Symptomatic Malunion of a Displaced Clavicle Fracture
A left comminuted clavicle fracture sustained in a polytrauma accident went on to a symptomatic malunion after a trial of non-operative management. Will thoughtful preoperative planning and operative execution lead to fracture union?
Krystin A. Hidden, MD, and Brandon J. Yuan, MD
A 19-year-old, otherwise healthy right-hand-dominant female is brought to the trauma unit via ambulance after being involved in a utility vehicle rollover collision. She was intubated at the scene and arrived at the hospital with a severe head injury with diffuse axonal injury, a subarachnoid hemorrhage requiring an emergent craniectomy, multiple rib fractures with a pneumothorax, a lumbar spine burst fracture, and a clavicle fracture.
This article will describe management of the clavicle fracture, which is a closed, displaced fracture of the left clavicle with an ipsilateral mildly displaced left extra-articular scapular body fracture (Figure 1).
Figure 1. Radiographs and CT of the left shoulder demonstrate the left upper extremity injuries: A closed left mid-diaphyseal clavicle fracture and a left extra-articular scapular body fracture at the glenoid neck with mild displacement.
Ipsilateral upper extremity injuries in a patient with polytrauma warrant a conversation with the patient and family regarding operative versus non-operative management. Fractures of the ipsilateral mid-diaphyseal clavicle and glenoid neck create a “floating shoulder,” a term first used in 1975 by Ganz and Noesberger  when describing a discontinuous glenohumeral joint from the appendicular skeleton.
In 1993, Goss  further described this injury pattern as a double disruption to the “superior shoulder suspensory complex” (SSSC), which is a continuous ring of bony and soft tissue attachments between the distal clavicle and scapula. Collectively, the SSSC allows for biomechanical advantages during overhead activity. When the degree of osseous displacement suggests a disruption to this SSSC relationship, surgery should be considered for the clavicle, the scapula, or both. 
Our patient’s scapular body fracture remained extra-articular with minimal sagittal plane angulation. The clavicle fracture appeared to be distracted by 1 cm with a degree of superior comminution. Ultimately, however, the decision was made to treat these fractures non-operatively due to the patient’s closed head injury. Her mental status remained tenuous during her admission, and her closed head injury required multiple inpatient procedures, including a staged cranioplasty and prolonged intubation followed by tracheostomy.
The patient recovered from her head injury and remained neurologically intact without paresthesias in her left upper extremity. She had minimal pain when elevating her left arm over her head, and radiographs at 4 weeks from injury demonstrated interval callus formation (Figure 2). The decision was made to continue with non-operative management.
Figure 2. Upright clavicle films 4 weeks from injury demonstrate inferior translation of the clavicle by 100%. However, the patient demonstrated early callus formation circumferentially.
Non–operative Treatment Versus Plate Fixation
In a multicenter prospective clinical trial, members of the Canadian Orthopaedic Trauma Society (COTS) randomized 132 patients with displaced mid-diaphyseal clavicle fractures to either operative or nonoperative management.  The study authors concluded that early plate fixation of displaced mid-diaphyseal clavicle fractures leads to improved patient outcome scores, earlier return to function, and decreased rates of non-union and malunion. Hardware removal was the most common reason for re-operation. 
Although our patient’s fracture characteristics qualified as operative criteria, the COTS trial excluded patients with associated head injuries. 
Morley et al  evaluated the relationship between traumatic brain injury and accelerated bone healing and concluded from the literature that traumatic brain injury leads to increased osteogenesis.  However, no studies to date have evaluated clavicle fracture non-union rates in relation to concomitant closed head injuries.
Upright films obtained 4 months after the patient’s injury showed callus formation with persistent caudal translation of the lateral clavicle (Figure 3).
Figure 3. Upright clavicle radiographs demonstrate interval callus formation with persistent caudal translation of the lateral clavicle.
Clinically, the patient had a significant shoulder droop with paresthesias when her left arm was at her side for a prolonged period of time. She had functional limitations with overhead activities despite dedicated physical therapy.
Although the patient may have achieved union with continued non-operative management, her symptomatic paresthesias and functional limitations were concerning enough to warrant surgical intervention. The decision was made to proceed with a corrective osteotomy of the left clavicle with open reduction internal fixation.
The degree of callus formation was re-assuring; however, case reports of hypertrophic callus formation with subsequent brachial plexus compression or development of thoracic outlet syndrome have been described with clavicle malunions.  Our patient likely had transient compression of her brachial plexus with gravity-dependent arm positioning, given the degree of caudal displacement of the lateral segment and the weight of her arm.
Prior to surgery, we obtained a 3D-printed model of the patient’s contralateral clavicle to assist with a mirrored correction of the left clavicle deformity (Figure 4).
Figure 4. A 3D–printed model of the patient’s native contralateral right clavicle was utilized as a template for deformity correction of the left clavicle.
