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Shin S, Lee JW, Lee H, Yu CG. Thoracic outlet syndrome caused by callus formed after clavicle fracture. Trauma Case Rep 2023. [DOI: 10.1016/j.tcr.2023.100831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Kim MS. Conservative treatment for brachial plexus injury after a displaced clavicle fracture: a case report and literature review. BMC Musculoskelet Disord 2022; 23:632. [PMID: 35780083 PMCID: PMC9250205 DOI: 10.1186/s12891-022-05601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background A brachial plexus injury is a rare complication of clavicle fractures. Previous case reports only examined the surgical outcomes of brachial plexus injuries that occurred after a clavicle fracture and did not report on the outcomes of conservative treatment. In this report, we present the prognosis of a patient with an acute displaced clavicle fracture accompanied by a brachial plexus injury that was conservatively treated. Case presentation A 51-year-old man with a middle-third clavicle fracture due to a direct trauma after falling down the stairs. A brachial plexus injury experienced symptoms, including numbness occurred in the affected upper extremity, at 1 day after the injury. The patient’s motor power in the elbow, wrist, and hand decreased at 3 days after the injury. Magnetic resonance imaging (MRI) showed no loss of continuity in the brachial plexus, but showed nerve compression by displaced fracture fragments. Electromyography revealed brachial plexopathy. Conservative treatment, including a shoulder sling, was performed with satisfactory outcomes; the patient reported a 70% improvement at 6 months after the injury. Conclusions A brachial plexus injury is a rare complication of clavicle fractures that can cause serious dysfunction of the upper extremities affected by the injury. Conservative treatment may be considered for acute nerve compression by displaced fracture fragments rather than extensive callus or granulation tissue formation to achieve a satisfactory recovery in young patients. MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking.
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Affiliation(s)
- Myung-Seo Kim
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, 05278, Seoul, Republic of Korea.
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Babu TS, Devendra A, Venkatramani H, Bharadwaj P, Dheenadhayalan J, Rajasekaran S. Unusual Presentation of a Clavicle Fracture Locked Under the First Rib with Global Brachial Plexus Injury: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00042. [PMID: 35108224 DOI: 10.2106/jbjs.cc.20.00814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Thoracic penetration of the medial half of clavicle fracture is rare and can be life-threatening and limb-threatening because of its proximity to the pleura and neurovascular structures. We report an unusual presentation of the medial portion of clavicle fracture locked under the first rib associated with the pneumothorax and global brachial plexus palsy successfully reduced by gentle manipulation. Partial injury to the subclavian vein was repaired. Nerve transfer was performed for brachial plexus palsy. The patient showed good functional recovery. CONCLUSION Reduction of locked intrathoracic clavicle fracture was performed safely by gentle manipulation. Subsequent appropriate interventions for the brachial plexus palsy led to a good outcome.
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Affiliation(s)
- T Shanmukha Babu
- Department of Orthopaedics, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
| | - Agraharam Devendra
- Department of Orthopaedics, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Deparment of Plastic & Micro Reconstructive Surgery, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
| | - Praveen Bharadwaj
- Deparment of Plastic & Micro Reconstructive Surgery, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
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Katsuse K, Kodama S, Okazaki K, Toda T. Delayed Brachial Plexus Palsy after Clavicular Fracture. Intern Med 2021; 60:2511-2512. [PMID: 33612690 PMCID: PMC8381169 DOI: 10.2169/internalmedicine.6988-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kazuto Katsuse
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Satoshi Kodama
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kayako Okazaki
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Japan
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5
