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Alzahrani MM. Late brachial plexopathy after a mid-shaft clavicle fracture: A case report. World J Orthop 2023; 14:776-783. [PMID: 37970622 PMCID: PMC10642401 DOI: 10.5312/wjo.v14.i10.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Clavicle fractures can rarely be associated with brachial plexus injury. These are commonly caused by tractional injury at the time of trauma, but unfrequently can be caused by compression of the brachial plexus from excessive callus or granulation tissue formation. CASE SUMMARY We report a rare case of an adult male who sustained a mid-shaft clavicle fracture and had a late presentation of brachial plexus palsy due to compression from excessive callus formation. CONCLUSION We reported a case of a rare occurrence of delayed brachial plexus palsy due to compression from excessive callus formation in a midshaft clavicle fracture. Early diagnosis and surgical decompression of the brachial plexus is critical, as when managed efficiently, a full recovery of the brachial plexus palsy can be expected in these patients.
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Affiliation(s)
- Mohammad M Alzahrani
- Department of Orthopaedic Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
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2
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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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3
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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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4
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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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5
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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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Kluemper C, Koestner T, Cowart J, Higgins M. Intercostal Entrapment of Clavicle Fracture Causing a Pulseless, Flaccid Upper Extremity. J Hand Surg Am 2018; 43:1143.e1-1143.e4. [PMID: 29678429 DOI: 10.1016/j.jhsa.2018.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/04/2018] [Accepted: 03/13/2018] [Indexed: 02/02/2023]
Abstract
Limb-threatening vascular compromise from an isolated closed clavicle fracture is exceedingly rare. We report a case of a posteriorly angulated, closed clavicle fracture segment causing right upper-extremity ischemia, numbness, and paresis caused by entrapment of the clavicle between the first and second ribs.
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Affiliation(s)
- Chase Kluemper
- Department of Orthopedic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN.
| | - Tyler Koestner
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN
| | - Justin Cowart
- Department of Orthopedic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN
| | - Matt Higgins
- Department of Orthopedic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN
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7
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Baek JK, Lee YH, Kim MB, Baek GH. Operative Treatment for Midshaft Clavicle Fractures in Adults: A 10-Year Study Conducted in a Korean Metropolitan Hospital. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.4.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeong Kook Baek
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Goo Hyun Baek
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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Gieger J, Beeres F, Birrer K, Babst R. Misalignment of the clavicle after intramedullary fixation of a midshaft fracture with a titanium elastic nail results in acute neurovascular thoracic outlet syndrome. J Shoulder Elbow Surg 2016; 25:e110-4. [PMID: 26995460 DOI: 10.1016/j.jse.2015.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 12/05/2015] [Accepted: 12/14/2015] [Indexed: 02/01/2023]
Affiliation(s)
- Jochen Gieger
- Department of Traumatology, Kantonsspital Luzern, Luzern, Switzerland.
| | - Frank Beeres
- Department of Traumatology, Kantonsspital Luzern, Luzern, Switzerland
| | - Konrad Birrer
- Department of Traumatology, Kantonsspital Luzern, Luzern, Switzerland
| | - Reto Babst
- Department of Traumatology, Kantonsspital Luzern, Luzern, Switzerland
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10
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Abstract
Clavicle fractures are common, and most are isolated injuries. Injury to the nearby subclavian vessels and brachial plexus have classically been described as potential complications of clavicle fractures. However, in the setting of a substantially displaced clavicle fracture, concomitant thoracic trauma is relatively frequent. Injury to the thorax can be difficult to identify on physical examination, and advanced imaging modalities may be required for diagnosis. The evaluation, workup, and management of a patient with intrathoracic displacement of a clavicle fracture are described. Despite the significant fracture displacement and associated pneumothorax, the injury severity was not clinically obvious. Imaging, including a screening chest radiograph and subsequent axial computed tomography, played an important role in diagnosis and management. The patient underwent successful open reduction and plate fixation. A thoracostomy tube was not required at any point during the hospitalization. The patient recovered uneventfully and returned to full work duty by 3 months postoperatively. Including the current report, only 3 cases of intrathoracic displacement of the clavicle have been published in the English literature. All involved fractures of the middle third of the clavicle. The severity of displacement was not obvious in any patient, and diagnosis was dependent on additional imaging. Given the frequency of associated chest trauma and limitations of physical examination, chest radiography should be considered in the evaluation of patients with substantially displaced clavicle fractures.
