting with impending skin compromise 4
• Neurological deficits suggesting brachial plexus injury 2
• Significantly displaced or comminuted fractures requiring surgical fixation 2, 7
• Type IV, V, or VI AC joint dislocations 5, 6
• Posterior sternoclavicular dislocation (requires cardiothoracic surgery presence for reduction due to proximity to great vessels) 8

Common Pitfalls to Avoid

• Do not assume absence of significant trauma means absence of fracture, especially in elderly patients where osteoporotic fractures can occur with minimal or unrecognized trauma 3
• Do not misinterpret AC joint pain as rotator cuff impingement; superior shoulder pain specifically indicates AC pathology 3, 2
• Do not delay vascular assessment in high-energy trauma; neurovascular compromise requires immediate intervention 3
• Avoid premature return to overhead activities or contact sports before complete fracture healing (typically 6-12 weeks) 6, 7

Follow-Up and Monitoring

• Document neurovascular status at each follow-up visit 1
• Serial radiographs at 2,6, and 12 weeks to assess fracture healing 7
• Elective orthopedic referral is indicated for failure of 6-12 weeks of appropriate conservative treatment or progressive functional decline despite therapy 2
• Evaluate for signs of complex regional pain syndrome in patients with chronic post-traumatic pain lacking clear etiology 3