late lesions of the brachial plexus after fracture of the clavicle

$: Late lesions of the brachial plexus after fracture of the clavicle$
Original articles 531

Late lesions of the brachial plexus after fracture of the clavicle

D. D E L L A SANTA 1, A. N A R A K A S 2, C. B O N N A R D 2

SUMMARY : Fractures of the clavicle, particularly those which are markedly displaced, may, in rare instances cause injury to the subclavian vessels and the brachial plexus which manifest progressively days or weeks after the initial trauma. More often than not, however, a costo-clavicular compression syndrome appears months or years after the clavicular fracture as a result of constriction by scar which invests the neuro-vascular bundle, by a secondary aneurysm or by hypertrophic callus. The authors report 16 such cases, one of which was treated conservatively, thirteen treated by surgical intervention while two cases are awaiting operation. These patients represent just over 1% of brachial plexus lesions seen over a period of twenty years in two surgical centres. Operative treatment consists of reduction of the clavicular deformity, possibly first rib resection, liberation of the plexus and correction of a vascular lesion as required. The outcome is usually good.

Ann Hand Surg, 1991, 10, n ° 6, 531-540.

KEY-WORDS : Fracture of clavicle. -- Brachial plexus. -- Subclavian vessels. -- Costo- clavicular neurovascular compression. -- Thoracic outlet syndrome.

I N T R O D U C T I O N

Fracture of the lateral third o f the clavicle secondary to direct t rauma will usually not en- danger neurovascular structures. When the fracture involves the middle third, comminu t ion is frequent, with the fragments tending to overr ide each other. This displacement is p roduced by the divergent pull o f a number of muscles including the s ternocleidomastoid, pectoralis major, deltoid, the upper part o f t rapez ius and even the subclavius. Trapezius and deltoid pull the lateral fragment dorsally, with the powerful ante- rior deltoid tending to produce caudal shift since upward displacement is prevented by the coraco-clavicular ligaments.

The combined pull o f pectoralis major and s ternocleidomastoid, particularly the latter, tends to displace the medial f ragment dorsally

and cranially away f rom the neurovascular pedicle, while the in termediate fragment tends to rotate in the coronal plane with the medial end tenting up skin. As a result, the lateral fragment comes to point downwards and dorsally and may impinge on the neurovascular pedicle. This scenario is exceptional with direct injury to vessels and nerves occurring very rarely [2, 6, 23].

With indirect t r auma to the clavicle the force of impact is t ransmit ted by humerus and sca- pula. The fracture is usually spiral, possibly including an intermediate fragment [11, 23] which occurs in the convex part o f the bone.

1. Unit~ de Chirurgie de la Main, HCU, GENEVA (Switzer- land). 2. Clinique Longeraie, 9, av. de la Gare, LAUSANNE(Swit- zerland).

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Indirect t rauma may also cause sterno-clavicular or acromio-clavicular dislocations possibly including wedge-shaped articular fractures [21 ].

High kinetic energy trauma, as occurs in road traffic accidents, will cause significant displacement of fragments not only secondary to muscu- lar pull but also as a direct result o f the force of impact. This may damage underlying ner- vous and vascular structures [2, 12, 19, 20, 22, 24]. Injury to the carotid artery and even pneumothorax is possible [23]. The cords of the brachial plexus and the subclavian vessels are vul- nerable to compression or penetration by bony fragments. Vascular lesions may manifest immediately or late, in the form of aneurysm or arteriovenous fistula.

The costo-clavicular space may be narrowed secondary to the formation of hypertrophic callus, non-union or pseudarthrosis of the overri- ding fragments [3, 8, 11, 17, 20, 21]. Sometime after the initial trauma the nerves will come to be compressed, with development of thoracic outlet syndrome while vascular pathology may manifest as vessel stenosis, venous and/or arterial thrombosis or arterial poststenotic aneu- rysms (6, 16, 23).

DIAGNOSIS

In the sixteen cases which form our series, lesions of the plexus were initially either absent or so limited that no clinical signs could be elicited. They manifested gradually, days, weeks, even years after the accident. The first symptoms to manifest included brachialgia, acropa- resthesiae and fatigue on use. Much later, motor deficits affected eleven patients.

Signs such as congestion of the extremity and alteration of the radial pulse [16] manifest from the onset and are suggestive of associated vascular lesions.

Neurological disturbance commonly affects the medial portion of the forearm and hand as well as ulnar nerve function, indicating likely injury to the medial cord [4]. Symptoms and signs will be further elicited by some of the tests employed in the diagnosis of thoracic outlet or costo-clavicular syndrome, especially later in the course of events.

Standard radiological examination will eva- luate the clavicle. The so-called antero-posterior view is, in effect, an oblique and produces a relative magnification in bone size. A long, transverse, film held behind both shoulders during exposure will allow simultaneous com- parison with the contralateral side. The axial view (a true AP view according to Carotti [20]), is obtained by positioning the film above the

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FRACTURE OF THE CLAVICLE SURGERY

shoulder and directing the shot upwards through the axilla.