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11
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Gill I, Quayle J, Fox M. A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression. Ann R Coll Surg Engl 2013; 95:e30-3. [PMID: 23484977 PMCID: PMC4098608 DOI: 10.1308/003588413x13511609955256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres. We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.
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Affiliation(s)
- I Gill
- Frimley Park Hospital NHS Foundation Trust, Frimley, Surrey, UK.
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12
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A patient with clavicle fracture and recurrent scapular winging with spontaneous resolutions. Case Rep Orthop 2012; 2012:603726. [PMID: 23259125 PMCID: PMC3505890 DOI: 10.1155/2012/603726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/26/2012] [Indexed: 11/24/2022] Open
Abstract
Injury to the long thoracic nerve with resulting serratus anterior palsy is a typical cause of medial scapular winging. We report a case of a 70-year-old female with scapular winging in the setting of a mildly comminuted midshaft clavicle fracture. The winging persisted for three months after the fracture, which became a nonunion. The winging spontaneously resolved prior to open reduction and internal fixation of the nonunion. The winging recurred after this surgery. The recurrence was attributed to transient irritation and/or inflammatory neuropathy of the brachial plexus caused by the surgical manipulation. This second episode of winging again spontaneously resolved. There are few reported cases of scapular winging in the setting of a clavicle fracture and only one case of recurrent scapular winging. In that case, which was in the setting of an acromioclavicular joint separation, the second episode of winging required long-term use of a brace. By contrast, our patient did not require bracing because the recurrent winging spontaneously resolved, making this a novel case. This case is important because it illustrates that recurrent scapular winging can occur, and spontaneously resolve, in the setting of a mid-shaft clavicle fracture after subsequent reconstruction of a fracture nonunion.
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13
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Smekal V, Attal R, Dallapozza C, Krappinger D. Elastisch stabile intramedulläre Nagelung nach Korrekturosteotomie von symptomatisch fehlverheilten Klavikulafrakturen. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2011; 23:375-84. [DOI: 10.1007/s00064-011-0137-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Tjoumakaris FP, Matzon JL, Williams GR. Clavicle fracture with thoracic penetration and hemopneumothorax but without neurovascular compromise. Orthopedics 2011; 34:e692-5. [PMID: 21956070 DOI: 10.3928/01477447-20110826-31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Clavicle fractures are rarely associated with more severe neurologic or vascular injuries. When these associated injuries are encountered, prompt recognition and treatment are paramount to optimize outcome. The majority of fractures that result in neurovascular compromise are from high-energy trauma; however, a high index of suspicion should be present in all cases as low-energy trauma can also result in more catastrophic injury. This article describes a case of a low-energy clavicle fracture in a 28-year-old woman that resulted in intrathoracic penetration of the fracture fragment with hemopneumothorax. The patient underwent successful chest tube placement and open reduction and internal fixation of the fracture. A multidisciplinary team was used during surgery, including cardiothoracic, trauma, and orthopedic surgery. Two years postoperatively, the patient was back to normal activities with no neurologic, pulmonary, or vascular sequelae. This case highlights the importance of a comprehensive physical examination and inspection of all radiographs so that associated injuries are not missed.
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Affiliation(s)
- Fotios P Tjoumakaris
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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15
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Rüst CA, Knechtle B, Knechtle P, Rosemann T. Atrophy of the brachialis muscle after a displaced clavicle fracture in an Ironman triathlete: case report. J Brachial Plex Peripher Nerve Inj 2011; 6:7. [PMID: 21961883 PMCID: PMC3201889 DOI: 10.1186/1749-7221-6-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 10/02/2011] [Indexed: 11/10/2022] Open
Abstract
Clavicle fractures are frequent injuries in athletes and midshaft clavicle fractures in particular are well-known injuries in Ironman triathletes. In 2000, Auzou et al. described the mechanism leading to an isolated truncular paralysis of the musculocutaneous nerve after a shoulder trauma. It is well-known that nerve palsies can lead to an atrophy of the associated muscle if they persist for months or even longer. In this case report we describe a new case of an Ironman triathlete suffering from a persistent isolated atrophy of the brachialis muscle. The atrophy occurred following a displaced midshaft clavicle fracture acquiring while falling off his bike after hitting a duck during a competition.
