Posttraumatic nonunion of the clavicle in a 13-year-old boy causing an arteriovenous fistula

Nonunion of the Clavicle Among Children: A Review of the Literature and a Report of Three New Cases

Nonunion of the clavicle among children and adolescents is rare. A systematic review was conducted to identify published reports of nonunion of the clavicle among children after conservative treatment. A retrospective study was performed of 2096 children who were treated for clavicle fractures at our institution to identify cases of nonunion. Fourteen studies (27 children) from the literature met the inclusion criteria, and 3 new cases from our institution were identified. The mean age at injury was 11 years. Male sex, age younger than 12 years at the time of injury, and refracture of the clavicle are possible predisposing factors for nonunion. [Orthopedics. 2022;45(4):e190-e195.].

Fracture Nonunion of the Clavicle After Surgical Reduction in a 13-Year-Old Girl: A Case Report

CASE

Although congenital nonunion of the clavicle is a well-known pathology in children, posttraumatic nonunion is a rare entity. Nonunion after open reduction and internal fixation of a clavicle fracture is exceptional in the pediatric population. We report on a patient presenting posttraumatic pseudarthrosis of the clavicle after surgical treatment. Pseudarthrosis was resected, and the defect was bridged with an iliac crest autograft, supplemented with bone morphogenetic protein, and fixed with an elastic stable intramedullary nail.

CONCLUSION

This procedure offered enough stability for achieving fracture consolidation and is a safe alternative to plating in clavicle nonunion.

Adolescent mid-shaft clavicular fracture displacement does not predict nonunion or inferior functional outcome at long-term follow-up

AIMS

The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture.

METHODS

We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671).

RESULTS

The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients' demography or functional outcomes between operative and nonoperative treatments.

CONCLUSION

Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951-957.

Contribution of Digital Subtraction Angiogram in Diagnosis and Anatomic Recognition of Traumatic Pulsatile Mass

Traumatic pulsating masses are difficult to make a definitive diagnosis due to anatomic variation of malformed vessels and rarely clinical incidence. It is essentially to recognizing the anatomy of such vessels, otherwise it may lead to an improperly treatment or serious complication. Digital subtraction angiogram (DSA) has a distinct advantage in both diagnosis and treatment of this subject. Here the authors report a case of venous malformation in the supraclavicular fossa with an underlying arteriovenous fistula following nonoperative management of a clavicle fracture in an adult, and discuss how to rule out potential differential diagnoses and get minimally invasive treatment with DSA.

Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture: A Case Report

CASE

We report a case of prominent venous dilation in the supraclavicular area with an underlying arteriovenous fistula following nonoperative management of a fracture in the medial third of the clavicle in an adult. The venous dilation indicated elevated venous pressures, likely caused by hypertrophic callus formation and/or fistula development.

CONCLUSION

Arteriovenous fistula and prominent venous dilation are possible sequelae of nonoperative treatment of clavicular fractures. Surgeons should be aware of their possibility when planning either operative or nonoperative treatment. More information is needed to guide management of these issues when they occur.

Clavicle fracture nonunion in the paediatric population: a systematic review of the literature

AIMS

Clavicle fracture nonunions are extremely rare in children. The aim of this systematic review was to assess what factors may predispose children to form clavicle fracture nonunions and evaluate the treatment methods and outcomes.

METHODS

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming to find papers reporting clavicle fracture nonunion in children under the age of 18 years. Data was collected on patient demographics, fracture type, mechanism of injury (MOI), surgical intervention and reported outcome. Two independent reviewers evaluated all the data.

RESULTS

A total of 13 articles reporting 21 cases of clavicle fracture nonunion were identified. The mean age at time of injury was 11.4 years (4 to 17). Falls were the most common MOI. The majority of nonunions occurred after displaced fractures on the right side. Six were refractures. Mean time of presentation following injury was 13.5 months (4 to 60). In all, 16 were treated surgically. Radiographic union was eventually achieved in 12 cases, with functional outcome satisfactory in all cases.

CONCLUSION

Clavicle nonunion is an extremely rare but possible complication in children. The majority occur after displaced right-sided fractures or refractures and present around one year after injury. Surgical fixation provides good radiographic healing and functional outcomes.

LEVEL OF EVIDENCE

IV.

Adolescent clavicle nonunions: potential risk factors and surgical management

BACKGROUND

Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes.

METHODS

A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture.

RESULTS

There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture.

CONCLUSIONS

Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft.

Post-traumatic nonunion of a clavicle fracture in a 9-year-old child

Clavicular fractures account for around 15% of fractures in children. Although nonunion is a recognized complication in adults, post-traumatic nonunion of the clavicle in children is extremely rare. To the best of our knowledge, post-traumatic nonunion of the clavicle in a child following repeated clavicular fracture has not yet been published in the English literature. Here, we report a case of a 9-year-old boy who presented with post-traumatic nonunion of his right clavicle following his third fracture after radiologically documented healing of the first two fractures. He underwent open reduction and internal fixation, supplemented with ipsilateral iliac crest bone graft, with resultant healing on follow-up radiographs.