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A Devastating Complication Of Treatment Of Fracture Clavicle With Plating: A Bitter Experience

Suraj Bajracharya *,  Singh M P*

*Department of Orthopaedics, B P Koirala Institute of Health Sciences, Dharan Nepal 

Address for Correspondence:  

Dr Suraj Bajracharya MS (Orthopaedics)
Assistant Professor
Department of Orthopaedics
B P Koirala Institute of Health Sciences
Dharan Nepal
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We present a case of fracture clavicle left treated with open reduction and internal fixation with reconstruction plate and screws in a 32 years old young man from a remote hilly village of Eastern Nepal. He presented with chronic osteomyelitis of clavicle with exposed implant in situ. This devastating complication was noted after he had got treatment 14 months back. This case is presented to share our bitter experience and highlight one of the known but rare complications of this fracture treatment.

J.Orthopaedics 2008;5(4)e11


Fracture clavicle; chronic osteomyletis of clavicle; treatment options of fracture clavicle


Clavicle fractures are common injuries, representing about 4-10% of all adult fractures and 35-45% of all fractures that occur in the shoulder girdle area. If these fractures are classified into thirds, as proposed by Allman, the most frequent site of injury is at the middle third (group I fractures). These fractures account for approximately 72-80% of all fractures of the clavicle. Approximately 25-30% of clavicle fractures occur at the lateral clavicle (group II). Fractures of the medial clavicle are quite rare, accounting for 2% of all clavicle fractures in a recent epidemiological study by Nowak. 1 

The clavicular fractures can be treated by non operative or operative methods according to its type, status of patient and the patient’s choice. Nonoperative treatment of clavicle fractures consists of sling support for 6 weeks. During this period, the patient does perform pendulum exercises for shoulder motion and active range of motion of the elbow and hand. After 6 weeks, the patient begins passive assisted motion of the shoulder and progresses to active range of motion as tolerated. Use of the sling may be discontinued as pain allows. 

Many techniques of surgical fixation of clavicle fractures have been described in the literature. When using plate and screw fixation to treat clavicle fractures, the surgeon must remember that the hardware will likely be prominent. Proper closure of these incisions is imperative to decrease the risk of painful, prominent hardware along with exposure late.

Case Report :

A 32 years old young man from remote hilly village of Eastern Nepal presented to Department of Orthopaedics B P Koirala Institute of Health Sciences Dharan Nepal with complains of exposed left clavicle with implant in situ with discharging sinuses on the operated site for open reduction and internal fixation with reconstruction plate and screws from fracture clavicle left 14 months back. He had no problems for 1 and half months after getting treatment of fracture clavicle with operative intervention as mentioned above. He then developed a discharging sinus over the site and was increased gradually leading to spontaneous sloughing of skin exposing the implant. Then screws were extruded leaving only two screws on either side of plate. The proper Orthopaedic care was not possible due to its unavailability along with his socio-economic status and geo-political problems of the country. As soon as he presented to our Institute, the removal of implant, debridement of the wound and dressing of the wound was done in the priority basis in the first stage. The wound was daily dressed till it was covered by granulation tissue. Then split skin grafting was done over the granulation tissue. With due course of time, the wound was healed without further complications. At the end of 9 month from the time of debridement, patient had a good outcome with full range of movement of the left shoulder.

Fig A .Radiograph showing implant failure for treatment of fracture clavicle with plate

Fig B. patient with exposed implant on the clavicle with osteomyelitis of clavicle

Fig C. Close up view of exposed implant and osteomyelitis of clavicle


Discussion :

In neonates and children, these fractures are very common and generally heal well. In adults, the force required to fracture the clavicle is greater, healing occurs at a slower rate, and risk of potential complications is higher. The clavicle is the sole articulation of the shoulder girdle to the trunk. It protects major underlying vessels, lung, and brachial plexus. Displaced clavicle fractures can injure these structures because of their proximity and sharp edges.  