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Affiliation(s)
- Christoph Alexander Rüst
- Institute of General Practice and Health Services Research, University of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland.
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16
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Nonoperative treatment of closed displaced midshaft clavicle fractures. J Orthop Traumatol 2010; 11:229-36. [PMID: 20936323 PMCID: PMC3014468 DOI: 10.1007/s10195-010-0113-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 09/23/2010] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND closed displaced midshaft clavicle fractures used to be treated nonoperatively, and many studies have reported that nonoperative treatment gave good results. However, more recent studies have reported poorer results following nonoperative treatment, whereas the results of operative treatment have improved considerably. The aim of this paper was to report the results of treating closed displaced midshaft clavicle fractures nonoperatively. MATERIALS AND METHODS one hundred Edinburgh type 2B clavicle fractures (69 type 2B1 and 31 type 2B2) in 100 patients (78 males and 22 females) aged between 18 and 67 ears (mean 32 years) were treated. All patients were treated using a figure-of-eight bandage. Clinical and radiographic assessment was performed at the time of trauma, 1, 2 and 3 months after the trauma, and then at an average follow-up of 3 years (range 1-5 years). The outcome was rated at the last follow-up using the DASH score. RESULTS ninety-seven of the 100 fractures healed. Three nonunions were observed. Average healing time was 9 weeks (range 8-12 weeks). No statistically significant correlation between the type of fracture and the healing time was observed. The average DASH score was 24 (range 0-78) and, based on this score, 81 patients presented excellent results, 12 good, 5 fair, and 2 poor. No statistically significant correlation between the type of the fracture and the score was observed. CONCLUSIONS we believe that nonoperative treatment is still appropriate in most cases, as it yields good results without incurring the potential complications of surgery.
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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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18
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Smekal V, Deml C, Kamelger F, Dallapozza C, Krappinger D. Corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails. Arch Orthop Trauma Surg 2010; 130:681-5. [PMID: 19885664 DOI: 10.1007/s00402-009-0994-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION It is our goal to present an alternative, less invasive surgical technique for corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails (ESIN) and to present our results in a consecutive patients series. METHOD AND PATIENTS Between January 2003 and December 2006, five patients aged between 23 and 44 years presented with a symptomatic malunion after nonoperative treatment of displaced midshaft clavicular fractures. Corrective osteotomy was performed without bone grafting. RESULTS The osteotomy sites united in all patients after a mean of 4.4 months. The nails were removed in all patients after 7 months. At final follow-up, DASH and Constant Scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with cosmetical appearance and overall outcome. Clavicular shortening was also significantly improved. Elastic stable intramedullary nailing leads to favourable results in corrective osteotomy of malunited midshaft clavicular fractures. CONCLUSION We therefore recommend this technique for corrective osteotomy of symptomatic midshaft clavicular malunions.
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Affiliation(s)
- Vinzenz Smekal
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Abstract
Clavicular fractures represent 2.6—5% of all fractures, with middle third fractures being the commonest. The shape of the clavicle bone is such that it has a flat medial and lateral expanses, linked by a thin, tubular middle. This central transitional area represents a weak link in clavicular structure, which is not protected by or reinforced with muscle or ligamentous attachments, therefore rendering it prone to fracture. Due to the subcutaneous position of the clavicle, there is an inherent susceptibility to direct injury. These fractures are easy to diagnose due to the presence of swelling and bruising present. Radiographical examination should include an anteroposterior and a 45° caudal tilt view. Optimal treatment in undisplaced or minimally displaced fractures is with a sling. In displaced or comminuted fractures the risk of non-union and poor functional outcome may be markedly higher and may be best treated with surgical fixation.
