nonunion of the fractured clavicle.doc

8/10/2019 Nonunion of the Fractured Clavicle.doc

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Nonunion of the Fractured Clavicle: Evaluation, Etiology, and Treatment

Grant L. Jones, MD, George M. McCluskey III, MD, David T. Curd, MS, Hughston Clinic PC,

the Hughston Shoulder Service, and the Hughston Sorts Medicine !oundation Inc, Colu"#us,Ga $Dr. Jones is no% %ith the Deart"ent o& 'rthoaedic Surgery, 'hio State (niversity,

Colu"#us, 'hio.)

J South 'rtho *ssoc. +-$/)

Abstract

*lthough o&ten vie%ed as #enign in0uries, clavicular &ractures can lead to co"lications,articularly nonunions. The nonunion rate has #een reorted to #e #et%een ./1 and /21.

Contri#uting &actors to nonunion include severe initial trau"a, "arked initial dislace"ent and

shortening, so&t tissue interosition, ri"ary oen reduction and internal &i3ation, re&racture,oen &racture, olytrau"a, and inade4uate initial i""o#ili5ation. * clavicular nonunion is rarely

asy"to"atic and o&ten results in disa#ility &ro" ain at the site o& nonunion, altered shoulder"echanics, or a co"ression lesion involving the underlying #rachial le3us or vascular

structures. Treat"ent otions include nonsurgical "anage"ent, salvage rocedures, andreconstructive rocedures. The resent goal is to o#tain union %ith reconstructive rocedures.

The &i3ation "ethods descri#ed range &ro" e3ternal &i3ation to late and scre% osteosynthesis.

6e re&er oen reduction and internal &i3ation %ith lates and scre%s and %ith intercalarytricorticocancellous gra&ts to o#tain union and restore the clavicle to its nor"al length.

Introduction

!ro" 21 to /1 o& all &ractures are clavicular &ractures,7/,+8and the incidence has increased over

the ast decades.798

Clavicular &ractures are o&ten vie%ed as entirely #enign lesions %ith a highrate o& healing and e3cellent &unctional results. Ho%ever, &ro" the ti"e the &racture initially

occurs to the ti"e the &racture heals, "any co"lications can occur. :erkheiser7;8sho%ed the

ro#le" o& co"lications a&ter clavicular &ractures. He reorted nine cases o& nonunion $si3 %ith

#rachial le3us in0ury) and attri#uted this high co"lication rate to the increased energy o& theinitial trau"a. 'ther authors7+,2


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re4uires a thorough understanding o& the anato"y and &unction o& the clavicle, the etiology and

the sy"to"atology o& nonunion, and the %ide array o& treat"ent otions.

Figure 1.

>onunion clavicular &racture.

The urose o& this aer is to revie% the current and ast literature on the etiology and

treat"ent o& clavicular nonunions. 6e also resent our series o& /; clavicular nonunions treated

%ith late and scre% osteosynthesis and tricorticocancellous #one gra&ting.

The clavicle is the only long #one to ossi&y #y the intra"e"#ranous rocess and is the &irst #oneto ossi&y $&i&th %eek o& &etal li&e).7/;8The ossi&ication co""ences at a centrally situated

ossi&ication center. Secondary centers o& ossi&ication develo at #oth ends o& the gro%ing #one,

%ith the "edial ossi&ication center ulti"ately accounting &or u to =1 o& the longitudinalgro%th.7/8

The clavicleBs con&iguration is a dou#le curvature %ith a conve3 anterior curve "edially and aconve3 osterior curve laterally.7/;8The distal and ro3i"al ends o& the clavicle are secured

&ir"ly #y strong liga"ents and "uscle attach"ents, %hereas the central section is relatively &reeo& rotective attach"ents.728The %eight o& the ar" and the ull o& the ectoralis "a0or "uscle

roduce an in&erior and "edial &orce to the lateral clavicle, %hile the sternocleido"astoid "uscle

creates a suerior &orce vector "edially $!ig +).7/28During elevation o& the ar", the clavicleangles u%ard #y 9 and osteriorly #y 92 and rotates a#out its longitudinal a3is as "uch as

2.7/8These "otions co"#ine to roduce #ending "o"ents in the coronal and sagittal lanes,


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%hich are largely concentrated at the "iddle section o& the clavicle.7/8*nato"ically, the "iddle

third o& the clavicle has relatively sarse cancellous #one. These large &orces concentrated in an

area o& sarse cancellous #one and &e% so&t tissue attach"ents e3lain %hy the "iddle third isthe "ost co""only &ractured section o& the clavicle and %hy it is "ore rone to nonunion than

other sections o& the clavicle.7/28

Figure .