Extensive clinical studies reported in the literature have indicated that non-operative treatment is the treatment of choice for clavicular fractures. It has also been suggested by some that open reduction may contribute to the development of non-union. From 1970 to 1978, twenty-five of approximately 800 patients with a fracture of the clavicle were treated by open reduction and internal fixation with a threaded intramedullary wire or pin or with cerclage suture (one case). The patients' ages ranged from thirteen to fifty-nine years. All fractures healed without infection or migration of the pin. Based on this experience and a review of the English-language literature, they concluded that the indications for open reduction and internal fixation should be: (1) neurovascular compromise due to posterior displacement and impingement of the bone fragments on the brachial plexus, subclavian vessels, and even the common carotid artery; (2) fracture of the distal third of the clavicle with disruption of the coracoclavicular ligament; (3) severe angulation or comminution of a fracture in the middle third of the clavicle; (4) the patient's inability to tolerate prolonged immobilization (required by closed treatment) because of Parkinson's disease, a seizure disorder, or other neuromuscular disease; and (5) symptomatic non-union following treatment by closed methods. 2 

Internal fixation of the clavicle is rarely necessary. When it is warranted, the clavicle's complex three-dimensional morphology and functional anatomy, proximity to vital structures, and the multidirectional biomechanical forces acting upon it place considerable demands on any implant used for skeletal fixation. Mullaji AB et al treated nine clavicles with the recently-introduced 3.5 mm low contact-dynamic compression plate (LC-DCP). Surgery was performed for symptomatic non-union in six patients, shoulder dysfunction following a malunited fracture in one, for an open fracture in one, and for an acute fracture associated with brachial plexus injury in one. After an average follow-up period of 17 months union was secured in each case. The advantages afforded by the 3.5 mm LC-DCP in internal fixation of the clavicle with its uniquely demanding anatomical and biomechanical characteristics are discussed. 3 

In a multicenter, prospective clinical trial, conducted by Canadian Orthopaedic Trauma Society, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disability of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). They concluded that operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients. 4

In another series of study done by Poigenfürst J et al, there was no bony infection or infected pseudarthrosis. Four clavicles refractured after removal of the plate and five operations led to pseudarthroses which were successfully treated by reoperation. Radiological and clinical results in the majority of the re-examined patients were excellent. Among total of 131 fractures of the clavicle treated with plate and screws, such a devastating complication as we found in our case, was not mentioned. 5

Ali Khan MA etc al. reported treatment of twenty mid-clavicular fractures by plate fixation. They mentioned that the technique they used gave relief from pain within 12 hours and resulted in bony union all cases. There were no such complications as they reported. 6

23 fresh type II (Neer 1963) lateral clavicular fractures were treated operatively. In 19 cases fixation was done with two Kirschner wires, in four cases plating was performed. The coracoclavicular ligament was left unsutured. The average follow-up period was 4.5 (1-12) years. In 22 cases out of 23 the subjective outcome was good or satisfactory. 22 fractures united and there were few complications, but above mentioned complications were not found. 7

From the different large and small studies from case series to multi-centric controlled trials, we reviewed, did not mention such a devastating complication. Till date there are controversies and debates on the treatment of fracture clavicle, though we mostly observe its acceptable alignment and union without specific interventions. We, therefore, recommend conservative treatment of fracture clavicle in our setup with geo-socio-economic conditions.

Reference :

  1. L Joseph Rubino. Clavicular fractures.
  2. Zenni-EJ Jr; Krieg-JK; Rosen-MJ. Open reduction and internal fixation of clavicular fractures J-Bone-Joint-Surg-Am. 1981 Jan; 63(1): 147-51
  3. Mullaji AB. Jupiter JB. Low-contact dynamic compression plating of the clavicle. Injury. 1994 Jan 25(1):41-5.
  4. Michael D. McKee et al. (Canadian Orthopaedic Trauma Society)  Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan; 89 (1):1-10.
  5. Poigenfürst J, Rappold G, Fischer W. Plating of fresh clavicular fractures: results of 122 operations. Injury. 1992;23(4):237-41
  6. Ali Khan MA, Lucas HK. Plating of fractures of the middle third of the clavicle. Injury. 1978 May;9(4):263-7.
  7. Eskola A, Vainionpää S, Pätiälä H, Rokkanen P. Outcome of operative treatment in fresh lateral clavicular fracture.Ann Chir Gynaecol. 1987; 76 (3):167-9.


This is a peer reviewed paper 

Please cite as : Suraj Bajracharya: A Devastating Complication Of Treatment Of Fracture Clavicle With Plating: A Bitter Experience

J.Orthopaedics 2008;5(4)e11





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