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Affiliation(s)
- Pradeep Moonot
- Epsom & St Helier NHS Trust, Epsom, Surrey KT18 7EG, UK,
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20
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Abstract
Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union, and the functional outcomes are good after nonoperative treatment. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits than previously reported. However, it remains difficult to predict which patients will have these complications. Since a satisfactory functional outcome may be obtained after operative treatment of a clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment of these injuries. Displaced lateral-end fractures have a higher risk of nonunion after nonoperative treatment than do shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in elderly individuals. The results of operative treatment are more unpredictable than they are for shaft fractures.
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Affiliation(s)
- L A Kashif Khan
- Edinburgh Shoulder Clinic, Royal Infirmary of Edinburgh, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom
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21
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Abstract
It has been believed since the time of Hippocrates that clavicle fractures require little more than benign neglect by clinicians. Although many patients who have clavicle injuries do achieve adequate healing and functional recovery without surgical interventions, good outcomes, especially with displaced fractures, are not universal. Recent literature suggests that a subset of midclavicular injuries may warrant primary surgical treatment to minimize the incidence of nonunion and/or symptomatic malunion. Furthermore, certain types of clavicular injuries result in suboptimal outcomes when managed nonoperatively. This article is based on the currently available clinical evidence on the evolving management of acute clavicle fractures.
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Affiliation(s)
- Won Kim
- Division of Orthopaedic Surgery, St. Michaels Hospital and the University of Toronto, 55 Queen Street East, Suite 800, Ontario M5C 1R6, Canada
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22
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Chapman TWL, Harris NM, Rogers M, Wilson P, McDiarmid J. Delayed brachial plexopathy in clavicular fracture with tri-cord neurapraxia and complete recovery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2007. [DOI: 10.1007/s00238-006-0074-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bumbasirević M, Lesić A, Tomić S, Milićević M, Djukić V, Ivancević N, Mitković M, Bumbasirević V, Sudjić V. [Modern aspects of shoulder injury treatment]. ACTA CHIRURGICA IUGOSLAVICA 2005; 52:15-22. [PMID: 16237890 DOI: 10.2298/aci0502015b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The article describes injuries of soft and bone structures of the shoulder region, with special emphasis on the following clinical forms: instabilities and luxations of the glenohumeral joint, fractures of the proximal humerus, clavicle and the states of painful shoulder. Fractures and dislocations, but also significant entities - painful states caused not only by fractures but also by minor trauma such as tendinitises and m.supraspinatus tendon and bicipital tendon ruptures are discussed in more detail. Moreover, their consequences - painful and stiff shoulder - as well as modern diagnostic and therapeutic procedures applied in the painful shoulder treatment are also discussed.
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24
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Shackford SR, Connolly JF. Taming of the Screw: A Case Report and Literature Review of Limb-Threatening Complications after Plate Osteosynthesis of a Clavicular Nonunion. ACTA ACUST UNITED AC 2003; 55:840-3; discussion 843. [PMID: 14608153 DOI: 10.1097/01.ta.0000085862.32648.05] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Steven R Shackford
- Department of Surgery, College of Medicine, University of Vermont, and Fletcher Allen Health Care, Fletcher House 301, 111 Colchester Avenue, Burlington, VT 05401, USA.
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25
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Abstract
BACKGROUND The purpose of this study was to analyze the functional results of corrective osteotomy of a malunited clavicular fracture in patients with chronic pain, weakness, neurologic symptoms, and dissatisfaction with the appearance of the shoulder. METHODS We identified fifteen patients (nine men and six women with a mean age of thirty-seven years) who had a malunion following nonoperative treatment of a displaced midshaft fracture of the clavicle. The mean time from the injury to presentation was three years (range, one to fifteen years). Outcome scores revealed major residual deficits. The mean amount of clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. RESULTS At the time of follow-up, at a mean of twenty months (range, twelve to forty-two months) postoperatively, the osteotomy site had united in fourteen of the fifteen patients. All fourteen patients expressed satisfaction with the result. The mean DASH (Disabilities of the Arm, Shoulder and Hand) score for all fifteen patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). The mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was one nonunion, and two patients had elective removal of the plate. CONCLUSIONS Malunion following clavicular fracture may be associated with orthopaedic, neurologic, and cosmetic complications. In selected cases, corrective osteotomy results in a high degree of patient satisfaction and improves patient-based upper-extremity scores.