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Meyer MA, Zhang D, Price MD, Chen NC, Weaver MJ, Dyer GSM, Earp BE. Clavicle Fractures With Associated Acute Neurovascular Injury. Orthopedics 2021; 44:e390-e394. [PMID: 34039202 DOI: 10.3928/01477447-20210414-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Descriptions of acute neurovascular injury after clavicle fracture are limited to case reports. The objectives of this study were to assess both the prevalence of acute neurovascular injury after midshaft clavicle fracture and the outcomes of early fracture stabilization. A retrospective chart review was conducted of all adult patients with midshaft clavicle fracture who were treated surgically at 2 tertiary care referral centers from January 2010 to March 2019. The records of patients who were identified as having clinical or radiographic evidence of neurovascular compromise were reviewed to assess for deficits on physical examination on presentation, relevant radiographic and electro-diagnostic findings, timing and type of fixation, and time until resolution of symptoms and radiographic union postoperatively. Of the 443 adult patients undergoing surgical treatment for displaced midshaft clavicle fracture, 3 (1%) experienced acute neurovascular compromise and underwent early fixation. In all cases, fracture displacement caused compression of adjacent neurovascular structures in the costoclavicular space. No lacerations of underlying neurovascular structures were encountered intraoperatively, suggesting a pattern of nerve contusion or vascular compression from the initial injury and fracture displacement. Postoperatively, 2 patients had full recovery of preoperative neurologic deficits and 1 patient experienced partial recovery of motor deficits with persistent neuropathic pain. There were no instances of symptomatic vascular insufficiency at final follow-up. Acute neurovascular injury as a result of compression of underlying structures in the costoclavicular space is a rare complication of displaced midshaft clavicle fracture. Early surgical decompression of compressed neurovascular structures and rigid clavicle osteosynthesis can lead to significant postoperative functional improvement. [Orthopedics. 2021;44(3):e390-e394.].
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6
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Delaune LA, Wehrli L, Maeder Y, Vauclair F, Moerenhout K. Acute brachial plexus deficit due to clavicle fractures. JSES Int 2021; 5:46-50. [PMID: 33554163 PMCID: PMC7846699 DOI: 10.1016/j.jseint.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Laurent Wehrli
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Yael Maeder
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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7
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Distribution of Peripheral Nerve Injuries in Patients with a History of Shoulder Trauma Referred to a Tertiary Care Electrodiagnostic Laboratory. Diagnostics (Basel) 2020; 10:diagnostics10110887. [PMID: 33143188 PMCID: PMC7693958 DOI: 10.3390/diagnostics10110887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
Peripheral nerve injury after shoulder trauma is an underestimated complication. The distribution of the affected nerves has been reported to be heterogeneous in previous studies. This study aimed to describe the distribution of peripheral nerve injuries in patients with a history of shoulder trauma who were referred to a tertiary care electrodiagnostic laboratory. A retrospective chart review was performed for all cases referred to a tertiary care electrodiagnostic laboratory between March 2012 and February 2020. The inclusion criteria were a history of shoulder trauma and electrodiagnostic evidence of nerve injury. Data on patient demographics, mechanism of injury, degree of weakness, clinical outcomes at the final follow-up, and electrodiagnostic results were retrieved from medical records. Fifty-six patients had peripheral nerve injuries after shoulder trauma. Overall, isolated axillary nerve injury was the most common. A brachial plexus lesion affecting the supraclavicular branches (pan-brachial plexus and upper trunk brachial plexus lesions) was the second most common injury. In cases of shoulder dislocation and proximal humerus fracture, isolated axillary nerve injury was the most common. Among acromioclavicular joint injuries and clavicular fractures, lower trunk brachial plexus injuries and ulnar neuropathy were more common than axillary nerve or upper trunk brachial plexus injuries. Patients with isolated axillary nerve lesions showed a relatively good recovery; those with pan-brachial plexus injuries showed a poor recovery. Our study demonstrated the distribution of peripheral nerve injuries remote from displaced bony structures. Mechanisms other than direct compression by displaced bony structures might be involved in nerve injuries associated with shoulder trauma. Electrodiagnostic tests are useful for determining the extent of nerve damage after shoulder trauma.
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Johnson CS, Acebo JB, Aya K, Somerson JS. Transient Brachial Plexopathy After Fixation of a Clavicle Fracture Nonunion: A Case Report. JBJS Case Connect 2020; 10:e0434. [PMID: 32649110 DOI: 10.2106/jbjs.cc.19.00434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 54-year-old man presented with a comminuted left midclavicle fracture that progressed to a symptomatic nonunion after nonsurgical management. Nonunion open reduction and internal fixation (ORIF) was performed, but a left brachial plexopathy developed 48 hours postoperatively. Imaging failed to demonstrate an emergent cause. The patient was monitored and completely recovered, with occasional neuralgia and mildly limited forward elevation of the shoulder. CONCLUSION Development of a brachial plexopathy 48 hours after routine clavicle nonunion ORIF using plate fixation is an unusual complication. Future studies are needed to determine if this "wait-and-see" approach can be generalized to similar cases.