6eight o& ar" and ull o& ectoralis "a0or "uscle roduce in&erior and "edial &orce vector to

lateral asect o& clavicle, %hile sternocleido"astoid "uscle creates suerior &orce vector

"edially.

The clavicle serves several i"ortant uroses.7/;8!irst, it acts as a rigid #ase &or "uscularattach"ents. >e3t, it &or"s a strut holding the glenohu"eral 0oint in the arasagittal lane, thus

increasing the range o& "otion o& the shoulder 0oint and the range o& gras in three


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curve to the #ase o& the neck. *#sence o& the clavicle results in a &oreshortened aearance to the

shoulder girdle. There&ore, &racture, loss, or shortening o& the clavicle can result in signi&icant

disa#ility. That is %hy it is i"ortant to try to restore the continuity and nor"al length o& theclavicle %hen treating a clavicular nonunion.

Many &actors leading to nonunion have #een discussed in the literature. These &actors includesevere initial trau"a, "arked initial dislace"ent and shortening, so&t tissue interosition,

inade4uate initial i""o#ili5ation, ri"ary oen reduction and internal &i3ation, re&racture, oen&ractures, and olytrau"a.7+,;


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in the nonoerative "anage"ent o& dislaced &ractures. Hill et al 7/98revie%ed 2+ atients %ho

had dislaced &ractures o& the "iddle third o& the clavicle. !i&teen ercent o& these atients had a

nonunion, and 9/1 reorted unsatis&actory results. These authors &ound a signi&icant correlation#et%een initial shortening o& + c" and nonunion and #et%een &inal shortening o& + c" and

unsatis&actory results. Eskola et al7/?8reorted that 91 o& atients %ith clavicular &ractures had

neurologic sy"to"s a&ter the &racture healed, and there %as a signi&icant correlation #et%eenshortening F/.2 c" on &ollo%


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resonse to ain or #ecause o& "alosition o& the &racture &rag"ents), tosis o& the shoulder, or

a co"ression lesion involving the underlying #rachial le3us or vascular structures.7/8Manske

and S5a#o7/+8&ound ain to #e the ro"inent sy"to" in all / o& their atients %ith nonunion,%hereas 6ilkins and Johnston7//8reorted that /A o& / atients %ho had sy"to"atic nonunions

reorted "oderate to severe ain. :oeh"e et al7/28also reorted that ain %as the ro"inent

sy"to" in "ost o& their atients %ith nonunion $/= o& +/).

>eurologic sy"to"s can develo in the acute hase as a result o& stretch in0ury or #one&rag"ent co"ression, in the chronic hase as a result o& co"ression &ro" healing o& the

&racture %ith in&erior and osterior dislace"ent o& the distal &rag"ent or "assive callous, or

&ro" "otion o& the nonunion.79/onetheless, vascular in0uries ranging&ro" su#clavian vein co"ression or thro"#osis to arterial ische"ia have #een reorted.7+,9/


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The various rocedures can #e divided into t%o "ain categories salvage and reconstructive.7/8

Salvage rocedures atte"t to alleviate sy"to"s or de&or"ities %ithout achieving #one union.

@econstructive rocedures, ho%ever, are designed to achieve #one union. 6ithin each category,there are "ultile rocedures.

Salvage rocedures involve re"oving a #ony ro"inence or er&or"ing a artial or totalclaviculecto"y to rovide relie& &ro" ain&ul grating or to release entraed neurovascular

structures. *##ott and Lucas79=8ointed out that the "iddle third o& the clavicle "ay #e re"oved%ithout signi&icant disa#ility as long as the distal and ro3i"al ortions are le&t intact. @o%e 728

noted that re"oval o& the entire clavicle results in a surrisingly good &unctional and cos"etic

aearance #ut stated that this should #e done only a&ter a atient has had several unsuccess&ul#one


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intra"edullary in is a load


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'en reduction and internal &i3ation o& clavicular nonunion %ith late and scre% osteosynthesis.