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Affiliation(s)
- Michael D McKee
- Department of Surgery, St. Michael's Hospital and the University of Toronto, Ontario, Canada.
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Rezzouk J, Farlin F, Boireau P, Fabre T, Durandeau A. [Surgical management of traumatic lesions of the axillary nerve: 83 cases]. CHIRURGIE DE LA MAIN 2003; 22:73-7. [PMID: 12822240 DOI: 10.1016/s1297-3203(03)00027-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Axillary nerve injuries still go undiagnosed far too often despite their frequency. However the quality of the outcome depends on expert management and prompt surgery. To optimise the latter, we re-examined 83 operated cases of traumatic lesions of the axillary nerve. We analysed the neurological and functional recovery of these patients by means of a follow-up evaluation at 6 years postop. The results were classified by age, mechanism of injury, delay to surgery and the presence or otherwise of associated neurological or osteo-articular lesions. We highlighted that a high index of suspicion ought to exist in all cases of trauma to the shoulder in a patient aged more than 40, any injury associated with palsy of the long head of triceps and in the case of an osteo-articular lesion due to high-velocity trauma. A complete lack of shoulder abduction must always prompt a search for a lesion of the axillary nerve as well as a suprascapular nerve palsy or rotator cuff lesion. There are few literature reports of surgical management of this particular nerve injury. An early MRI scan as part of the management should improve results by a reduction in the delay before surgery. As a result of our investigation we conclude that a lesion of the axillary nerve without signs of recovery at 3 months should be referred to a centre specialized in peripheral nerve surgery.
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Affiliation(s)
- J Rezzouk
- Service de chirurgie orthopédique et traumatologique, CHU Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux, France.
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27
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Abstract
The majority of clavicle fractures heal with some degree of malunion. There has been an increased appreciation that malunion with significant shortening may lead to clinical symptoms. In a review of a large number of clavicle specimens, 73 fractures with 54 malunions were found. Distinctive patterns of malunion were identified. Shortening usually comprised a combination of overlapping and angulation of fracture fragments in a predictable fashion. An appreciation of these fracture patterns will be of interest to surgeons attempting to minimize or correct complications from such injuries.
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Affiliation(s)
- J Gordon Edelson
- Department of Orthopedics, Poriya Government Hospital, Tiberias, Israel
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Chen DJ, Chuang DCC, Wei FC. Unusual thoracic outlet syndrome secondary to fractured clavicle. THE JOURNAL OF TRAUMA 2002; 52:393-8; discussion 398-9. [PMID: 11835011 DOI: 10.1097/00005373-200202000-00033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Da-Jeng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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29
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Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000; 106:1097-1122; quiz 1123-4. [PMID: 11039383 DOI: 10.1097/00006534-200010000-00022] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.
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Affiliation(s)
- J K Terzis
- Microsurgery Research Center, Department of Surgery, Eastern Virginia Medical School, Norfolk 23510, USA
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30
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Nichols JF, Robinson D, Douglass D, Anthony J. Retraining of a competitive master athlete following traumatic injury: a case study. Med Sci Sports Exerc 2000; 32:1037-42. [PMID: 10862527 DOI: 10.1097/00005768-200006000-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to examine the physiological effects of detraining and retraining in a female master cyclist (age, 49.5 yr; wt, 54 kg) following a surgically-treated clavicular fracture complicated by brachial plexus impingement. METHODS Variables associated with cycling performance, including VO2max, lactate threshold (LT), power output at a blood lactate concentration of 4 mM (LT(4 mM)), peak power output (PPO), muscular resistance to fatigue measured by a timed ride to exhaustion at 110% of peak power output (PPO110), and body composition (hydrostatic weight) were assessed 2 d before the injury when the subject was at the peak of her competitive season, and at days 0, 14, 28, 42, and 77 of the retraining period. Retraining gradually increased from 3 h x wk(-1) to 9-10 h x wk(-1) with an increase in intensity from approximately 70 to 95+% of HRmax. RESULTS Detraining resulted in a 25.7% decrease in VO2max and a 16.7% and 18.9% decrease in LT and LT(4 mM), respectively, while peak power output and PPO110 declined 18.2% and 16.6%, respectively. Body fat percent increased 2.1 percentage points, while fat-free mass decreased nearly 2 kg. After 2 wk of retraining, all variables except the LT and LT(4 mM) had improved considerably; however, VO2max was still 14.8% lower and PPO and PPO110 were 12.7% and 5.7% lower than preinjury values. By the 11th week of retraining, all variables had essentially returned to their preinjury values. CONCLUSION These data demonstrate a pattern of retraining in which aerobic power steadily improved over 6 wk, while measures of lactate threshold did not change until the fourth week of retraining when the intensity of training was markedly increased. Additional data are needed to determine whether this pattern of retraining would be consistent in other master athletes.