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Affiliation(s)
- Connor S Johnson
- 1School of Medicine, The University of Texas Medical Branch, Galveston, Texas 2Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
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Mazal AT, Faramarzalian A, Samet JD, Gill K, Cheng J, Chhabra A. MR neurography of the brachial plexus in adult and pediatric age groups: evolution, recent advances, and future directions. Expert Rev Med Devices 2020; 17:111-122. [PMID: 31964194 DOI: 10.1080/17434440.2020.1719830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: MR neurography (MRN) of the brachial plexus has emerged in recent years as a safe and accurate modality for the identification of brachial plexopathies in pediatric and adult populations. While clinical differentiation of brachial plexopathy from cervical spine-related radiculopathy or nerve injury has long relied upon nonspecific physical exam and electrodiagnostic testing modalities, MRN now permits detailed interrogation of peripheral nerve anatomy and pathology, as well as assessment of surrounding soft tissues and musculature, thereby facilitating accurate diagnosis. The reader will learn about the current state of brachial plexus MRN, including recent advances and future directions, and gain knowledge about the adult and pediatric brachial plexopathies that can be characterized using these techniques.Areas Covered: The review details recent developments in brachial plexus MRN, including increasing availability of 3.0-T MR scanners at both private and academic diagnostic imaging centers, as well as the advent of multiple new vascular and fat signal suppression techniques. A literature search of PubMed and SCOPUS was used as the principal source of information gathered for this review.Expert Opinion: Refinement of fat-suppression, 3D techniques and diffusion MR imaging modalities has improved the accuracy of MRN, rendering it as a useful adjunct to clinical findings during the evaluation of suspected brachial plexus lesions.
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Affiliation(s)
- Alexander T Mazal
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ali Faramarzalian
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan D Samet
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin Gill
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Cheng
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA.,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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Saito T, Matusmura T, Takeshita K. Brachial plexus palsy after clavicle fracture: 3 cases. J Shoulder Elbow Surg 2020; 29:e60-e65. [PMID: 31784383 DOI: 10.1016/j.jse.2019.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Brachial plexus palsy after clavicle fracture is extremely rare. We experienced 3 cases of brachial plexus palsy after clavicle fracture and investigated the findings that such patients have in common and the clinical results of these cases. METHODS We retrospectively analyzed the data of 3 patients with clavicle fracture who had no neurovascular symptoms at the time of the initial injury but gradually developed brachial plexus palsy within 1 month after the injury. The patients were aged 70, 62, and 68 years; 2 patients were male and 1 was female. The patients' backgrounds and clinical results were assessed. RESULTS All patients had a displaced middle-third clavicle fracture and underwent conservative therapy with a figure-8 bandage. The intervals between fracture and symptoms of brachial plexus palsy were 8, 30, and 14 days. The times from symptoms of brachial plexus palsy to surgery were 27, 75, and 28 days. In all patients, surgery revealed a ruptured subclavius muscle and abnormal development of granulation tissue around the fracture site, compressing the brachial plexus. Open reduction and plate fixation was performed in 2 patients, and clavicle resection was performed in 1 patient. The intervals between surgery and full recovery of muscle strength were 11, 6, and 6 months. CONCLUSION The findings our 3 patients with brachial plexus palsy after clavicle fracture had in common are old age, middle-third displaced clavicle fracture, and abnormal development of granulation tissue around the fracture site. Surgical intervention yielded good clinical outcomes.