We utilized the native right clavicle anatomy to pre-contour a 3.5-mm variable angle locking compression plate (DePuy Synthes; West Chester, Pennsylvania), which was then sterilized for the day of surgery
- The patient was taken to the operating room and placed in the supine position. General anesthesia was induced.
- The malunion site was easily palpable and prominent. We made a straight incision overlying the clavicle and carefully isolated the malunion anteriorly and superiorly.
- Malleable retractors were then placed to protect the subclavian vessels and thoracoacromial trunk, and a periosteal dissection was taken posteriorly and inferiorly.
- A longitudinal osteotomy was then performed in accordance with our preoperative 3D template.
- The proximal and distal clavicle were mobilized and the medullary canals were cannulated with a 3.5-mm drill bit.
- We then made 2 transverse osteotomies at either end of the clavicle to provide flat ends for compression.
- The clavicle was distracted, restoring appropriate length with cortical apposition.
- We applied our pre-contoured plate and affixed it to the clavicle with reduction clamps and K-wires. Screws were then placed in compression mode across the malunion site (Figure 5).
Figure 5. Intraoperative fluoroscopy demonstrating the pre-contoured clavicle plate that was utilized as a template. The medial and lateral ends of the newly osteotomized clavicle were held to the plate with bone clamps. The plate was then affixed to bone with multiple screws, mirroring the contralateral right clavicle’s length and alignment.
- We utilized an oscillating saw to contour the osteotomy site, which provided bone fragments for local autograft.
- The platysma fascial layer was closed with synthetic absorbable sutures: size 0 (Vicryl, Ethicon; Somerset, New Jersey) followed by size 2-0 (Monocryl, Ethicon) for the subcutaneous layer and size 3-0 (Monocryl, Ethicon) for the skin.
- The patient was made coffee-cup weight-bearing for 6 weeks with immediate elbow, wrist, and hand range of motion.
- Shoulder range of motion was limited for 2 weeks until the wound had healed.
Radiographs obtained 12 months following operative fixation showed a healed clavicle fracture with stable fixation (Figure 6). Fracture lines are no longer visible.
Figure 6. Radiographs obtained at 1–year follow-up demonstrate a healed clavicle and stable hardware.
The patient had returned to 100% of her pre-injury activities without limitations, working part-time and attending college full-time. She denied any plate prominence and was not interested in hardware removal.
- Ipsilateral mid-diaphyseal clavicle fractures and glenoid neck fractures warrant conversations with the patient and family regarding both operative and non-operative management options, especially in the setting of polytrauma injuries.
- A double disruption to the superior shoulder suspensory complex may have a biomechanical disadvantage in the setting of displacement and potential malunion. Operative management of the clavicle, the scapula, or both should be considered.
- The COTS trial concluded that early plate fixation of displaced mid-diaphyseal clavicle fractures leads to improved patient outcome scores, earlier return to function, and decreased rates of non-union and malunion. Hardware removal was the most common reason for re-operation.
- Research has also shown that patients with closed head injuries have increased osteogenesis compared with controls, but little is known about non-union or malunion rates in concomitant clavicle fractures.
- Our patient had a significant head injury with signs of early healing at just 4 weeks. She was watched closely until a symptomatic malunion developed 4 months post-injury, at which point the indications for surgery were clearer.
- This example highlights the advantages of 3D printing for preoperative surgical planning. The severity of the patient’s malunion would have made it difficult to determine the appropriate length, alignment, and rotation of the clavicle intraoperatively. The use of 3D printed models of the malunited and contralateral clavicles provided a clear osteotomy site of the malunion, as well as a contouring surface for a plate, prior to proceeding to the operating room. This saved significant time intraoperatively, allowing for a mirrored reduction and restoration of symmetric shoulder girdles.
Krystin A. Hidden, MD, and Brandon J. Yuan, MD, are orthopaedic trauma surgeons at Mayo Clinic, Rochester, Minnesota.
Disclosures: Dr. Hidden and Dr. Yuan have no disclosures relevant to this article.
- Ganz R, Noesberger B. Treatment of scapular fractures. Hefte Unfallheilkd. 1975;126:59–62 (in German).
- Goss TP. Double disruptions of the superior shoulder complex. J Orthop Trauma. 1993;7:99–106.
- Owens BD, Goss TP. The floating shoulder. J Bone Joint Surgery Br. 2006;88-B(11):1419-1424.
- Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: A multicenter, randomized clinical trial. J Bone Joint Surg. 2007;89A(1):1-10.
- Morley J, Marsh S, Drakoulakis E, Pape HC, Giannoudis PV. Does traumatic brain injury result in accelerated fracture healing? Injury. 2005;36:363-368.
- Della Santa D, Narakas A, Bonnard C. Late lesions of the brachial plexus after fracture of the clavicle. Annales de Chirurgie de la Main et du Membre Superieur. 1991;10(6):531-540.