Immobilization and nonoperative care
›Immobilization and nonoperative care
›Sling and swathe
›Comfort positioning
›Neutral shoulder posture
›Early mobility plan
›Elbow, wrist, hand range of motion
›Pendulum exercises once pain allows
›Figure-of-eight brace considerations
›Avoid as routine due to discomfort and skin issues
›Use only if specialist preference and patient tolerance
›Analgesia
›Multimodal baseline
›Acetaminophen
›1000 mg PO every 6-8 hours
›Maximum 3000 mg per 24 hours for most adults
›Ibuprofen
›400 mg PO every 6-8 hours
›Maximum 2400 mg per 24 hours
›Naproxen
›500 mg PO initial dose
›250 mg PO every 6-8 hours as needed
›Opioid for breakthrough pain
›Oxycodone immediate release
›2.5 mg PO every 6 hours as needed
›5 mg PO every 6 hours as needed for severe pain
›Morphine immediate release
›5 mg PO every 4 hours as needed
›10 mg PO every 4 hours as needed for severe pain
›ED parenteral options for severe pain
›Fentanyl IV
›25 mcg IV every 5 minutes as needed
›Titrate to comfort with respiratory monitoring
›Morphine IV
›2 mg IV every 10 minutes as needed
›Titrate to comfort with respiratory monitoring
›Ketorolac IV
›15 mg IV once
›Avoid if renal impairment or bleeding risk
›Regional anesthesia adjunct
›Superficial cervical plexus block option
›Consider if severe pain limiting imaging
›Contraindications include local infection and allergy
›Intra-articular shoulder injection not indicated for clavicle fracture pain
Wound care and infection prevention
›Wound care and infection prevention
›Open fracture pathway
›If open fracture, immediate IV antibiotics
›Cefazolin IV
›2 g IV once
›If weight ≥ 120 kg, 3 g IV once
›If severe beta-lactam allergy, clindamycin IV
›900 mg IV once
›Monitor for hypotension
›Tetanus prophylaxis
›If immunization unknown or incomplete, tetanus vaccine
›If dirty wound and incomplete immunization, add tetanus immune globulin
›Immediate irrigation and sterile dressing
›Large-volume irrigation as feasible
›Occlusive dressing if bleeding controlled
Operative vs nonoperative decision support
›Operative vs nonoperative decision support
›Absolute indications for operative management
›Open fracture
›Infection risk reduction priority
›Operative debridement and fixation planning
›Threatened skin viability
›Tenting with blanching
›Progressive skin compromise
›Neurovascular compromise
›Absent pulse
›Progressive neurologic deficit
›Symptomatic sternoclavicular posterior displacement
›Mediastinal structure risk
›CT confirmation priority
›Relative indications often used for referral discussion
›Completely displaced midshaft fracture in adult
›Higher nonunion risk compared with nondisplaced
›Shared decision-making based on goals
›Significant shortening in adult midshaft fracture
›Functional deficit risk discussion
›Cosmetic concern discussion
›Floating shoulder pattern
›Clavicle fracture plus scapular neck fracture
›Stability and alignment considerations
›Guideline framing
›Displaced midshaft fractures in adults may benefit from operative fixation with improved union and early function (AAOS strong recommendation; Class I)
›Long-term functional differences smaller
›Surgical complication trade-offs
›Nondisplaced fractures typically managed nonoperatively (AAOS strong recommendation; Class I)
›High union rates
›Lower complication burden