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Affiliation(s)
- Tomohiro Saito
- Department of Orthopaedic Surgery, Jichi Medical University, Tochigi, Japan.
| | - Tomohiro Matusmura
- Department of Orthopaedic Surgery, Jichi Medical University, Tochigi, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, Tochigi, Japan
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11
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Makida K, Iwase T, Tanaka K, Kobayashi M. Hybrid surgery for a pseudoaneurysm caused by a clavicle fracture. J Orthop Sci 2019; 24:1130-1132. [PMID: 28554715 DOI: 10.1016/j.jos.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/26/2017] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Kazuya Makida
- Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan.
| | - Toshiki Iwase
- Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Kuniyoshi Tanaka
- Department of Cardiovascular Surgery, Hamamatsu Medical Center, Hamamatsu, Japan
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12
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Two cases of brachial plexus compression secondary to displaced clavicle fractures. Trauma Case Rep 2019; 23:100219. [PMID: 31467966 PMCID: PMC6710716 DOI: 10.1016/j.tcr.2019.100219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2019] [Indexed: 11/23/2022] Open
Abstract
Brachial plexus compression is a rare complication of displaced clavicle fractures, with few reports existing in the literature. Neurologic symptoms can present immediately after the injury or in a delayed fashion months later. Following polytrauma, two patients presented with displaced middle-third left clavicle fractures initially treated conservatively at other institutions. Both patients developed neurologic symptoms in the left upper extremity consistent with brachial plexus compression. Magnetic resonance imaging and electrodiagnostic testing were used to help confirm the diagnosis of thoracic outlet syndrome/brachial plexopathy, and both patients underwent open reduction internal fixation with dual plating, local bone grafting and brachial plexus decompression. Both patients experienced successful relief of neurologic symptoms postoperatively. The purpose of this case series is to report on a rare complication of delayed- and non-united clavicle fractures and describe successful treatment with a novel fracture fixation construct.
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Kilic M, Kilic B, Aydin MD, Yilmaz I, Yilmaz A, Yilmaz F, Kurt A, Nuri Kocak M. The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study. J Clin Neurosci 2019; 66:235-238. [PMID: 31153749 DOI: 10.1016/j.jocn.2019.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
AIM Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH. MATERIAL AND METHODS Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed. RESULTS The average degenerated soma intensity/mm3 at the C5-6 levels in the spinal cord was 2 ± 1/mm3, 13 ± 4/mm3, and 56 ± 10/mm3 for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm2, 34 ± 9/mm2, and 234 ± 78/mm2 for Groups I, II, and III. CONCLUSION Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Betul Kilic
- Department of Pediatric Neurology, Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
| | - Mehmet Dumlu Aydin
- Department of Neurosurgery, Medical Faculty of Ataturk University, Erzurum, Turkey.
| | - Ilhan Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Adem Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Figen Yilmaz
- Department of Physical Therapy and Rehabilitation, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Ali Kurt
- Department of Pathology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Mehmet Nuri Kocak
- Department of Neurosurgery, Medical Faculty of Ataturk University, Erzurum, Turkey
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Ashman BD, Tewari A, Castle J, Hasan SS, Bhatia S. Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report. JBJS Case Connect 2018; 8:e85. [PMID: 30601768 DOI: 10.2106/jbjs.cc.18.00040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE Brachial plexopathy is a rare complication of nonoperatively treated clavicular fractures. We describe a 68-year-old man who presented with fracture-callus-induced acute brachial plexopathy and dynamic thoracic outlet syndrome after 9 weeks of nonoperative management for a clavicular fracture. He underwent fracture fixation with brachial plexus decompression via callus excision; intraoperative neuromonitoring was used to evaluate brachial plexus function. Postsurgery, his neurologic function recovered completely. CONCLUSION Intraoperative neuromonitoring is a useful tool for minimizing the risk of additional brachial plexus injury and determining the adequacy of neural decompression during delayed open reduction and internal fixation of clavicular fractures with fracture-callus-induced brachial plexus compression.
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Affiliation(s)
- Bradley D Ashman
- Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio
| | | | | | - Samer S Hasan
- Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio
| | - Sanjeev Bhatia
- Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio
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Campfield B, Barzideh OS. Clavicular Fracture Associated with Life-Threatening Hemorrhage: A Case Report. JBJS Case Connect 2016; 6:e31. [PMID: 29252665 DOI: 10.2106/jbjs.cc.15.00193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A sixty-four-year-old woman sustained a displaced midshaft clavicular fracture. Shortly after admission to the hospital, she developed symptoms of hypovolemic shock as well as neurologic compromise of the ipsilateral upper extremity. Her workup demonstrated a large periclavicular hematoma. She underwent surgical exploration, during which a subclavian artery laceration was identified and repaired. CONCLUSION This case serves as a reminder to the treating physician to maintain an appropriate index of suspicion for associated injuries when treating clavicular fractures.