Juiter and Le&&ert7+8reorted on an =1 union rate a&ter late &i3ation and #one gra&ting in /=

nonunited &ractures o& the "iddle third o& the clavicle. The authors e"hasi5ed the i"ortance o&restoring the nor"al length o& the clavicle #ecause shortening can cause a#duction %eakness and

can increase the "o"ents and &orces at the site o& the &racture.7/?,+8

Seiler and Juiter7;+8

seci&ically addressed the restoration o& clavicular length in a "ore recent study- they used

intercalary tricortical iliac crest #one gra&ts to treat clavicular nonunions %ith #ony de&ects.Preoeratively, the authors o#tained a vie% o& the contralateral clavicle to esta#lish the nor"al

length o& the clavicle, and they deter"ined the si5e o& the #one gra&t #y co"aring the

anteroosterior radiograhs o& each clavicle. The nonunion site %as de#rided, and the "edullarycanals %ere oened "edially and laterally %ith a drill #it. They rocured a tricortical iliac crest

that %as /.2 ti"es larger than the calculated de&ect. The gra&t %as then laced in the de&ect and

secured to the "edial and lateral &rag"ents %ith a li"ited contact dyna"ic co"ression late,co"ressing #oth the "edial and lateral 0unctions. The authors reorted union in all eight

atients treated %ith this techni4ue %ithin 9 "onths o& surgery. 'lsen et al7+/8also e"hasi5ed the

i"ortance o& reesta#lishing native clavicular length. These authors, ho%ever, 0ust usedautologous cancellous #one gra&t to &ill the de&ect rather than a tricorticocancellous gra&t.

More recently, :all"er et al7;8e"hasi5ed the i"ortance o& restoring clavicular length. These

authors treated 9A delayed union and nonunion &ractures %ith decortication, late osteosynthesis,

and #one gra&ts, and they achieved a 21 union rate. >ine atients re4uired tricorticocancellousgra&ts to restore clavicular length. The authorsB indication &or using the tricorticocancellous gra&t

%as clavicular shortening F/.2 c" co"ared %ith the contralateral clavicle.

:oyer and *3elrod7;28descri#ed a techni4ue that entailed shortening the clavicle. The nonunion is

e3cised #y cuts at ;2 to the long a3is o& the clavicle, and either a elvic reconstruction or

dyna"ic co"ression late %ith a lag scre% $to rovide inter&rag"entary co"ression) is used&or &i3ation. Cancellous #one is then laced at the nonunion site. The authors stated that their

techni4ue resects *' rinciles &or the treat"ent o& nonunions, allo%s early "o#ili5ation, and"ini"i5es "or#idity at the donor site $ie, cancellous #one gra&t is rocured rather than

tricorticocancellous gra&t). In their study, all seven atients %ith clavicular nonunions healed and

returned to nor"al &unction. The average reduction in length o& the clavicle %as /.2 c".

Ho%ever, according to the authors, the resultant lack o& restoration o& the shoulder %idth rovedto #e cos"etically acceta#le and gave e3cellent &unction.

The &inal issue &or late and scre% &i3ation is the tye o& late used. :rad#ury et al 7;;8co"ared

the results o& an *' dyna"ic co"ression late $Synthes, Paoli, Penn) and an *' elvic

reconstruction late &or treat"ent o& clavicular nonunion. The authors reorted a A1 union rate$9/ o& 9+ nonunions) and noted no signi&icant di&&erences #et%een the t%o lates. They stated,

ho%ever, that the reconstruction late %as "uch easier to contour to the sig"oid shae o& the

clavicle.

Mulla0i and Juiter,7/8on the other hand, re&er a 9.2


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suly #eneath the late, avoidance o& stress risers a&ter i"lant re"oval, and o#li4ue undercuts

to the scre% holes that allo% &or insertion o& lag scre%s u to an angle o& ;. *lso, the late is

"ade o& titaniu", %hich is t%ice as &le3i#le as steel, thus rendering it less rone to &atigue &ailure%hen used to san a de&ect. * &eature that is seci&ically valua#le to treat"ent o& clavicular

nonunions is the uni&or"ly laced scre% holes %ithout a solid "iddle section, %hich &acilitates

introduction o& a scre% or scre%s into the intercalary #one gra&t. *lso, the uni&or" #endingsti&&ness o& the late allo%s easier contouring in "ultile lanes, i"ortant in the clavicle

#ecause o& its co"le3 shae. !inally, the LC


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Figure %.

$To) Healed clavicular nonunion a&ter oen reduction and internal &i3ation %ith late and scre%osteosynthesis and intercalary #one gra&ting. $Center) Hard%are %as re"oved 2; %eeks a&ter

oen reductioninternal &i3ation rocedure. $:otto") @e&racture o& clavicle 2; %eeks a&terhard%are re"oval.

