268 Injury, 9, 268--270 Printedin Great Britain

Non-union of fractures of the clavicle J. B. Pyper Belfast City Hospital

Summary Three cases of non-union of the clavicle were success- fully treated by compression fixation using AO semitubular plates.

INTRODUCTION NON-UNION of the clavicle is rare (Weber and Cech, 1976), with an incidence of only 0.9 per cent according to Taylor (1969). Considering the obvious mechanical inefficiency of traditional methods of treating fresh fractures of the clavicle, it is perhaps surprising that non-union is not more common, but, when it does occur, it is regarded as very difficult to deal with. Of the various different treatments advocated, one of the most frequently recommended (Watson-Jones, 1955; Taylor, 1969; Marsh and Hazarian, 1970) involves the use of intramedullary wires, pins or rods, but the shape of the clavicle makes the insertion of such devices technically difficult and the outcome is by no means universally success- ful. It has been widely recommended that such intramedullary inserts be supplemented by onlay bone grafting and by external fixation as well. Indeed, to quote Watson-Jones (1955),'whichever technique is used the complete support of a shoulder spica for 2 or 3 months is essential'.

Many workers have subsequently produced evidence that in the treatment of non-union of various fractures the use of bone grafts and external fixation is not essential, and the history of this work is admirably summarized by Hicks (1977), who reported the successful treatment of 17 cases of non-union by rigid fixation alone. This series did not include any cases of clavicular fracture, but Thompson and Batten (1977) described more cases of non-union treated by AO methods, including two cases of pseud- arthrosis of the clavicle. The largest series of

cases of non-union of the clavicle treated by AO methods is that reported by Weber and Cech (1976), who report 18 cases.

The purpose of the present paper is to describe three more cases similarly treated.

Case 1 A boy of 16 was reported by his mother to have had 'about eighteen fractures' of his left clavicle--the first when he was a year-and-a-half old. Complete verifi- cation of this was not possible from the patient's records, which were incomplete, but although several true fractures may have occurred, it seems likely that many of the incidents referred to were no more than episodes of pain resulting from trauma at the site of a pre-existing non-union. (Equally, it is unlikely that the condition was an example of congenital pseud- arthrosis since it appears that this condition affects only the right clavicle.) In any event X-ray examina- tion (Fig. 1) showed an obviously long-established pseudarthrosis (at least 5 years according to available X-rays) of the left clavicle. Operation consisted of compression fixation with an AO semitubular plate and 4 screws (Fig. 2) and in 10 weeks the patient had an almost full range of practically painless shoulder movement. The plate was removed 1 year after insertion (Fig. 3).

Case 2 A man aged 24 had been struck on the right clavicle with a revolver. The resulting fracture was treated by a figure-of-eight bandage for 6 weeks. When seen 2 years later, he was still complaining of pain, and X-rays (Fig. 4) showed non-union. At operation the small inferior fragment was removed and the infero- lateral corner of the main medial fragment was trimmed to allow firm coaptation of the upper two- thirds of the main fragments in good alignment and without loss of length. This position was then main- tained with a semitubular compression plate. The preliminary excision of bone left a small triangular defect inferiorly and this was filled with a very small amount of iliac cancellous bone. This was probably

Pyper : Non-un ion of Fractured Clavicle 269

Fig. 1. Case 1. Non-union of the left clavicle of at Fig. 2. Case 1. Appearance immediately after opera- least 5 years' duration, tion.

Fig. 3. Case 1. Final result one year after operation. Fig. 4. Case 2. Non-union of the right clavicle 2 years after injury.

Fig. 5. Case 2. Appearance immediately after opera- Fig. 6. Case 2. Appearance 6 months after operation. tion.

superfluous as two-thirds of the bone's diameter was in apposition, and completely rigid fixation had been achieved before this small amount of bone was added (Fig. 5). Following operation, only a short period of immobilization in a sling was necessary and within approximately 2 months the patient had a full range of movement. X-ray examination at 6 months (Fig. 6) showed consolidation. Union had undoubtedly

occurred long before this though no satisfactory X-ray films had been obtained in the interim.

Case 3 A woman of 31 was seen 3�89 months after sustaining a fracture of the left clavicle with non-union in spite of 'almost continuous immobilization' since the time of injury (Fig. 7). Operat ionwas by semitubular plate

270 Injury: the British Journal of Accident Surgery Vol. 9/No. 4

Fig. 7. Case 3. The left clavicle immediately before Fig. 8. Case 3. Appearance 1 month after operation. operation.

fixation without any bone grafting or external fixation (apart from a few days in a sling). Within 2 weeks she could actively elevate the arm at the shoulder. X-ray examination after 1 month suggested solid union (Fig. 8) and active movements of the shoulder were full except for a slight loss of rotation.

All 3 patients had previously been given a rather guarded prognosis, being warned that operation would probably involve bone grafting, would require up to 3 months in a plaster shoulder cast and might well, in the end, not be successful. The third patient was in fact referred to the author when about to undergo a bone grafting operation and was already wearing the ' thoraco' part of a thoracobrachial plaster which was to be completed at the conclusion of the operation. Needless to say, she was delighted to have this encumbrance removed instead of having it extended to include her arm, and to find that she did not have an additional wound over the iliac crest.

CONCLUSION Three cases are described which support the view that external fixation is unnecessary in treating non-union of the clavicle. In 2 of these cases bone grafting was not used and in the third, although a little cancellous bone was used to fill a partial gap between the bone ends, this was probably not a major factor in securing union.

It is advocated that non-union of the clavicle be treated by compression plating without

external fixation rather than by previously recommended methods involving intramedullary pinning, bone grafting and prolonged immobiliza- tion in a cumbersome plaster.

Acknowledgements It is not the easiest thing to describe in detail to a patient the operation that you propose to carry out and then, later, tell her that you have agreed to another surgeon doing something quite different. It is a pleasure to record my indebtedness to Mr J. H. Lowry for so generously doing just this in the case of the third patient in this series. I would also like to thank Mr T. Welsh for the care taken in the preparation of the illustrations.

REFERENCES Hicks J. H. (1977) Rigid fixation as a treatment for

hypertrophic non-union. Injury 8, 199. Marsh H. O. and Hazarian E. (1970) Pseudarthrosis

of the clavicle. J. Bone Joint SurE. 52B, 793. Taylor A. R. (1969) Non-union of fractures of the

clavicle: a review of thirty-one cases. 2. Bone Joint SurE. 51B, 568.

Thompson A. G. and Batten R. L. (1977) The appli- cation of rigid internal fixation to the treatment of non-union and delayed union using the AO tech- nique. Injury 8, 188.

Watson-Jones R. (1955) Fractures and Joint Injuries. Edinburgh, Livingstone, vol. 2, p. 462.

Weber B. G. and Cech O. (1976) Pseudarthrosis. Berne, Huber, p. 104.

Requests for reprints should be addressed to: Mr J. B. Pyper, Musgrave Park Hospital, Stockman's Lane, Belfast, BT9 7JB.