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Leroux T, Wasserstein D, Henry P, Khoshbin A, Dwyer T, Ogilvie-Harris D, Mahomed N, Veillette C. Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada. J Bone Joint Surg Am 2014; 96:1119-1125. [PMID: 24990977 DOI: 10.2106/jbjs.m.00607] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort. METHODS Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes. RESULTS We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients. CONCLUSIONS Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Timothy Leroux
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux:
| | - David Wasserstein
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux:
| | - Patrick Henry
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux:
| | - Amir Khoshbin
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for T. Leroux:
| | - Tim Dwyer
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - Darrell Ogilvie-Harris
- Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette:
| | - Nizar Mahomed
- Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette:
| | - Christian Veillette
- Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for C. Veillette:
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Abstract
We present our experience of managing patients with iatropathic brachial plexus injury after delayed fixation of a fracture of the clavicle. It is a retrospective cohort study of patients treated at our peripheral nerve injury unit and a single illustrative case report. We identified 21 patients in whom a brachial plexus injury occurred as a direct consequence of fixation of a fracture of the clavicle between September 2000 and September 2011. The predominant injury involved the C5/C6 nerves, upper trunk, lateral cord and the suprascapular nerve. In all patients, the injured nerve was found to be tethered to the under surface of the clavicle by scar tissue at the site of the fracture and was usually associated with pathognomonic neuropathic pain and paralysis. Delayed fixation of a fracture of the clavicle, especially between two and four weeks after injury, can result in iatropathic brachial plexus injury. The risk can be reduced by thorough release of the tissues from the inferior surface of the clavicle before mobilisation of the fracture fragments. If features of nerve damage appear post-operatively urgent specialist referral is recommended. Cite this article: Bone Joint J 2013;95-B:106–10.
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Affiliation(s)
- L. Jeyaseelan
- Peripheral Nerve Injury Unit, Royal National
Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - V. K. Singh
- Peripheral Nerve Injury Unit, Royal National
Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - S. Ghosh
- Peripheral Nerve Injury Unit, Royal National
Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - M. Sinisi
- Peripheral Nerve Injury Unit, Royal National
Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - M. Fox
- Peripheral Nerve Injury Unit, Royal National
Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex
HA7 4LP, UK
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18
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Namdari S, Voleti PB, Huffman GR. Compressive Brachial Plexopathy After Fixation of a Clavicular Fracture Nonunion: A Case Report. JBJS Case Connect 2012; 2:e26. [PMID: 29252427 DOI: 10.2106/jbjs.cc.k.00124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Surena Namdari
- The Penn Shoulder Service, Penn Presbyterian Hospital, 1 Cupp Pavilion, Philadelphia, PA 19104.
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19
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Kassim S, Lovejoy JF. Late Neurovascular Compromise Secondary to a Malunited Clavicular Fracture in a Preadolescent: A Case Report. JBJS Case Connect 2012; 2:e8. [PMID: 29252459 DOI: 10.2106/jbjs.cc.k.00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sekinat Kassim
- Department of Orthopaedic Surgery, Howard University Hospital, Room 4C-34, 2041 Georgia Avenue, Washington, DC 20060
| | - John F Lovejoy
- Department of Orthopaedics and Sports Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010.