When injury to the brachial plexus is suspected, electrodiagnosis is mandatory. It will confirm the distribution established by the clinical picture and determine the severity of injury [6, 22].

Bloodflow and angiographic investigation such as echography and Doppler flowmetry [2, 6, 13, 22] must be performed if a vascular lesion or thoracic outlet syndrome are suspected.

MANAGEMENT

In the absence of vascular or nerve lesions, early treatment of a closed fracture of the clavicle consists of a figure-of-eight sling as described by Watson-Jones [22].

Surgery is considered when the fracture is exposed, when vascular or nerve lesions have been diagnosed at the onset and when displacement of the fracture is such that it threatens skin viability and cannot be reduced by conservative means. Some [20] would advocate operation when persistent displacement measures over 1.5-2 cm. Vessel and nerve damage is treated if found and the clavicle stabilised by appro- priate osteosynthesis [1, 12, 24].

Secondary treatment depends on the neurovascular lesion and preference is given to the simplest and safest procedures.

Chronic compression of the neurovascular subclavian pedicle is generally a consequence of the formation of a hypertrophic callus irres- pective of union. It may also be caused by scar retraction following the initial displacement of bony fragments. In the presence of solid union the exuberant callus may be resected and the clavicle malunion corrected by osteotomy [16]. In the event of non-union or pseudoarthrosis, fibrous tissue is resected, the fragments are ali- gned with intervening bone graft and stabilised [1, 4, 10].

A narrowed costo-clavicular space may be widened by resection of the first rib [5, 11] as a solitary procedure or in association with procedures described above [23]. Some authors fa- vour excision of the clavicle itself [12, 23], a procedure for which we do not see an indica- tion. We have used it only once, and then in a patient with thoracic outlet syndrome, already subjected to seven operative procedures and in whom resection of the first rib was excluded by pre-existing lesions to muscles stabilising the neck. In all cases an external neurolysis of the brachial plexus is performed [12, 13, 18]. The epineurium is opened only in cases where one suspects an intra-troncular scar [18].

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TABLE I. - - Late plexopathies after fracture of the clavicule.

TABLEAU I, - - Lesions tardives du plexus brachial apres fracture de la clavicule,

TABLA I. - - Lesiones tardivas del p lexo braquial despues de fractura de clavicula.

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Patient Sex/Age Domin./non- Cause of TOS Initial treatment Late treatment Result detain, side

1 Male/22 D Intermed fragment Orthop. Osteosynth, + neurolysis Good 2 Female/52 ND Arterial rupture Orthop. Osteosynth, 4- neurolysis Good

4- vasc. suture 3 Male/40 ND Pseudarthr, Pinning then osteo- Re-osteosynth. 4- graft Good

synth. 4- neurolysis 4 Male/53 D Pseudarthr. Orthop. Osteosynth. 4- graft then Good

spur resect. 5 Male/29 ND Malunion Orthop. Bone abrasion Good

+ neurolysis 6 Male/27 ND Malunion Orthop. Osteotomy 4- graft then Fair

spur resect. 7 Male/48 D Pseudarthr. Orthop. Osteosynth. 4- graft then Bad

1 st rib resect 8 Female/25 ND Malunion Orthop. I st rib resect then Good

neurolysis 9 Female/48 N D Malunion Orthop. None (spont recovery) Good

10 Male/60 ND Malunion Orthop, Osteotomy + graft Good 11 Fernale/32 ND Pseudarthr. Orthop. Osteosynth. 4- graft Good

4- 1st rib resect. 12 Female/22 D Malunion Osteosynth. On waiging list - - 13 Female/37 ND Malunion Orthop. On waiting list - - 14 Male/26 ND Pseudarth. Osteotomy 4- plexus Re-osteosynth. 4- graft Fair

op. 15 Female/17 ND Malunion Orthop. On waiting list - - 16 Male/35 D Malunion Orthop. Osteotomy + neurolysis Good

PRESENTATION OF CASES

Over a 20 year period, we have identified 16 cases of late lesions of the brachial plexus following fracture of the clavicle (13 cases at the Clinique Longeraie, 3 cases at the University Hospital of Geneva) (table I). They consisted of 9 males and 7 females with an age range of 17 to 60 years (average 35 years).

In half the cases the shoulder lesion affected the non-dominant side. Mechanisms of injury included : one case of direct trauma by a falling girder on a building site, five cases of falls on the shoulder and ten cases of trauma in car accidents. All fractures but one occurred in the middle third of the clavicle. All were displaced and in nine cases included an intermediate fragment. In one case there was moderate posterior sterno-clavicular dislocation including a wedge shaped fracture (case 11).

In 13 patients, initial treatment was conservative. Two patients underwent successful plate fixation at four weeks. The last patient underwent fixation by axial pinning at 24 hours. It proved an unstable fixation and proceeded to non-union. Two subsequent operations were required to produce bony union.

Of the group of thirteen patients managed conservatively, eight proceeded to bony union. Non-union was recorded in the remaining four, which included the patient with the sterno-clavicular dislocation.

