|Year : 2013 | Volume
| Issue : 1 | Page : 49-51
Management of clavicular non-union with plate fixation and bone grafting
Mazharuddin A Khan, Sujitkumar R Vakati
Department of Orthopedics, Deccan College of Medical Sciences, Hyderabad, India
|Date of Web Publication||28-Aug-2013|
Mazharuddin A Khan
Department of Orthopedics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad
Source of Support: None, Conflict of Interest: None
Symptomatic clavicular non-union is a rare clinical condition which causes pain and functional disability, if not managed on time. We report the long-term consequences in a 25 year old young male patient with established atrophic and aseptic non-union of the middle third of the clavicle. Patient was treated by open reduction and internal fixation with Arbeitsgemeinschaft für Osteosynthesefragen (AO) Dynamic Compression Plate and autologous cancellous bone grafting harvested from the iliac crest. There was no operative or post-operative complications and the patient returned to the previous level of activities. We conclude that plate fixation with bone grafting is a reliable and safe method for the management of symptomatic non-united fractures of the middle third of the clavicle.
Keywords: Cancellous bone grafting, clavicular non-union, dynamic compression plate
|How to cite this article:|
Khan MA, Vakati SR. Management of clavicular non-union with plate fixation and bone grafting. Arch Int Surg 2013;3:49-51
| Introduction|| |
Clavicular non-union is a rare clinical presentation. Its incidence is approximately, between 0.1% and 13% with the lowest after conservative and the highest after operative treatment. Neer reported non-union rates of 0.1% after conservative treatment and 4.4% after operative treatment.  Symptomatic clavicular non-union is even rarer. When it does occur, however, it may pose a difficult problem causing pain and functional impairment. About 75% of symptomatic non-unions are located in the shaft and 25% in the distal-third of the clavicle. 
Failure to show clinical or radiographic progression of healing at 4-6 months is considered as clavicular non-union. Tapered, sclerotic, atrophic bone ends at 16 weeks are also considered as non-union. 
We report a case of clavicular non-union in a male who presented to our tertiary care center and was successfully treated with dynamic compression plate.
| Case Report|| |
A 25-year-old male patient presented with features of non-union of left clavicle, which was fractured 2.5 years ago in a road traffic accident and underwent massaging of the fractured clavicle by traditional bone-setters, instead of medical treatment. The patient complained of pain and tenderness over left clavicle. Pain was radiating to the neck and down into the forearm. Routine daily activities were carried out with difficulty. There were no neurological or vascular symptoms.
Left shoulder appeared to sag forward, inward, medially and a localized deformity was constantly maintained. Muscular atrophy over the left clavicular region was noted. No signs of neurological or vascular insufficiency were found. A diagnosis of clavicular non-union was made and confirmed radiographically, which revealed callus formation (25%) with rounded sclerotic ends of the bone fragments with displacement [Figure 1]. Other causes of local pain such as subacromial or glenohumeral joint diseases and acromioclavicular arthritis were ruled out. The non-united clavicular fracture was treated with dynamic compression plate.
The patient was positioned in supine position with the head turned toward the opposite shoulder. A horizontal incision was made parallel to the middle-third clavicular segment along its superior border under general anesthesia. The ends of the clavicle were exposed subperiosteally and interposed soft-tissue was removed. The bone ends were freshened and the medullary canal was opened. The fracture was reduced and fixed with a contoured 3.5 mm dynamic compression plate of five holes with the help of c-arm guidance. Blunt retractors were used to protect the infraclavicular structures during drilling of the plate holes. The fracture line was oblique enough, an interfragmentary screw was used. Cancellous bone from the iliac crest was harvested and packed at the fracture site [Figure 2]. [Figure 3] shows the narrow dynamic compression plate in situ over clavicle.
|Figure 2: Internal fi xation of left clavicular non-union with narrow dynamic compression plate|
Click here to view
|Figure 3: Post-operative X-ray showing narrow dynamic compression plate in situ over clavicle bone|
Click here to view
Passive movements in all planes were started on the first post-operative day. When signs of union were observed radiographically (6 weeks), active exercises and full range of motion were started. Resisted exercises were added gradually. Full active use of the arm was permitted with the complete radiographic union at 2 months.
| Discussion|| |
Non-union of displaced and fractured clavicle with shortening and rotational deformity has been reported to be 10-15%.  Several factors appear to predispose to non-union of the clavicle including inadequate conservative treatment and immobilization, severity of trauma and fracture comminution, refracture, distal-third fracture, marked displacement, soft-tissue interposition, and primary open reduction. Trauma and management by traditional bone setter was the cause for non-union of clavicle in our patient.
Indications for surgical treatment of the clavicular non-union are: (1) Pain or aching clearly attributable to the non-union, (2) shoulder girdle dysfunction, weakness or fatigue, and (3) neurovascular compromise. About 75% of patients with non-united clavicular fractures have symptoms, including moderate to severe pain.  Singh et al.  have observed that only 11.7% of their patients required surgical intervention. Study by Böhme et al.  is in favor of surgical intervention for displaced fractures of clavicle. In our patient, indication for surgery was radiating pain and restriction of movements affecting the daily routine of the patient.
