Had history of left clavicular fracture. Alleged fall 4 days ago. Now

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Had history of left clavicular fracture. Alleged fall 4 days ago. Now pain and swelling at left clavicle. Is this refracture ? And what the management

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clavicle fracture malunion refracture management conservative vs surgical 2024

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X-Ray Analysis: Left Clavicle

This is NOT a new/acute refracture. The X-ray shows an old, well-healed (or near-fully healed) malunion of the left midshaft clavicle - not a fresh fracture.

Key radiological findings on this film:

Mature, abundant bridging callus - the new bone growth is dense, smooth, and rounded (not the sharp, jagged edges of a fresh fracture line)
Bayonet apposition / overlapping malunion - the medial fragment is displaced superiorly, the lateral fragment sits lower; the fragments have healed in this overlapped position
Clavicular shortening - due to the overlapping malunion
No hardware - previously managed conservatively
No acute fracture line - no dark, sharp lucency to suggest a new break through the callus or adjacent bone

What Does This Mean Clinically?

The patient has a symptomatic malunion of a previously healed clavicle fracture. The pain and swelling at 4 days post-fall can be explained by one or more of the following:

Soft tissue contusion/bruising over the already-deformed clavicle (most likely)
Periosteal irritation of the callus/malunion site from the new trauma
Incomplete crack/stress reaction through mature callus (less likely given the imaging appearance, but worth clinical correlation)
A true refracture through the malunion site - this cannot be completely excluded without comparing to prior X-rays and possibly obtaining a CT if clinical suspicion remains high

Important: If prior X-rays are available, compare the fracture line pattern. If there is any clinical concern for a new cortical break, a CT scan of the left clavicle is the next best step - it will detect subtle cortical disruption that plain X-ray misses in the setting of pre-existing callus.

Management

Immediate / Conservative (First-Line for Symptomatic Malunion + Contusion)

Step	Action
Analgesia	NSAIDs (e.g., ibuprofen 400-600 mg TDS) + paracetamol
Immobilization	Broad arm sling for 2-4 weeks for comfort
Ice/elevation	For swelling in acute phase (first 48-72 hours)
Neurovascular check	Examine for brachial plexus signs, subclavian vessel injury (especially given displacement)
Physiotherapy	Pendulum exercises after pain subsides; progressive shoulder rehab

Note: Figure-of-eight bandage is not recommended - it does not improve alignment and risks brachial plexus compression. A simple sling is preferred, per Rosen's Emergency Medicine and Miller's Orthopaedics.

Indications to Consider Surgical Referral / ORIF

Per Miller's Review of Orthopaedics (9th Ed.), operative treatment should be considered when:

Symptomatic malunion causing functional limitation or significant cosmetic deformity
Non-union develops (1-3% in adults)
Neurovascular compromise (subclavian vessels, brachial plexus)
Displacement > 2 cm with functional restriction
Open fracture
If CT confirms a true refracture through the malunion site with significant displacement

Surgical options include open reduction and plate fixation (preferred for midshaft malunions) or intramedullary nailing. 2024 evidence confirms surgical fixation has higher union rates, faster recovery, and less malunion than conservative treatment for displaced/comminuted midshaft fractures.

Follow-Up Plan

Repeat X-ray at 2-3 weeks to assess for any progressive displacement or new fracture line
CT clavicle if pain worsens or doubt remains about acute refracture
Orthopedic referral if functional limitation persists beyond 6-8 weeks, or if surgical indications arise
Screen for bone metabolic issues (vitamin D deficiency, osteoporosis) if refracture is confirmed, especially if patient is older

Bottom line: This X-ray shows an old malunited clavicle fracture, not a new acute fracture. The presenting symptoms are most likely soft tissue injury over the malunion site. Start conservative management with a sling and analgesia, obtain a CT if refracture is strongly suspected clinically, and refer to orthopaedics for ongoing symptomatic malunion assessment.

If referral can you write me referral to orthopedic

Here is a referral letter you can adapt with the patient's details:

MEDICAL REFERRAL LETTER

Date: 12 August 2026

To: The Orthopaedic Surgeon From: [Your Name], [Designation] Facility: [Your Clinic/Hospital Name] Contact: [Phone / Email]

Re: Referral for Orthopaedic Assessment - Left Clavicle Malunion with Acute Injury

Patient Name: ___________________________ Age/DOB: ___________________________ Gender: ___________________________ MRN / ID: ___________________________

Dear Colleague,

I am referring the above-named patient for orthopaedic assessment and further management of a symptomatic left clavicle malunion following a recent fall.

History of Presenting Complaint:

This patient presents with a 4-day history of pain and swelling over the left clavicle following an alleged fall. There is a background history of a previous left clavicular fracture managed conservatively, which has healed with malunion.

Clinical Findings:

Pain and swelling localised to the left clavicle region
Palpable deformity consistent with known malunion
Neurovascular examination: [document findings - sensation, pulses, motor function of upper limb]
Shoulder range of motion: [document any restriction]

Investigations:

Plain X-ray of the left clavicle/shoulder (dated 12/08/2026) demonstrates:
- Old, well-healed midshaft left clavicle fracture with bayonet apposition malunion
- Abundant mature bridging callus
- Clavicular shortening due to overlapping malunion
- No acute fracture line clearly identified on plain film; however, a new cortical disruption through the malunion site cannot be excluded without cross-sectional imaging
- No surgical hardware in situ

Current Management:

Broad arm sling for comfort
Analgesia: [document what was prescribed]
Patient advised regarding activity restriction

Reason for Referral:

Assessment for possible refracture through existing malunion - CT clavicle recommended to exclude cortical disruption not visible on plain film
Orthopaedic opinion on definitive management of symptomatic malunion - possible ORIF / corrective osteotomy if functionally limiting
Assessment of neurovascular status in the context of clavicular displacement and new injury
Consideration of operative vs. conservative management plan going forward

Background Medical History: [Relevant comorbidities, medications, allergies]

Urgency: Semi-urgent - please review within 1-2 weeks, or sooner if symptoms worsen or neurovascular compromise develops.

I would be grateful for your expert opinion and management plan. Please do not hesitate to contact me should you require any further information.

Yours sincerely,

[Your Full Name] [Designation / Qualification] [Clinic/Hospital] [Date] [Signature]

Fill in the bracketed fields with the patient's actual details before sending. If there are any neurovascular deficits on examination, upgrade the urgency to urgent/same-day.

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