Clavicle Nonunion and Malunion: Surgical Interventions for Functional Improvement

Clavicle nonunion and malunion are relatively uncommon but, when symptomatic, can result in pain and dysfunction that requires surgical intervention. Various reconstructive and grafting techniques are available to achieve stable fixation and union. In the setting of persistent nonunion, vascularized bone grafting may be necessary. A thorough understanding of the patient's type of nonunion and potential for healing is crucial for achieving satisfactory results because is thoughtful preoperative planning and surgical fixation.

Osteosynthesis with autologous dual bone graft for nonunion of midshaft clavicle fractures: clinical and radiological outcomes

PURPOSE

This study evaluated the clinical and radiological results of plate osteosynthesis with autologous cortical and cancellous bone graft for nonunion of midshaft clavicle fracture.

METHODS

A retrospective review was performed for all patients who underwent surgery for midshaft clavicle nonunion at a Level I trauma center. Visual analog scales (VAS) for pain and Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score were assessed. Bone union rate, change in length of affected clavicle, complications, and reoperation were determined. Risk factors were identified to determine the effect on the healing.

RESULTS

Thirty-four patients were included for analysis. All patients achieved solid bone union at mean 16 weeks (range 8-36) after surgery. The mean shortening of affected clavicle decreased significantly postoperatively (P < 0.001). There was significant improvement in both pain VAS and Quick-DASH score (P < 0.001). There was no wound complication, infection, or major neurovascular injury. Ten patients (29%) complained of plate irritation and underwent removal of implant without any subsequent adverse event. Multiple regression analysis demonstrated that high-energy trauma and previous surgery were the independent risk factors that significantly delayed time to union (P < 0.05).

CONCLUSION

Osteosynthesis with autologous dual bone graft for nonunion of midshaft clavicle produced an excellent union rate with good clinical outcome and minimal complications.

Floating Shoulder Injury Resulting in Delayed Onset of Infraclavicular Brachial Plexus Palsy

As the brachial plexus traverses the costoclavicular space, it is susceptible to compression by pathologies affecting the clavicle. Clavicle nonunions with hypertrophic callus may cause a delayed onset of brachial plexus palsy. We present a rare case of a floating shoulder injury causing medial and posterior cord brachial plexus palsy two months after initial injury. After the diagnosis was established, the patient was treated successfully with expeditious brachial plexus decompression, callus excision, and rigid osteosynthesis, with healing of the clavicle nonunion and scapular fracture, and recovery of sensory and motor deficits.

Two cases of brachial plexus compression secondary to displaced clavicle fractures

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.

Clavicular caution: an anatomic study of neurovascular structures

Open reduction and internal fixation of the clavicle is used to treat displaced fractures of the midshaft of the clavicle. Complications of operative intervention include injuries to major neurovascular structures including the subclavian artery and vein. Unlike other surgical approaches, palpation or visualization of the deep neurovascular structures at risk is rarely performed and is not part of the routine approach. This study aims to further elucidate the relationship of major neurovascular structures in the shoulder to the clavicle using sectioned fresh frozen cadaveric specimens. Using five cadaveric specimens, sagittal sections were performed using a band saw. Sections were taken every 15mm. Using these sections, structures were identified and photos were taken using a standardized approach to allow for precise and accurate measurements. Measurements taken included the distance from the nearest clavicular cortex to the centre of the subclavian artery, vein, and brachial plexus. These measurements were taken from five limbs on five different cadavers. Our results were consistent with previous studies. Medially, the subclavian vein was intimately related medially (4.8mm) to the clavicle, whereas the artery and brachial plexus were both >2cm from the clavicle. At about the junction of the middle and second-thirds of the clavicle, all three structures were within 2cm of the clavicle. Moving laterally, these structures moved further away and at the acromioclavicular (AC) joint were at least 4.5cm away from the clavicle on average. This study reiterates that the medial third of the clavicle is closely associated with neurovascular structures and that care should be taken here when using drills, depth gauges, and clamps.

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

Context:

Fractures of the clavicle are one of the most common injuries to the bone in childhood, but posttraumatic nonunion of pediatric clavicle fractures are extremely rare, with only isolated reports in literature.

Case Report:

We report a case of a posttraumatic painful nonunion of a clavicle fracture in a 13-year-old boy that caused symptomatic compression of the external jugular vein (EJV) and the formation of an arteriovenous fistula. The fracture was treated successfully with open reduction and internal fixation with a contoured recon plate 6 months following the injury. The fistula was treated by ligation and closure.

Conclusion:

The patient made a full recovery 6 months following surgery and was asymptomatic with full range of shoulder movement. Fracture union was confirmed by computed tomography (CT) scanning and no residual fistula was found.

Recurrent peripheral embolism following nonunion of the clavicle

Vascular complications in closed clavicular fractures are uncommon, with an incidence of only 0.4%. Subclavian artery injury can present acutely or can have a delayed presentation with arm ischemia. We report the case of an undetected subclavian pseudoaneurysm in a patient with a nonunion fracture clavicle who was referred with persistent ischemia following attempted brachial embolectomy at another center, along with a review of literature to support the hypothesis that in addition to repair of the aneurysm, treatment of the psuedarthrosis by fixation of the clavicle is essential.