Symptoms of neurovascular lesions manifested in these sixteen patients over a range of 5 days to 9 years following fracture of the clavicle. In two patients symptoms appeared early, within four weeks post-fracture.

The first patient (case 1, fig. 1) rapidly developed pain and after five days, parasthesiae in the territory of the axillary and radial nerves followed, within days, by weakness progressing to a complete paralysis of the territory of the posterior cord secondary to direct pressure by a bone fragment.

In the second patient (case 2, fig. 2), the intermediate fragment of clavicle perforated the subclavio-axillary artery and vein causing pseudo- aneurysm of the artery and thrombosis of the veto. The resultant haematoma compressed the plexus.

Eight patients complained from the outset of brachialgia and acroparasthesiae, a not uncom- mon finding in fractures of the clavicle. The

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Fig. 1. - - a) Trifragmented fracture of clavicle with an intermediate vertical fragment (arrow). The patient presented parasthesiae in the cutaneous territory of the axillary and ulnar nerves with paralysis of axillary and radial nerves, b) Exposure to show compression of the posterior cord (arrowed) close to the fascicles of the ulnar nerve in the medial cord. c) A third-circular ASIF 6-hole plate has been used to fix the clavicle with two screws fixing the intermediate fragment, d) Post-fixation radiograph of the clavicle.

Fig. 1. - - a) Fracture tri-fragmentaire de la clavicule avec fragment vertical intermediaire (fleche). Le patient presente des paresthesies dans le territoire cutane des nerfs ulnaire et cir- conflexe avec paralysie des nerfs radial et cubital, b) L'intervention met en evidence le fragment osseux qui comprime le tronc posterieur situe pres des fascicules du nerf ulnaire dans le tronc antero interne, c) Une plaque tiers de tube a 6 trous a ete utilisee pour I'osteosynthe" se de la clavicule, deux vis etant fixees dans le fragment intermediaire, d) Radiogra- phies presentant la reparation de la clavicule.

Fig. 1. - - a) Fractura trifragmentaria de la clavfcula con un fragmento vertical intermediario (flecha). El paciente presenta parestesias en el territorio cut~ineo de los nervios ulnar y cir- cunflejo con par~.lisis de los nervios radial y cubital, b) La intervenci6n pone en evidencia un fragmento 6seo que comprime el tronco posterior situado cerca de los fasciculos del nervio ulnar en el tronco antero interno, c) Una placa en tercio de tubo de 6 orificios fue utilizada para la osteosintesis de la clavicula, dos tornillos se fijaron en el segmento intermediario, d) Radiografias que muestran la reparacion de la clavfcula.

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hand was affected later. Inconsistent numbness was noted by these patients immediately following trauma and after months or years by all patients. Palsy appeared in 8 patients and pro- gressed in all but one. One patient, a nurse (case 9), resumed normal work four weeks following conservative management of her clavicular fracture, then developed a progressive paralysis of the posterior cord with total loss of function of the latissimus dorsi and teres major and sub- total loss of the triceps, while the remaining muscles innervated by the radial nerve were graded M2-M3. The musculocutaneous and median nerves were only slightly affected and the ulnar nerve was unaffected. Radiography

revealed hypertrophic callus of the clavicle. EMG showed fibrillation in all affected muscle and a conduction velocity slowed to 48.6 m/sec from Erb's point to the axilla. Muscle power began to return three months after injury and was complete by 5 months post-injury. Eight months after the accident, the patient was considered completely recovered clinically although conduction velocity remained low at 45.4 m/sec.

Brachial plexus injury was diagnosed early in one patient (case 13), a secretary aged 21 who suffered multiple skeletal and soft tissue injuries in a motorcycle accident. The nerve lesion

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Fig. 2. - - a) Fracture of the middle third of the clavicle accompanying parasthesiae in the median nerve distribution and a weak radial pulse. A retroclavicular pulsating haematoma is diagnosed. There is general decrease in power and reflex responses of the upper limb. b) Arterio- graphy demonstrates pseudo-aneurysm (arrow) of the subclavio-axillary artery, c) The pseudo-aneurysm is resected (arrow). d) End-to-end repair of the artery (arrow) is performed. The plexus cords are liberated. A partial division of the lateral cord is discovered, e) Union of the clavicle following osteosynthesis.

Fig. 2. - - a) Fracture du tiers moyen de la clavicule provoquant des paresthesies dans le territoire du nerf median. Un hematome pulsatile retro-claviculaire a +te diagnostique, ac- compagne d'un affaiblissement du pouls radial. On constate une reduction globale de la force et des reflexes du membre superieur, b) L'arteriographie met en evidence un faux anevrysme (fleche) de I'artere sous-clavio-axillaire, c) Le faux anevrysme est reseque (fleche) Iors de I'intervention. d) Une suture directe de I'artere (fleche) est effectuee. Les troncs plexiques sont liberes. Une section partielle du tronc artero- externe est raise en evidence, e) Vue de I'osteosynthese de ta clavicule en cours de consolidation.