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Affiliation(s)
- J F Nichols
- Department of Exercise & Nutritional Sciences, San Diego State University, and San Diego Sports Medicine and Family Health Center, CA 92182-0171, USA.
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31
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Abstract
The term thoracic outlet syndromes, is a group designation for several distinct disorders (one of questionable validity) involving various components of the brachial plexus, the blood vessels, or both, at various points between the base of the neck and the axilla. Four of the five subgroups (true neurologic TOS, arterial vascular TOS, venous vascular TOS, and traumatic neurovascular TOS) are universally recognized to be rare lesions, with characteristic clinical and laboratory presentations; and none is particularly controversial. In contrast, disputed neurologic TOS is highly controversial. This article limits discussion to the three subgroups of TOS in which neurologic symptoms are caused, or reputedly are caused, by compromise of the brachial plexus fibers.
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Affiliation(s)
- A J Wilbourn
- EMG Laboratory, Department of Neurology, The Cleveland Clinic Foundation, Case Western Reserve University Medical School, Cleveland, Ohio 44195, USA
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32
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Wu CC, Shih CH, Chen WJ, Tai CL. Treatment of clavicular aseptic nonunion: comparison of plating and intramedullary nailing techniques. THE JOURNAL OF TRAUMA 1998; 45:512-6. [PMID: 9751542 DOI: 10.1097/00005373-199809000-00014] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this retrospective study was to investigate and compare the effects of plating and intramedullary nailing in the treatment of clavicular aseptic nonunion. METHODS Thirty-three consecutive patients with middle-third clavicular aseptic nonunions with previous nonoperative treatment were treated by plating (13 patients) and intramedullary nailing (20 patients) with supplementary cancellous bone grafting. The indications for such treatment were middle-third aseptic nonunions without previous operative treatment and with local pain or tenderness, deformity, or neurologic complaint. The choice of plating or intramedullary nailing was according to the surgeon's individual preference. RESULTS Twenty-nine patients were followed for at least 1 year (range, 1-7 years; median, 3 years; plating, 11; intramedullary nailing, 18). The union rate was 81.8% (9 of 11) for plating and 88.9% (16 of 18) for intramedullary nailing (p = 0.35, Fisher's exact test). The union period was 4.0 +/- 1.3 months for plating and 4.1 +/- 1.1 months for intramedullary nailing (p = 0.80, unpaired Student's t test). The complication rate was 27.3% (3 of 11) for plating and 11.1% (2 of 18) for intramedullary nailing (p = 0.21, Fisher's exact test). There were no significant differences in other parameters. CONCLUSION Intramedullary nailing may have a higher union rate with a lower complication rate than plating (p > 0.05). At least in common situations, it is not inferior to plating. Whenever possible, therefore, intramedullary nailing should be used preferentially to treat clavicular aseptic nonunion without previous operative treatment. Nevertheless, both techniques have relatively higher nonunion rates in the treatment of clavicular nonunion than in the treatment of other long-bone nonunions. Gentle handling of surrounding soft tissues to reduce bony fragments should be strictly executed.
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Affiliation(s)
- C C Wu
- Department of Orthopedics, Chang Gung Memorial Hospital, Taoyuan, Taiwan, Republic of China.
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