Orthopaedics & Traumatology: Surgery & Research (2010) 96, 821—824

CLINICAL REPORT

Bilateral clavicle fracture external fixation

N. Bonnevialle ∗, Y. Delannis, P. Mansat, O. Peter,B. Chemama, P. Bonnevialle

Orthopaedics and Traumatology Department, Toulouse-Purpan Teaching Hospital Center,place-du-Dr-Baylac, 31059 Toulouse, France

Accepted: 15 February 2010

KEYWORDSPropionibacteriumacnes;Clavicle fracture;

Summary Fractures of the middle third of the clavicle are frequent and their conservativetreatment ends in bone union in nearly 95% of cases. Surgical treatment is unanimously indi-cated with open fractures or in cases of cutaneous damage, neurovascular complications, andimpaction of the shoulder stump syndromes. We report herein a case of bilateral fractures of the

Bilateral externalfixator

clavicle that required double stabilization with an external fixator following major cutaneousdamage appearing after the initial conservative management. The intraoperative discoveryof Propionibacterium acnes infection and bone union obtained within the classical time frame,with a satisfactory functional result, all retrospectively proved the soundness of this indication.© 2010 Elsevier Masson SAS. All rights reserved.

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Introduction

Fractures of the middle third of the clavicle are amongthe most frequent fractures in adults, with an incidenceof 5—10% in young patients [1—3]. However, bilateralinvolvement is reported more rarely [4—7]. Most of thesefractures heal after orthopaedic treatment with satisfac-tory functional results. Atrophic nonunion has a less than5% incidence: the predictive factors of nonunion are female

gender, advanced age, severe comminution, and major dis-placement of the fracture locus [8].

In addition, the indications for osteosynthesis are openfractures or the possibility of cutaneous opening caused by

∗ Corresponding author. Tel.: +33 5 61 77 21 78;fax: +33 5 61 77 76 17.

E-mail address: nicolasbonnevialle@yahoo.fr (N. Bonnevialle).

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1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights redoi:10.1016/j.otsr.2010.02.017

bone splinter, impaction syndromes of the should stump,ilateral fractures, existence of an associated neurovascularesion, and intolerance of the orthopaedic treatment [9,10].

Through one case of bilateral fracture of the clavicles, weonfirm the requirement for osteosynthesis and report ourxperience in indirect stabilization using an external fixator,equired in suspected cases of underlying infection.

bservation

58-year-old female patient, victim of a traffic accidentith lateral collision and multiple rollovers, was brought to

he emergency department of our institution for thoracicnd pelvic injury. Other than a treated depressive syndrome,he had no medical or surgical history.

Questioning the patient and clinical examinationevealed a brief loss of consciousness. A linear, superficial

served.

822 N. Bonnevialle et al.

avicles according to the Robinson classification [3].

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Figure 2 Radiographic follow-up at the 3rd postoperativeweek.

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Figure 1 Type 2B2 bilateral fracture of the cl

utaneous lesion was found on the anterior side of the tho-ax, suggesting a high-energy injury from the seatbelt.

The central and peripheral nerve examination was nor-al, palpation of the spinal axis and the abdomen wasithout pain. On the other hand, gentle mobilization of the

wo shoulders found pain located in the root of the limb.imilarly, partial functional painful impotence of the hipsas identified. The respiratory rate was 20 breaths/min with2 saturation at 99% without oxygen therapy.

A conventional radiological examination confirmed ailateral comminution fracture, with little displacement, ofoth clavicles, with a third fragment: a type 2B2 fractureccording to the Robinson classification (Fig. 1) [3]. Cuta-eous inspection at the locus of the fractures showed onlyiffuse hematoma.

Whole-body CT with contrast injection revealed a type2 stable pelvic fracture according to the Tile classificationnd bilateral pulmonary contusion with no pleural effusion11].

Despite the surgical team’s recommendations, theatient refused any surgical intervention on the clavicleractures and simple elbow-to-body immobilization was putn place. Standing was forbidden because of the pelvic frac-ure. Symptomatic antalgic treatment, preventive heparinherapy, and strict recommendations concerning surveil-ance of the skin were delivered.

During the follow-up consultation two weeks after injury,he skin at the two fracture loci appeared inflammatory, par-icularly on the right where it was clinically endangered by aone splint with an aspect of subcutaneous bullous detach-ent measuring 1 cm2. The X-ray work-up showed secondaryisplacement of the medial diaphyseal fragment of the rightracture.

Surgical treatment was accepted by the patient given theoor clinical progression.

A bilateral approach to the fracture loci with partialxcision of the fractured bone edges and multiple bac-erium samples were taken during the surgical procedure.n external fixator (Hoffman IITM, Stryker) was used forsteosynthesis: two medial bicortical pins were viewednd positioned in a horizontal anteroposterior direction orlightly ascending when the two lateral pins were implantedore vertically in the craniocaudal direction. A wide spat-

la was systematically inserted in contact with the clavicleo protect the cervical vessels and the pleural dome whenhe medial pins were put in place. Once the drainage was

n place, the different planes were sutured without ten-ion.