Several non-surgical and surgical methods for the treatment of clavicular non-union are widely reported.  Partial claviculectomy, with excision of the non-union site, seems to alleviate the crepitus and often results in symptomatic improvement including elimination of pain.  However, many patients treated in this manner remained symptomatic with persistence of mild to moderate symptoms due to loss of stabilizing function of clavicle. 
Currently, the choice of surgery is between plate fixation and intramedullary fixation and both have advantages and disadvantages. Open reduction with intramedullary fixation is a very popular method for treating clavicular non-unions.
Although, reports of these methods have been encouraging, rotation is poorly controlled under most circumstances; the intramedullary fixation can be difficult to insert if there are atrophic bone ends and external plaster support often is required. Especially with flat and curved clavicles, intramedullary fixation is even harder. Additionally, distraction of the fracture site can occur with threaded pins. Furthermore, the intramedullary device can bend or break, and several complications have been reported with pin migration. Despite reports of success the complication rate can be as high with intramedullary fixation as 75%. 
Plate fixation without bone grafting has been successful in clavicular non-union. Addition of supplemental bone graft to rigid plating has been the most popular approach to clavicular non-union. With this, union rates of nearly 100% have been achieved. We preferred the use of dynamic compression plate supplemented with bone grafting as this method is reliable, safe and has few complications.  Additionally, the internal fixation is so secure that it requires only sling for support without requiring post-operative external cast immobilization. In addition, screw holes weaken the bone, and protection is needed after hardware removal over which the low contact dynamic compression plate offers a significant advantage. Furthermore, the excellent biocompatibility of the titanium ensures excellent tissue tolerance and increases the possibility of leaving plates in situ, thus, obviating a second procedure.
Reconstruction plate is considered as an alternative for plate fixation. Though, both dynamic compression plate and reconstruction plate have given equally good results, but with latter it is easier to give contour to the complex form of the clavicle. 
Drawbacks of treating clavicular non-union with plating and bone grafting are significant clavicular shortening if sclerotic edges of the atrophic margin are resected to achieve primary osteosynthesis. We anticipated that an intercalary bone graft is not required and would not result in unacceptable reduction in length after surgery. Intraoperatively, placing excessive bone graft posteriorly and inferiorly was avoided to prevent irritation or crowding of the neurovascular structures. We fixed the plate antero-superiorly to avoid neurovascular injury and delayed complications.
| Conclusion|| |
Plate osteosynthesis and intramedullary fixation are the routine surgical interventions for the treatment of symptomatic clavicular non-unions. Achieving rotational control of the middle-third of the clavicle is more difficult with intramedullary device alone, particularly if associated with bone loss. Rotational and axial alignments are controlled by plate osteosynthesis. Use of bone grafting is advocated particularly in atrophic non-union. We conclude that plate fixation with bone grafting is a reliable and safe method for the management of symptomatic non-united fractures of the middle-third of the clavicle.
| Acknowledgments|| |
We acknowledge the support of Dr. M. S.Latha in the preparation of this manuscript.
| References|| |
|1.||NEER CS 2 nd . Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11. |
|2.||Jupiter JB, Leffert RD. Non-union of the clavicle. Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753-60. |
|3.||Manske DJ, Szabo RM. The operative treatment of mid-shaft clavicular non-unions. J Bone Joint Surg Am 1985;67:1367-71. |
|4.||Garg AK, Mukhopadhyay KK, Shaw R, Roy SK, Banerjee K, Mukhopadhyay K. Displaced middle-third fractures of the clavicle-operative management. J Indian Med Assoc 2011;109:409-10. |
|5.||Singh R, Rambani R, Kanakaris N, Giannoudis PV. A 2-year experience, management and outcome of 200 clavicle fractures. Injury 2012;43:159-63. |
|6.||Böhme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C. Current treatment concepts for mid-shaft fractures of the clavicle-results of a prospective multi centre study. Z Orthop Unfall 2011;149:68-76. |
|7.||Connolly JF. Electrical treatment of nonunions. Its use and abuse in 100 consecutive fractures. Orthop Clin North Am 1984;15:89-106. |
|8.||Flinkkilä T, Ristiniemi J, Hyvönen P, Hämäläinen M. Surgical treatment of unstable fractures of the distal clavicle: A comparative study of Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand 2002;73:50-3. |
|9.||Der Tavitian J, Davison JN, Dias JJ. Clavicular fracture non-union surgical outcome and complications. Injury 2002;33:135-43. |
|10.||Bradbury N, Hutchinson J, Hahn D, Colton CL. Clavicular nonunion. 31/32 healed after plate fixation and bone grafting. Acta Orthop Scand 1996;67:367-70. |
[Figure 1], [Figure 2], [Figure 3]