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20
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Abstract
BACKGROUND Midshaft clavicle fractures in adolescents have traditionally been treated nonoperatively. Recent studies in the adult literature have shown a higher prevalence of symptomatic malunion, nonunion, and poor functional outcome after nonoperative treatment of displaced fractures. The purpose of this study was to compare operative versus nonoperative treatment of displaced clavicle fractures in adolescents. MATERIALS AND METHODS Adolescents who sustained closed midshaft clavicle fractures between 2000 and 2008 were identified in our institutional trauma registry. Medical records were reviewed for patient demographics, injury characteristics, treatment, and outcomes. RESULTS Forty-two consecutive patients (mean age 15.4 y) with 43 closed midshaft clavicle fractures were identified. Twenty-five patients were treated nonoperatively with a sling or figure-of-8 brace. Seventeen patients were treated operatively with acute plate fixation for fractures displaced more than 2 centimeters. The average shortening at injury was 12.5 mm in the nonoperative group and 27.5 mm in the operative group (P=0.003). The mean time to radiographic union for displaced fractures was 8.7 weeks in the nonoperative group and 7.4 weeks in the operative group (P=0.02). There were no nonunions in either group. All complications in the operative group were related to local hardware prominence. The mean time to return to activities was 16 weeks in the nonoperative group and 12 weeks in the operative group. Symptomatic malunion, with a mean fracture shortening of 26 mm, developed in 5 patients in the nonoperative group. Four of these patients elected corrective osteotomy with internal fixation and all went on to union with resolution of their symptoms. CONCLUSIONS Plate fixation of displaced midshaft clavicle fracture reliably restores length and alignment. It resulted in shorter time to union with low complication rates. Symptomatic malunion in adolescents may be more common than earlier thought after significantly displaced fractures. Corrective osteotomy with plate fixation can restore clavicle anatomy and eliminate symptoms associated with malunion. LEVEL OF EVIDENCE Therapeutic level III.
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21
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Rodriguez-Merchan EC, Gomez-Cardero P. Delayed union of a fracture of the middle third of the clavicle presenting with a late subclavian pseudoaneurysm. Musculoskelet Surg 2010; 94:89-92. [PMID: 20443157 DOI: 10.1007/s12306-010-0076-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
Abstract
This is the case of a 46-year-old man who presented 3 months following a fracture of the middle third of the clavicle with an expanding mass in the supraclavicular fossa. Upon admission, a pulsatile mass was identified and X-rays showed delayed union of the fracture. Seven days after admission, skin necrosis developed. Arteriography performed 3 days later demonstrated a round subclavian pseudoaneurysm measuring 5 cm in diameter. It was occluded by means of an endovascular prosthesis. Four days after arteriography, the delayed union was treated by excision of the necrotic skin and internal fixation with a plate and screws. After 1 year of follow-up, the outcome was clinically and radiologically satisfactory.
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Affiliation(s)
- E C Rodriguez-Merchan
- Department of Orthopaedics, La Paz University Hospital, Paseo de la Castellana 261, Madrid, Spain.
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22
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Lin CC, Lin J. Brachial plexus palsy caused by secondary fracture displacement in a patient with closed clavicle fracture. Orthopedics 2009; 32:orthopedics.43780. [PMID: 19824597 DOI: 10.3928/01477447-20090818-24] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In adults, brachial plexus injury due to clavicle fractures is rare, and is most commonly caused by nonunion, malunited fragments, hypertrophic callus, or pseudoaneurysm of the subclavicular artery or vein. Brachial plexus palsy in acute fractures caused by direct fragment compression is exceptional. Conservative treatment of nondisplaced and displaced midclavicle fractures in adults usually produces satisfactory outcomes. This article presents a case of a 74-year-old man who sustained a closed, midshaft right clavicle fracture complicated by secondary displacement and brachial plexus injury. Initially, the fracture was nondisplaced, and he was treated conservatively. However, he returned 2 weeks later with shoulder pain and coldness, progressive numbness, and weakness of the right extremity. Physical examination revealed weakness of the flexion and extension of his elbow, wrist, and finger joints with slightly diminished right side radial pulsation. Radiographs demonstrated a displaced clavicle fracture with a vertically angulated intermediate fragment and narrowed costoclavicular space. Magnetic resonance imaging revealed bony fragments with a perifocal soft tissue mass encroaching on the brachial plexus and axillary artery. During surgery, the brachial plexus was found to be markedly stretched due to compression by the bony fragments and an organized blood clot. After meticulous neurolysis, the blood clot and intermediate bony fragments were removed and the distal fragments were reduced and fixed with a metal plate and interfragmentary screws. Secondary fracture displacement is possible after a nondisplaced clavicle fracture if the arm is not well protected, even if the original fracture appears stable and no neurological or circulatory symptoms are present.