Fig. 2. - - a) Fractura del tercio medio de la clavicula que causa parestesias en el territorio del nervio mediano, Se dia- gnostic6 un hematoma pulsatil retroclavicular, acompan&do de una disminuci6n de la intensidad del pulso radial. Se cons- tato una disminucion global de la fuerza y de los reflejos del miembro superior, b) La arteriografia puso en evidencia un falso aneurisma (flecha) de la arteria subclavia, c) En falso aneurisma fue resecado (flecha) en el momento de la inter- vencion, d) Una sutura directa de la arteria (flecha) se realizo. Los troncos plexicos fueron liberados. Se puso en evidencia una seccion parcial del tronco antero externo, e) Imagen de la osteosintesis de la clavicula en via de consolidacion.

appeared benign from the outset and the markedly displaced fracture was not operated. Her plexus lesion healed completely in one year, except for a tendency to muscle fatigue noted at three years when the case was closed. Eight years post- t rauma she became pregnant and developed significant costo-clavicular syndrome with positive electrophysiological and angiographic findings. She is now 37 years old, in the course of her second pregnancy, with even worse symptoms and is scheduled for operative correction, probably resection of the first rib, soon after delivery. It is predominant ly her medial cord that is affected.

In all patients but one, where lesions involved the posterior cord as well as the ulnar nerve, disturbance was spread evenly over the three cords with a slight bias on the medial cord.



SURGERY

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Fig. 3. - - a) This fracture was pinned in emergency and did not unite. X-ray appearance of clavicle fourteen weeks after the accident at which time plate fixation was performed. b) Unfortunate development of pseudoarthrosis 6 months later. Progressive parasthesiae developed in the ulnar nerve a r e a followed by weakness of the hand. Symptoms worsened over two years, c) At three years the clavicle was fixed by bone graft and osteosynthesis toge- ther with neurolysis of the medial cord. The result was good.

Fig. 3. - - a) Cette fracture a ete brochee en urgence, et n'a pas consolide. Aspect radiographique de la fracture trois mois 1/2 apres I'accident Iors de I'osteosynthese par plaque semi-circulaire, b) Malheureusement, I'evolution s'est faite vers la pseudarthrose six mois plus tard. Des paresthesies sont apparues progressivement clans le territoire du nerf ulnaire, suivies d'une diminution de force de la main. La situation s'est lentement aggravee au cours des deux annees suivantes, c) A trois ans, une osteosynthese avec greffe os- seuse de la clavicule a ete effectuee, ainsi qu'une neurolyse du tronc ant6ro-interne, qui ont donne de bons resultats.

Fig. 3. - - a) Esta fractura fue embrochada en urgencias, y no ha consolidado. Aspecto radiografico de la fractura tres meses y medio despues del accidente con una osteosintesis mediante placa semicircular, b) Lastimosamente, la evolucion seis meses mas tarde fue de una seudoartrosis. Con apari- cion progresiva de parestesias en el territorio del nervio ulnar, seguidas de una disminucion de la fuerza de la mano. La situacion se agrav6 lentamente en el curso de los dos afios siguientes, c) A tres afios, se realizo una osteosintesis con injerto 6seo de la clavicula, asociada a una neurolisis del tronco antero interno, que dieron buenos resultados.

Fig. 4. - - Fracture of the middle third of the clavicle with an intermediate, small fragment. Non-union followed and osteosynthesis was performed at four months, b) Three years later hypertrophic callus and a bony spur (arrow) causing pain and general weakness of the upper limb. c) The plate is removed and the spur filed down. Exploration of the plexus reveals additional constriction by scalenus minimus.

Fig. 4. - - a) Fracture du tiers moyen de la clavicule avec petit fragment intermediaire. En I'absence de consolidation, une osteosynthese a ete pratiquee a 4 mois. b) Trois mois plus tard, on note un cal hypertrophique avec une saillie os- seuse (fleche) provoquant des douleurs et un affaiblissement global du membre superieur, c) La plaque a ete enlevee, et la saillie abrasee. L'exploration du plexus a mis en evidence un scalene accessoire qui comprimait egalement le plexus brachial.

Fig. 4. - - a) Fractura del tercio medio.de la clavicula con un pequefio fragmento intermediario. En ausencia de consolida- ci6n, se realizo una osteosintesis a los cuatro meses, b) Tres meses mas tarde, se nota un callo hipertr6fico con una prominencia Osea (flecha) que provocaba dolores y un debilita- miento global del miembro superior, c) La placa fue retirada, y la prominencia tambien. La exploracion del p!exo puso en evidencia un escaleno accesorio que comprim~a igualmente el plexo braquial.

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With regard to associated vascular disturbance, one case was noted to have the arterial and venous lesion described above. Another patient was noted to have post-stenotic arterial dilatation. Two patients, including the one with the sternoclavicular dislocation, developed thoracic outlet syndrome with a sympathetic neu- ralgic dystrophy probably related to obstruction of the subclavian vein. Another patient showed variable signs of venous congestion as well as progressive loss of nerve function.