(sing late and scre% osteosynthesis %ith intercalary tricorticocancellous gra&t, %e treatsy"to"atic nonunions to achieve union o& the clavicle and to restore nor"al length. The atient

is given general anesthesia %ith endotracheal intu#ation and then is laced in the 2 #each chair

osition, %ith the head secured to a May&ield headrest $6iggins Medical Inc, Sunnyside, !la).


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The in0ured uer e3tre"ity and the isilateral or contralateral iliac crest region are reared and

draed.

6e "ake a la5y S tye o& incision over the involved clavicle, ensuring that the "idoint is at thesite o& the nonunion. *s dissection is carried do%n sharly, the latys"a "uscle is divided.

6hile rotecting the neurovascular structures, %e acco"lish a su#eriosteal e3osure o& the&racture and the "edial and lateral &rag"ents $!ig 2). *&ter the &racture is e3osed, the &i#rous

nonunion is de#rided and #ony ro"inences at the site o& nonunion are tri""ed. *&ter restoringthe clavicle to its nor"al length, %e "easure the resulting de&ect $!ig ?).

Figure &.

>onunion site is e3osed, and ends o& &rag"ents are &ound to #e atrohic. Lateral asect o&

clavicle is dislaced in&eriorly and "edially %ith resect to "edial asect.


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Figure '.

!racture is reduced a&ter de#riding &i#rous nonunion tissue and re"oving atrohic, sclerotic #one

ends. @esultant de&ect is "easured, and aroriately si5ed tricorticocancellous #one gra&t iso#tained &ro" iliac crest.

>e3t, %e "ake an incision over the anterior one third o& the iliac crest and acco"lish a

su#eriosteal e3osure o& the iliac crest. (sing straight and curved osteoto"es, %e re"ove a

iece o& tricorticocancellous #one gra&t that is the si5e o& the clavicular de&ect. Then, %e harvesta cancellous #one gra&t &ro" the inner ta#le o& the iliu". The %ound is coiously irrigated, and a

He"ovac drain $:a3tor Healthcare Cor, Deer&ield, Ill) is laced dee to the "uscle and &ascial

layer. 6e close the %ound in layers %ith interruted sutures and the skin %ith runningsu#cuticular stitch.

The tricorticocancellous #one gra&t serves as an interositional gra&t #et%een the ro3i"al and

distal clavicle &rag"ents. The cortical sur&aces lie sueriorly and in&eriorly to allo% &or scre%

&i3ation. 6e contour a 9.2


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Figure (.

$To) Plate is secured to suerior sur&ace o& clavicle %ith 9 or ; scre%s ro3i"al and distal to

&racture site and / or + scre%s in interosed gra&t. $:otto") Plain radiograh o& late and scre%&i3ation %ith intercalary tricorticocancellous #one gra&ting.

'ne o& us $G.M.M.) has treated /; atients $/; nonunions) %ith the receding techni4ue. The

average duration o& delayed union or nonunion &ro" the ti"e o& in0ury to surgery %as 9 "onths$range, 9 to +? "onths). T%elve o& the /; nonunions %ere atrohic, and t%o %ere hyertrohic.

The average ti"e to union %as /2.? %eeks $range, A to 9; %eeks). *verage &ollo%


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There %ere a &e% signi&icant co"lications. The "ost note%orthy %as re&racture a&ter hard%are

re"oval in three atients. T%o o& the re&ractures, though, %ere the result o& signi&icant trau"a a

#icycle accident and a signi&icant &all on an outstretched ar" at 9 %eeks and /+ %eeks a&terhard%are re"oval, resectively. The re&ractures %ere "anaged success&ully %ith reeated oen

reduction and internal &i3ation %ith 9.2 elvic reconstruction lates a&ter radiograhs sho%ed

lack o& healing at an average o& /? %eeks a&ter re&racture. >o #one gra&ts %ere re4uired.

!or ? %eeks a&ter surgery, the atient %ears a sling and er&or"s assive range


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A. Johnson E6, Collins H@ >onunion o& the clavicle. *rch Surg =A?9


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+A. han M**, Lucas H Plating o& &ractures o& the "iddle third o& the clavicle. In0ury

+?9*, Mekhail *', Dar%ich M 'en reduction and internal &i3ation %ith #onegra&ting o& clavicle nonunion. J Trau"a ;+A/, Hutchinson J, Hahn D Clavicle nonunion 9/9+ healed a&ter late &i3ation

and #one gra&ting. *cta 'rtho Scand ?A9?A


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;?. re"ens K, Glauser ! (nusual se4uelae &ollo%ing inning o& "edial clavicle &ractures.

*" J @oentgenol A;/??

nonunion of the fractured clavicle.doc

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