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Congenital pseudarthrosis of the clavicle: a review of the literature and surgical results of six cases.

This article is a retrospective review of six symptomatic patients who, when treated surgically, all healed with excision of pseudarthrosis, bone grafting, and plating. We discuss congenital pseudarthrosis of the clavicle with emphasis on etiologies, clinical presentation, differential diagnosis, and method of treatment. Our patients' chief complaints were cosmesis, pain, or shoulder deformity.

Adolescent↗

Operative treatment of congenital pseudarthrosis of the clavicle.

Eight children were treated operatively with resection of fibrous pseudarthrosis and sclerotic bone ends, careful dissection and preservation of the periosteal sleeve to maintain continuity, and approximation of bone ends. None had additional bone grafts or internal fixation. All had bridging ossification 6-8 weeks postoperatively, and all were solidly healed by 14 weeks after surgery. Follow-up has ranged from 2 to 14 years, with no evidence of recurrence. Remodeling of the prominence occurred slowly in 2-5 years, with the distal clavicle variably underdeveloped in all patients. Early resection of fibrous pseudarthrosis probably does not require the extensive grafting and internal fixation that has been recommended for older children.

Bone Development↗

'Duplication' of the clavicle or ossification in coracoclavicular ligament.

A case is presented in which plain films revealed a short band of ossification adjacent to the inferior aspect of the lateral part of the clavicle. CT findings indicated that the ossification was situated in the coracoclavicular ligament and was not a manifestation of clavicular 'duplication'.

Acromioclavicular Joint↗

Fracture shaft of clavicle, an indirect injury from bench pressing.

Injuries related to weight training are becoming increasingly common as the trend for body resistance training grows. There have been numerous injuries related to repeated stress, but this appears to be the first reported case of a fracture of the shaft of clavicle related to violent muscular contraction. It occurred in a 28 year old man during bench pressing. He was treated conservatively and the fracture united in six weeks. Resistant trainers should be made aware of the risks of heavy weight training and need proper supervision.

Adult↗

Resorption of the undersurface of the distal clavicle in rheumatoid arthritis.

An elongated erosion on the undersurface of the distal clavicle, adjacent to the coracoid process, may be seen in the shoulder of a patient with rheumatoid arthritis. This finding is apparently related to inflammatory changes in the coracoclavicular ligament. Such an erosion may occur with or without additional radiographic alterations and, although not entirely specific, suggests rheumatoid arthritis.

Arthritis, Rheumatoid↗

Osteomyelitis of the clavicle secondary to infected Hickman catheter.

A patient receiving home parenteral nutrition developed osteomyelitis of the clavicle associated with a Hickman catheter which had been functioning for 14 months. The infection was treated with bone curettage, parenteral antibiotics, and catheter removal. Although this has been a reported complication of subclavian vein catheters, this is the first reported case associated with a Hickman catheter.

Catheterization, Peripheral↗

Osteomyelitis of the clavicle after subclavian vein catheterization.

Osteomyelitis of the clavicle or the sternoclavicular joint is a rare complication of subclavian vein catheterization. Soft tissue infections around the puncture site occur frequently and respond well to topical and antibiotic treatment. If symptoms persist for several weeks, osteomyelitis or sternoclavicular pyo-arthrosis should be considered. Bone and gallium scintigraphy scans and computerized tomography scans are helpful diagnostic measures.

Aged↗

Early fracture of clavicle following neck dissection.

Fracture of the clavicle as a late complication following radical neck dissection is rare, with an incidence of approximately 0.4-0.5 per cent. We report a case where fracture occurred early following a selective neck dissection.

Aged↗

Traumatic floating clavicle. A case report.

Dislocation of both ends of the clavicle simultaneously is an injury usually sustained in a major accident; in this unusual case it resulted from a minor fall at home. The mechanism of injury and the treatment are discussed.

Accidents, Home↗

Atlanto-axial rotatory fixation and fracture of the clavicle. An association and a classification.

Five children with atlanto-axial rotatory fixation (AARF) in association with fractures of the clavicle are described. It is postulated that the rotary fixation is a direct result of the trauma which produces the fracture. The importance of early diagnosis is stressed, since delayed diagnosis may lead to chronic deformity. Early diagnosis depends on awareness of the possibility of AARF, and either fluoroscoping the patient in order to take appropriate spot films or imaging the atlanto-axial joint by CT. A simple classification of AARF is proposed based on distinct radiological features which differentiate subluxation from dislocation.

Atlanto-Axial Joint↗

The floating shoulder: ipsilateral clavicle and scapular neck fractures.