In seven cases we proceeded to osteosynthesis of the clavicle. A plate was used in two patients who presented with complications before the clavicle had united. Consolidated malunion in three patients was reduced by osteotomy and fixation with a plate and bone graft. Five cases of pseudoarthrosis were managed by resection of fibrous tissue, bone grafting and fixation.

In all cases where a bone graft was employed, the limb was immobil ised for 4 weeks. In the other cases gentle movement was permit ted at 10 days. In three other cases the hypertrophic callus was resected but the malunion was delibe- rately not corrected and an osteotomy of the clavicle thus avoided (case 4, fig. 4).

In three of the above cases, including the one with sterno-clavicular dislocation, we proceeded to resection of the first rib since correction of the clavicular deformity did not sufficiently widen the costoclavicular passage. In two of the patients this procedure was performed at the t ime of resection of the hypertrophic scar.

The other case (case 7) had already had the clavicular fracture plated but presented a persistent costo-clavicular syndrome and first rib resection was performed at the t ime of removal of the plate. One patient (case 14), a psychotic, difficult to manage individual, carries a non- united, partially resorbed clavicle which we have abandoned. Six of the twelve operated patients underwent extensive neurolysis of the brachial plexus. The other six underwent only external liberation of the neurovascular bundle since there was simple displacement of the pedicle but no investment in scar.

The patient with a pseudo-aneurysm of the subclavian artery required segmental resection of the vessel with end-to-end anastomosis. The procedures described above were the main ones performed on our patients. In practice, these patients each underwent one to four operations with an average of two per person since the initial operation proved unsuccessful. On three occasions clavicular osteotomy alone did not correct the costo-clavicular syndrome. In two patients, subsequent first rib resection was required as well as resection of a bony spur at the

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t ime of removal of the fixation plate, in order to relieve persistent signs and symptoms of plexus irritation. In one patient (case 3, fig. 3), the fractured clavicle was pinned but resulted in non-union. Subsequent plating was, likewise, unsuccessful. Further osteosynthesis, including bone grafting, was required to achieve union. This still produced a hypertrophic callus which required first rib resection and neurolysis. The post-operative outcome has been graded in three categories :

- G o o d : the patient 's symptoms were im- proved

- Fair : the patient 's symptoms were un- changed

- Bad : the patient 's symptoms have worsened.

Our thirteen operated cases produced ten good, two fair and one poor results.

DISCUSSION

Fractures of the clavicle make up 5 to 10 % of all fractures [7J. They are benign and generally heal within 4 weeks of simple external re- straint. When the fracture is caused by direct violent t rauma the fragments may be comminu- ted and displaced. This scenario may result in malunion, refracture by subsequent, relatively minor trauma, deformation of the bone without apparent fracture, hypertrophic callus, non- u m o n or pseudoarthrosis [2]. Compound fractures may result in infection [4, 10, 16].

Neurological complications are rare and few articles have appeared recently on the subject. In a series of 193 fractures of the clavicle, Al- brecht [1] recorded two early transient lesions of the brachial plexus. In a series of 300 conse- cutive traumatic lesions of the brachial plexus, one author (Narakas) recorded a 15.7 % incidence of retro- or infraclavicular lesions but in only 4.3 % was there an associated fracture of the clavicle. In all these cases, the nerve lesion presented at the onset.

It is exceptional to encounter lesions of the plexus which manifest several days after the initial trauma. Yates [21 ] records two cases with early complications, one a pseudo-aneurysm of the subclavian artery manifesting as brachialgia and the other a pneumothorax. He reviewed the pathology in these two cases and pointed out that occult vascular lesions may manifest late as we have ourselves noted in one of our cases.

Moderate, direct pressure on the plexus by a segment of clavicle may also produce symptoms long after the injury even when the latter is severe. Case no I illustrates just such an instance.

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The middle portion of the fractured clavicle penetrated the posterior cord but a progressive palsy only started by the 5th day and was complete by the 15th.

Late compression of the brachial plexus has been described more frequently [4, 5, 8, 9, 11, 13, 14, 15, 16]. Miller [7] for one, describes 4 cases of retroclavicular plexus compression occurring late after the fracture as a result of malunion. Narrowing of the costo-clavicular space by hypertrophic callus causes irritation of the plexus [1, 3, 11, 17]. We have recorded this situation on six occasions.

Berkheiser [4] reviewed 9 cases of pseudoarthrosis of the clavicle recording 6 cases of associated lesions of the brachial plexus. In the presence of non-union, the lateral fragment usually displaces caudally [1, 4, 10, 15]. This was noted in four of our patients.

In a survey of world literature over the period 1960 to 1987, Bahnini and Kieffer [2] noted only 76 cases of thoracic outlet syndrome secondary to clavicular trauma. In 2/3rd of cases the subclavian artery and vein were involved as well as the brachial plexus. One third of patients presented nerve compression in isolation or in association with a vascular lesion. The vein was involved in half of the patients stu- died. The authors insist on the frequency of neurological disturbance.