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Affiliation(s)
- Chen-Chiang Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
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Krishnan KG, Mucha D, Gupta R, Schackert G. Brachial plexus compression caused by recurrent clavicular nonunion and space-occupying pseudoarthrosis: definitive reconstruction using free vascularized bone flap-a series of eight cases. Neurosurgery 2008; 62:ONS461-9; discussion 469-70. [PMID: 18596530 DOI: 10.1227/01.neu.0000326036.54714.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE In rare cases, space-occupying pseudoarthrotic clavicular nonunion causes symptomatic brachial plexus compression. The surgical treatment of clavicular pseudoarthrosis has been extensively reported in the literature. This article reports our experience of a definitive treatment strategy using free vascularized fibula flaps in cases of persistent compression of the brachial plexus by relapsing bony nonunion mass lesions. METHODS Six men (age range, 46-59 yr) and two women (ages 48 and 52 yr) with nonunions of clavicular midshaft fractures were referred between August 2001 and March 2005 because of progressive compression of the subclavicular neurovascular bundle. All of them had displaced traumatic clavicle fractures that had been treated previously at other institutions. At least two surgical reconstructive procedures had been performed beforehand. Four patients had motor deficits owing to compressive brachial plexus lesions; all showed symptoms of combined thoracic outlet syndrome. Our surgery consisted of resection of the space-occupying clavicular pseudoarthrosis (all eight patients), external neurolysis of the brachial plexus (four patients) and reconstruction of the resulting bone defect with free vascularized fibula flap secured with plates (all eight patients). Vascularity of the bone flap was studied using three-phase bone scintigraphy. RESULTS All patients became free of pain symptoms after surgery. Muscle strength in two of the four patients with preoperative motor deficits improved to normal within 3 months; the other two patients required 6 and 8 months, respectively. Three-phase bone scintigraphy showed adequate perfusion of the bone flaps in all patients. Postoperative bleeding at the recipient site occurred in three patients; these required revision. One patient showed an osseosubcutaneous fistula 6 months after surgery, which was treated conservatively. There was no recurrence of pseudoarthrosis or neurovascular compression at a mean follow-up period of 38.5 months. CONCLUSION Recurrent space-occupying pseudoarthrosis of the clavicle complicated with neurovascular compression might warrant definitive reconstruction using a free vascularized bone flap.
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Affiliation(s)
- Kartik G Krishnan
- Department of Neuroradiology, Carl Gustav Carus University Hospital, Dresden, Germany.
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Abstract
Brachial plexus injuries requiring extensive exposure might benefit from a transclavicular approach. At a level 1 trauma center, 20 patients underwent surgical intervention for brachial plexus injuries, 10 via a transclavicular approach. For 5 patients, the transclavicular approach was accomplished through osteotomy with a technique presented herein, and for the other 5, through an established nonunion. All osteotomies and nonunions healed. No hardware-related complications occurred. We think that in the appropriate setting, a transclavicular approach facilitates exposure, decreases surgical time, and is associated with minimal risk.
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Abstract
Plate fixation remains a staple for open fractures, closed fractures requiring open management, and nonunions, especially if bone grafting is required.
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Affiliation(s)
- Matthew L Graves
- Section of Sports Medicine and Hand and Upper Extremity Surgery, University of Mississippi Medical Center, Jackson Miss. 39216-4505, USA
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Abstract
The brachial plexus, which is the most complex structure of the peripheral nervous system, supplies most of the upper extremity and shoulder. The high incidence of brachial plexopathies reflects its vulnerability to trauma and the tendency of disorders involving adjacent structures to affect it secondarily. The combination of anatomic, pathophysiologic, and neuromuscular knowledge with detailed clinical and ancillary study evaluations provides diagnostic and prognostic information that is important to clinical management. Since most brachial plexus disorders do not involve the entire brachial plexus but, rather, show a regional predilection, a regional approach to assessment of plexopathies is necessary.
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