In ipsilateral mid-clavicular and scapular-neck fractures, the mechanical stability of the suspensory structures is disrupted and muscle forces and the weight of the arm pull the glenoid fragment distally and anteromedially. To prevent late deformity we recommend internal fixation of the fractured clavicle by a plate and screws. We treated seven patients with this unusual injury; all achieved an excellent functional result without deformity.

Adolescent↗

Atrophic nonunion of the clavicle: treatment by compression plate, lag-screw fixation and bone graft.

We describe a new surgical treatment of atrophic nonunion of the clavicle. The nonunion is excised by cuts at 45 degrees to the long axis and repair uses 3.5 mm pelvic reconstruction or dynamic compression plates, with a lag screw to provide interfragmentary compression. The site is grafted with cancellous bone. We have been successful in all seven patients, with early return to normal function. The consequent narrowing of the shoulder girdle is fully acceptable for appearance and function.

Adolescent↗

Injury to the brachial plexus by a fragment of bone after fracture of the clavicle.

Clavicular fractures are occasionally responsible for lesions of the brachial plexus. The symptoms are usually delayed and due to compression by hypertrophic callus, nonunion or a subclavian pseudoaneurysm. We describe a patient in whom a displaced bone fragment was pressing on the retroclavicular part of the brachial plexus, leading to early symptoms of a lesion of the posterior cord. Internal fixation of the clavicle and external neurolysis of the brachial plexus gave an almost full recovery.

Adult↗

Fixation of fractures of the midshaft of the clavicle with Kirschner wires. Results in 108 patients.

We treated 110 fractures of the middle third of the clavicle in 108 patients aged between 14 and 66 years, by fixation with 2 mm Kirschner wires. The wire was introduced, using an air drill and a telescoping guide, from the medial into the lateral fragment. The medial end of the wire which perforated the anterior cortex of the medial fragment was bent backwards to prevent migration into the lung or mediastinum. In cases of nonunion and acute fracture in which a bone gap was present, bone graft was laid around the fracture site after internal fixation. All the fractures united. No wires broke but in three patients one migrated before union was achieved. Twenty-one patients failed to return for removal of the wire; nine of them had radiological evidence of union before they were lost to follow-up.

Accidents, Traffic↗

Fractures of the clavicle in the adult. Epidemiology and classification.

From 1988 to 1994 a consecutive series of 1000 fractures of the adult clavicle was treated in the Orthopaedic Trauma Clinic of the Royal Infirmary of Edinburgh. In males, the annual incidence was highest under 20 years of age, decreasing in each subsequent cohort until the seventh decade. In females, the incidence was more constant, but relatively frequent in teenagers and the elderly. In young patients, fractures usually resulted from road-traffic accidents or sport and most were diaphyseal. Fractures in the outer fifth were produced by simple domestic falls and were more common in the elderly. A new classification was developed based on radiological review of the anatomical site and the extent of displacement, comminution and articular extension. There were satisfactory levels of inter- and intraobserver variation for reliability and reproducibility. Fractures of the medial fifth (type 1), undisplaced diaphyseal fractures (type 2A) and fractures of the outer fifth (type 3A) usually had a benign prognosis. The incidence of complications of union was higher in displaced diaphyseal (type 2B) and displaced outer-fifth (type 3B) fractures. In addition to displacement, the extent of comminution in type-2B fractures was a risk factor for delayed and nonunion.

Accidental Falls↗

Retrosternal displacement after physeal fracture of the medial clavicle in children treatment by open reduction and internal fixation.

Retrosternal displacement of the medial aspect of the clavicle after physeal fracture is rare. We treated six patients with this injury between 1995 and 1998, all as an emergency in order to avoid complications associated with compression of adjacent mediastinal structures. Attempted closed reduction was undertaken, but all required open reduction and internal fixation using a wire suture. There were no associated complications. Five were reviewed clinically and radiologically at a minimum of one year after operation. All had regained full use of the affected arm without pain and had resumed their preinjury level of activity including sports. Follow-up radiographs showed union in the anatomical position in all patients. We recommend attempted closed reduction in the operating room, followed, if necessary, by open reduction. Internal fixation after open reduction gives stable fixation with minimal morbidity.

Adolescent↗

Gorham's disease of the clavicle with bilateral pleural effusions.

A patient with Gorham's disease (massive osteolysis, disappearing bone disease) of the right clavicle had bilateral sanguinous pleural effusions. Complete cure was achieved by removal of the bony remnants with the hemangiomatous mass which caused bone destruction, and by obliteration of the pleural spaces using repeated talcum insertion. In six out of seven previously described cases of Gorham's disease with pleural effusions, the patients died, while the only survivor had a unilateral chylous effusion.

Adult↗