Whatever the early or late complication, injury to the brachial plexus results in brachialgia and acroparasthesia, in difficulty with use of the limb and in fatigue. This occurred in all our patients. Devin [6] states that motor deficien- cies appear later than sensory ones and that they are less frequent. We observed the contrary in 7 cases out of 13. Berkheiser [4] noted that it was the medial cord that was most affected, re- suiting in partial or complete paralysis of the intrinsic hand muscles. This we confirmed in 9 of our patients. In addition, we recorded 5 cases of injury to the posterior cord.

The clinically diagnosed distribution and severity of the lesions were confirmed, in all cases, by electrodiagnosis. These limited brachial plexus lesions manifesting late must be distin- guished from the severe and massive retro- and infraclavicular stretch injuries caused by violent t rauma to the shoulder and neck possibly involving root avulsions. In such cases, motor and sensory loss is present from the onset [1, 11].

It must also be remembered that acute ischae- mia of the upper limb may simulate lesion of the brachial plexus (Natali [19]) producing both motor and sensory deficit.


FRACTURE OF THE CLAVICLE SURGERY

In early neurovascular complications, the majority of authors consider that priority must be given to stabilisation of the clavicle [1, 10, 11, 22, 24]. Other authors adopt a radical atti- tude, favouring immediate resection of the clavicle on the grounds that osteosynthesis of the fracture is likely to lead to an unacceptab!y hypertrophic callus which will lead to persistent thoraco-cervico-brachial compression. Al- though extreme, this stance should by no means be discounted.

Twice we have encountered a similar scenario. In one case it resulted from a previously twice operated pseudoarthrosis ; in the other it was due to hypertrophic callus following three operations on the clavicle. In the first case we repeated the osteosynthesis of the clavicle combined with corticocancellous bone graft ; in the second case we simply resected the callus. Both cases were successful since the clavicle was stabilised. This is a crucial part of the treatment. It has been neglected in several situations where, from the onset, there were difficulties with the fracture as well as symptoms suggestive of nerve injury. It must be noted that in two thirds of our cases the initial osteosynthesis was stable and was invariably followed by primary bony union without hypertrophic callus. Plates are our preferred method of bony fixation. Nails, K-wires and tension wiring carry the risk of secondary displacement and non-union, des- pite the reported experience of Zenni [24] and Ghormeley [10]. The only case in our series where wiring was the method of fixation, developed a pseudoarthrosis.

We are convinced that stable osteosynthesis is essential. This assertion is based on our experience of 32 cases of non-union or pseudoarthrosis of the clavicle as well as the 212 cases of osteotomy we have performed in the course of brachial plexus surgery.

Our experience of resection of the clavicle is limited to one patient with thoracic outlet syndrome who had already been subjected to seven (!) operative procedures. On the basis of this one case, we concede the contention of Howard [11], of Natali [19] and of Yates [23] that cleidectomy is indeed effective in liberating the costo-clavicular passage. The impairment in function of the shoulder and the poor aesthetic appearance are serious negative factors which cannot be disregarded. Resection of the first rib is certainly more hazardous, but is more elegant and certainly equally effective in liberating the costo-clavicular space. Although more difficult, there are non functional consequences.

Because the neurovascular subclavian and infraclavicular pedicle is invested in a variably constricting scar which worsens with time, one

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must consider exposure of the plexus and neurolysis in such cases [11, 13, 18]. We have performed fairly extensive neurolysis in six of our thirteen operated cases, either simultaneous with bone fixation or as a later procedure.

Howard [11 ] noted that vascular disturbance is associated with neurological disturbance in half of all cases while Bahnini and Cormier [2] noted this association in one third of published cases. We noted this in only one case out of three in our small series, possibly because we specialize in peripheral nerve surgery. When such a complication is recognised, emergency surgery is justified [1, 19, 22, 24]. Surgical intervention is also indicated when secondary aneurysm [13, 23] or arterial obstruction is diagnosed. We have encountered one such case and proceeded to a segmental resection of the artery and end-to-end anastomosis with a good result. We must extend a warning to surgeons mana- ging fractures of the clavicle. Because these fractures are benign and usually heal easily without sequelae, patients presenting late symptoms are likely not to be believed and are easily considered as malingerers or compensation seekers. This was the case in nine of our sixteen patients until objective signs could be elicited, in four cases quite late in the course of events, perhaps too late since symptoms persist in three cases after treatment.

Finally, it is remarkable that all our cases but one required operative intervention which further proves that fracture displacement exceeding 15 to 20 mm is likely to lead to significant symptoms.

CONCLUSION

Fracture of the clavicle is a frequent and benign lesion. Only exceptionally do vascular or nerve complications occur. This demands stabilisation of bone, repair of vessel damage and liberation of nerves. The outcome of such procedures is good.

Late complications such as a costo-clavicular syndrome caused by malunion, hypertrophic callus or pseudoarthrosis are rare, probably not exceeding an incidence of a few percent. The condition progresses slowly and must be viewed as a dual problem involving both the clavicle and the nerves. Early, adequate corrective measures addressing both aspects will be rewarding. Cases tackled late are less likely to yield a good outcome.