Two bacteriological samples out of three taken on theight clavicle were positive for Propionibacterium acnesfter 18 days of culture. An oral double antibiotic therapy

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igure 3 Clinical examination at the 3rd postoperative weekith good local tolerance of the external fixator.

ith Fucidin and penicillin A was initiated for 6 weeks, asso-iated with local and biological monitoring (CBC, CRP).

At 3 weeks postoperative, tolerance of the external fix-tor was good because of twice daily local disinfectionFigs. 2 and 3).

At the 2nd month postoperative, the two external fixatorsere removed in consultation. The fractures were consid-red clinically healed (Fig. 4A and B).

At 8 months, the active mobility of both shoulders wasatisfactory: active anterior elevation, 170◦; external rota-ion elbow to body, 70◦; internal rotation, T12. The DASHcore was 5 points (Fig. 5A and B).

iscussion

lthough clavicle fractures account for 5—10% of fracturesn adults, atrophic nonunion is rare [1—3]. Nonsurgicalreatment is based on partial immobilization with an elbow-o-body sling or placing retropulsion rings for 3—6 weeks.

Bilateral clavicle fracture external fixation 823

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Figure 4 AP X-rays before removal of the two external fixatorsosseous callous formation while lysis around the pins is beginnin

The failure rate for bone union between the two types ofimmobilization was not significantly different but the func-tional result seems less good after the rings and when thefracture is a comminution fracture [12,13].

Bilateral fractures are rarely reported in the literature[4—7]. Surgical treatment is necessary immediately whenthese fractures are associated with major thoracic injury:stabilization with osteosynthesis improves respiratory func-tion [5]. Be that as it may, independently of this situation,immobilization of both upper limbs is difficult for patientsto accept because of the consequences on daily life andsurgical treatment is warranted to reduce the duration offunctional disability.

In the case that we report herein, the indication forearly osteosynthesis was necessary but only carried out sec-ondarily for nonmedical reasons, within a context of poorlocal conditions at the fracture locations. Turning to directstabilization seemed to pose a greater risk of postopera-tive infection exacerbated by the presence of osteosynthesismaterial than external fixation allowing regular local mon-itoring. In addition, the intolerance of the fixator pinsconsidered a disadvantage is generally resolved after imme-diate removal of the material, which can be done easily

without a new surgery [14]. The anatomy of the clavicleas well as the proximity of the neurovascular structures andthe pleural dome require particular attention when plac-ing the medial pins. Some authors suggest fluoroscopically

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Figure 5 A. AP X-ray of both clavicles at follow-up. Although dysmClinical examination at follow-up. Complete recuperation of mobilit

ht (A) and left (B), bone union is progressing with an identifiableappear.

uided percutaneous placement, but this does not seem suf-ciently safe when attempting to place perfectly bicorticalins [15]. Nevertheless, opening the fracture locus requiredo take the biological samples in our case allowed us toisually check the pin implantation.

Moreover, some authors have suggested this mode ofsteosynthesis in aseptic nonunion with a risk of cutaneousecrosis. Schuind et al. [16] reported the results of 20 clav-cles treated in this context. The mean time maintaininghe external fixator was 51 days. In their series, a singleatient presented bilateral fractures. The nonunions wereseptic and the authors suggested adding a bone graft to theefect. Tomic et al. [15] used fixation following the Ilizarovrinciple without opening the focus or using bone grafting,ut the nonunions were hypertropic, probably because ofhe absence of fracture stability. Union was obtained in 11atients out of 12.

The results of the bacteriological samples taken intraop-ratively, positive to Propionibacterium acnes, confirmedhe contamination of the fracture locus suggested by theocal aspect of the surrounding tissues. Although this bac-erium is frequently looked for in postoperative infectionsf the shoulder, we believe it should also be suspected in

ases with an unusually inflammatory aspect in a fractureone in the shoulder girdle area [17—21]. Two to 3 weeksf culture are always required for this very-slow-growingacterium [22]. Duncan et al. [17] treated six patients

orphic, the osseous callous formation presents good density. B.y and excellent functional result according to the DASH score.

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24

or clavicular osteitis and identified three cases of Pro-ionibacterium acnes infection. None of these patientsere treated with external fixation. Four patients out of

ix did not achieve bone union, consequently with a poorunctional result at follow-up.

In conclusion, external fixation in clavicle fracturesithin a poor-quality cutaneous environment is a satis-

actory and safe alternative providing bone union andoncurrent treatment of a potential bone infection, as longs the bacteria are properly identified and the antibioticherapy adapted.

onflict of interest statement

one.

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