The plexus lesion is frequently long standing since it is commonly neglected initially. Prolon- ged compression leads to intrafascicular fibro- sis. Minor symptoms are prone to dismissal by

the physician and as a result are fixed in the patient's ailment spectrum and will be subjected to somatic conversion. In such cases, the patient focuses disproportionately on his lesion however benign. Given this situation, no surgery can be fully successful. It seems important, therefore, to recognise the problem early and to treat it adequately.

REFERENCES

1. ALBRECHT H.U., BAMERT P. - - Die Klavicularfractur : Therapie und Komplikationen. Helv chir Acta, 1981, 48, 571-583.

2. BAHNINI A., KIEFFER E. - - Pathologic de la clavicule et syndromes de la traversde thoraco-brachiale. In : K I E F F E R E. - - Les syndromes de la traversOe thoraco-brachiale. AERCV, Paris, 1989, 93-102.

3. BARGAR W.L., MARCUS R.E., IFFLEMAN F.P. - - Late thoracic outlet syndrome secondary to pseudarthrosis of the clavicle. J Trauma, 1984, 24, 857-859.

4. BERKEISER E.J, - - Old ununited clavicular fractures in the adult. Surg Gynecol Obstet, 1939, 64, 1064-1072.

5. D A S H U.N., H A N D L E R D. - - A case of compression of sub- c lav ian vessels by a fractured clavicle treated by excision of the first rib. J Bone Joint Surg, 1960, 42A, 798-801.

6. D E V I N R., K A S B A R I A N M., B R A N C H E R E A U A. - - Patho- logic des syndromes de compression du d6fi16 costo-claviculaire. Encycl MOd Chir Cwur, 9-1977, 11322 A-10.

7. D U G D A L E T.W., F U L K E R S O N J.P. - - Pneumotho rax com- p l ica t ing a closed fracture of the clavicle. Clin Orthop, 1987, 221, 212-214.

8. E N K E R S S., M U R P H Y K.K. - - Brachial plexus compression by excessive callus formation secondary to a fractured clavicle. Mt SinaiJ Med, 1970, 37, 67-68.

9. G A N G A H A R O.M., F L O G A I T E S T. - - Ret ros te rna l dislocation of the clavicle producing thoracic outlet syndrome. J Trauma, 1978, 18, 369-372.

10. G H O R M E L E Y R., B L A C K J.R. - - U n u n i t e d fractures of the clavicle. Am J Surg, 1941, LI, 343-349.

11. H O W A R D F.M., SHAFER S.J. - - In jur ies to the clavicle with neurovascular complications. A study of fourteen cases. J Bone Joint Surg, 1965, 47A, 1335-1346.

12. J U P I T E R J.B., LEFFERT R.O. - - Non-union of the clavicle. J Bone Joint Surg, 1987, 69A, 753-760.

13. L A U R I A N C., C O R M I E R J.M. - - Complications art6rielles tardives de fractures de la clavicule/1 propos de 4 observations. J Traumatol, 1980, 1, 49-53.

14. M A R T I N E Z N.S. - - Traumatic thoracic outlet syndrome. In : P O L L A K E.W. - - Thoracic outlet syndrome. New York, Fu- tura, 1986, 125-134.

15. M E L L I E R E D., E S C O U R R O U J., B E C Q U E M I N J.P., D A N I S R.K. - - Isch6mies aigu~s des membres : complications tardives de cals hypertrophiques et de la pseudarthrose. J Chir, 1981, 118, 641-645.

16. M I L L E R D.S., B O S W I C H J.A. - - Lesions of the brachial plexus associated with fractures of the clavicule. Clin Orthop, 1969, 64, I44-149.

17. M U L D E R D.S., G R E E N W O O D F.A.H., BROOKS C.E. - - Post-traumatic thoracic outlet syndromes. J Trauma, 1973, 13, 706-715.

18. N A R A K A S A., B O N N A R D C., E G L O F F D.V. - - The cervico- thorac ic compression syndrome. Analysis of surgical treatment. Ann ChirMain, 1986,5 , 195-207.

19. N A T A L I J. et coll. - - Fractures of the clavicle and injuries of the subclavian artery. Report of 10 cases. J Cardio-vasc Surg, 1975, 15, 541-547.

20. SAKELLARIDES H. - - Pseudarthrosis of the clavicle, A report of twenty cases. JBoneJoint Surg, 1961, 43A, 130-138.

21. SAVASTANO A.A., S T U T Z S.J. - - Traumatic sterno-clavicular dislocation. Int Surg, 1978, 63, 10-13.

22. S O M M E L E T J,, RERY A., COUDANE H. - - Traumatismes de la ceinture scapulaire. Encycl Mdd-Chir, 1986, Appareil moteur, 14035A 10, 11, 9 p.

23. YATES D.W. - - Complications of the fractures of the clavicle. Injury, 1976, 7, 189-193.

24. Z E N N I E.J., K R I E G J.K., R O S E N M.J. - - Open reduction and internal fixation of clavicular fractures. JBoneJoint Surg, 1981, 63A, 147-151.



SURGERY

D E L L A S A N T A A., N A R A K A S A.O. , B O N N A R D C. - - L 6 s i o n s t a r d i v e s d u p l e x u s b r a c h i a l apr~s f r a c t u r e de la cla- v icule . A n n H a n d Surg , 1991, 10, n ° 6, 531-540 .

D E L L A S A N T A D. , N A R A K A S A.O. , B O N N A R D C. L e s i o n e s t a r d i v a s del p l exo b r a q u i a l d e s p u e s de f r ac tu r a de c lav icu la . A n n H a n d Surg , 1991, 10, n ° 6, 531 -540 .

RI~SUMI~ • En de rares circonstances, une fracture fortement d6plac6e de Ia clavicule peut pro- duire une 16sion des vaisseaux sous-claviers et du plexus brachial qui apparalt progressivement apr~s plusieurs jours ou semaines. En outre, un syndrome de compression costo-claviculaire peut s'installer tardivement, provoqu6 par une cicatrice r6tractile entourant le p6dicule vasculo-nerveux, par un an6vrysme secondaire, par un cal hypertrophique. Les auteurs 6tudient 16 cas du genre, 13 6tant op6r6s, 2 6tant sur la liste d 'at tente alors qu 'une patiente a 6t6 trait6e conservativement. Ces 16 cas repr6sentent peine plus de 1% de 16sions du plexus brachial vues en 20 ans dans nos deux centres chirurgi- caux. Le t rai tement op6ratoire corrigeant la clavicule, r6s6quant 6ventuellement la premiere c6te et lib6rant le plexus avec ou sans correction vasculaire, donne en g6n6ral un bon r6sultat.

RESUMEN : En raras ocasiones, una fractura desplazada de la clavicula puede producir una lesi6n de los vasos sub-claviculares y tambi6n del plexo braquial que aparece de una manera progressiva, dfas o meses despu6s. Un sindrome de compressi6n costo-clavicular se manifiesta, o bien provocado por une cicatriz retractil ro- deando el pedlculo vasculo-nervoso, o bien por la presencia de un cal hypertr6fico puede producir el mismo tipo de sindrome. Los autores del presente articulo han estudiado 16 casos, de los cuales, 13 habian sido operados : 2 pacientes formaban parte de la lista en espera de interven- ci6n, una fue tratada con terapia conservadora, no quirtirgica. Estos 16 casos representan poco m~is del 1% de las lesiones del plexo braquial examinadas en estos filtimos veinte afios en dos centros quirfirgicos. E1 t ratamiento quirfirgico con correcci6n de la clavicula y resecci6n en ocasiones de la primera costilla con liberaci6n del plexo (con o sin correcci6n vascular) da en general un buen resultado.

M O T S - C L I ~ S : F r a c t u r e de la c lavicule . - - P l e x u s b rach ia l . - - V a i s s e a u x sous -c l av i e r s . - - C o m p r e s s i o n n e u r o - v a s c u - la i re cos to -c l av icu la i r e . - - S y n d r o m e de la t r a v e r s 6 e t ho - r a c o - c e r v i c o - b r a c h i a l e .

P A L A B R A S C L A V E : F r a c t u r a de la c lav icu la . - - P l ex o b raqu ia l . - - V a s o s sub -c l av i cu la re s . - - C o m p r e s s i 6 n n e u r o - v a s c u l a r . - - S i n d r o m e de la t r a v e s i a t o r aco -ce rv i co - b r aqu i a l .

• • •

ERRATUM

Concerning <~ The Rheumatoid Elbow : Patterns of Joint involvement and the Outcome of Synoviorthesis ~ by C. GREGOIR and C.J. MENKES (Ann Hand Surg, 1991, 10, n ° 3, 243-246), the last six references were omit- ted : ~ ...

7. LAINE V., VAINIO K. - - Elbow rheumatoid arthritis. In : HIJMANS W.D., PAUL W.D., HERSCHEL H. - - Early Syno- vectomy in Rheumatoid arthritis. Exeerpta Medica, Amsterdam, 1969, 19. 112.

8. MENKES C.J. - - Is there a place for chemical and radiation synovectomy in rheumatic diseases ?. Rheumalol Rehabil, 1979, 3, 65-77.

9. MENKES C.J. - - La synoviorth~se m6dicale. In : SIMON L., HERISSON C, - - Polyarthrite rhumatofde : traitements locaux et r~adaptation. Paris, Masson, 1986, 19. 55.

10. PORTER B.B., RICHARDSON C., VAINIO K. - - Rheuma- toid arthritis of the elbow : the results of synoveetomy. J Bone Joint Surg, 1974, 56B, 427-437.

11. R O U X H., NAIM C., ALBERTI J. et coll. - - A p r o p o s des synoviorth~ses isotopiques pr6coces au cours de la polyarthrite rhumatoi'de. Rev Rhum, 1976, 43, 327-332.

12. SANY J., BATAILLE R., ROSENBERG F., KALFA G., SERRE H . - - Le coude rhumatoYde : aspects symptomatiques. In : SIMON L. - - Coude et mkdecine de r~kducation. Paris, Masson, 1979.

late lesions of the brachial plexus after fracture of the clavicle

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