j: max.-fac. Surg. 14 (1986) 2 8 1

J. max.-fac. Surg. 14 (1986) 281-284 © Georg Thieme Verlag Stuttgart - New York

Stress Fracture of the Clavicle A Rare Late Complication of Radical Neck Dissection Robert A. Ord, John D. Langdon

Department of Oral and Maxillo Facial Surgery (Head: Prof. J. H. Sowray), King's College School of Medicine and Dentistry, London, Great Britain

Submitted 3 .9 . 1985; accepted 6 .11 . 1985

Summary

Stress fracture is a rarely reported late complication of radical neck dissection. The condition should be re- cognised as its clinical and radiological differentiation from avascular necrosis or bony metastasis may be difficult.

Key-Words

Radical neck dissection - Complications - Stress frac- ture clavicle

Introduction

Conventional radical neck dissection as described by Crile in 1906 involves sacrifice of the accessory nerve with its associated lymph node chain. More recently a functional neck dissection, which preserves the accessory nerve has been advocated for certain head and neck tumours in defined circumstances in the neck (Bocca, 1966). The advantage claimed for preservation of the accessory nerve and thus trapezius function is the possible prevention of the shoulder pain/disability syndrome described by Nahum et al. (1961), Haas and SolIberg (1962), and Pfeifle and Koch (1973). However, despite sacrifice of the accessory nerve the trape- zius muscle was noted to retain normal function following radical neck dissection in some patients as early as 1952 (Ewing and Martin). The reason for this clinical finding is the dual innervation of the trapezius muscle. The upper half is innervated by the spinal accessory and the lower half by the third and fourth cervical nerves (Szunyogh, 1959). Studies by Weitz et al. (1982) and Stell and Jones (1983) have shown that it is possible to preserve C3 and C4 branches to the trapezius during a radical neck dissection, and minimise post-operative dysfunction. Short et al. (1984) compared shoulder pain and function after neck dissection with or without preservation of the spinal accessory nerve, and found significantly less pain and functional disability where the accessory nerve was preserv- ed. However, 26 % of their patients with preserved acces- sory nerves had moderate to severe pain in their shoulders and 9 % had high scores in their disability rating. Short et al. (1984) also drew attention to the increased performance disability in both the preserved and sacrificed nerve groups when neck dissection was carried out on the side of the dominant hand. Although much attention has been focused on the shoulder pain/disability syndrome much less has been paid to the unusual problem of shoulder pain and disability associated with sternoclavicular joint dislocation and enlargement leading to fracture of the clavicle, following sacrifice of the accessory nerve. A case report and review of this condition is described.

with an ulcer in the floor of his mouth. The patient had first noted a small lump one year previously, his denture had become looser over the last six months, and in the last four weeks the lesion had ulcerated and become larger. The relevant medical history was of intermittent claudica- tion in the right leg for three years, and a past history of hypertension for which he received no treatment. He had stopped smoking 21/2 years ago, previously smoking 11/2 oz. of tobacco a day. Examination revealed a 3 cm ulcer with rolled raised edges and an indurated base involving the edentulous alveolar ridge and floor of mouth in 41-33 region. There was no cervical lymphadenopathy. An orthopantomogram showed some resorption of the alveolus. Full blood count, blood urea, electrolyte, liver function tests and chest x-ray were all normal. Biopsy confirmed the lesion as a well differentiated squamous cell carcinoma. The patient was admitted to the hospital in March, 1981, and a rim resection of the anterior mandible with removal of the floor of mouth and lesion carried out. The sectioned sub-mandibular ducts were replanted in the 47, 37 region, and a quilted split skin graft placed. Post-operatively the patient made a good recovery although the split skin graft sloughed. The histology report showed the margins to be clear but close to tumour in one area. In April, 1981, the patient was readmitted and on 10th April, the region where the tumour had been reported close to the margins was excised and the defect where the graft had sloughed reconstructed with naso-labial flaps. In November, 1981, a sulcoplasty with split skin graft was carried out to allow the patient to wear a prosthesis. The patient was followed up regularly without problems until May, 1984, three years after his original operation, when a firm 1.5 cm × 1 cm jugulo-digastric node was detected on the right side. This node persisted and he was admitted three weeks later and underwent right radical neck dissection on 1st June, 1984. Histology of the speci- men revealed no metastatic disease. Two months after his operation he complained of right shoulder pain for which he had been prescribed Piroxican by his medical practitioner. He had an obvious shoulder droop (Fig. 1) with wasting of the trapezius with an enlarg- ed sterno-clavicular joint. He was referred for physiothe- rapy but continued to complain of pain and swelling of the sterno-clavicular joint.

282 J. max.-fac. Surg. 14 (1986) R.A. Ord, J. D. Langdon

Fig. 1 Photograph taken in August, 1984, two months following a radical right neck dissection, A marked shoulder droop is evident.

Fig. 2 Photograph taken in November, 1984, five months post- operatively showing enlargement of the right sterno-clavicular joint.

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Fig. 3 Part of a pre-operative chest radiograph showing a normal sterno-clavicular joint.

Fig. 4 Part of a chest radiograph taken in November, 1984 showing anterior dislocation and destruction of the sterno-clavicular joint.

In Novernber, five months after his operation, he complain- ed of increasing pain extending from his right scapula to the right sterno-ctavicular joint, and difficulty in lifting his right arm which he had to support with his left arm. Examina- tion revealed him to have marked wasting of his deltoids and trapezius and a bony hard fusiform swelling 8 x 6 cm in the region of the right sterno-clavicular joint (Fig. 2). His abduction was limited to 80 ° . Radiographs taken at this time were reported as showing a destructive lesion in the head of the right clavicle with much sclerosis and overlying soft tissue swelling (Fig. 3, 4). This was thought to be more typical of an avascular necrosis than a metastatic deposit. Because of the patient's increasing pain and uncertainty of diagnosis he was admitted on the 9th November for exci-

sion of the sterno-clavicular joint. An incision was made along the medial aspect of the clavicle which was exposed by a sub-periosteal dissection. The body of clavicle was sectioned with a gigli saw and the sterno-clavicular joint capsule incised to free the clavicular head. Surgical findings were of an expanded mass of soft necrotic bone and carti- lage with a pathological fracture. The expanded head of clavicle extended down into the mediastinum (Fig. 5), and was removed. The wound was drained and closed. Post- operatively the patient developed a haematoma which required drainage under a local anaesthetic two weeks post- operatively. Initially the patient still had marked pain and restricted movements, but by 14th December, 1984, movement and

Stress Fracture o f the Clavicle J. max.-fac. Surg. 14 (1986) 2 8 3

Fig. 5 Operative photograph taken during the excision of the sterno-clavicular joint in November, 1984.

pain was improving. By February, 1985, the patient had good pain free function and reported that he had been able to paint a ceiling with only mild discomfort. The pathology report confirmed a diagnosis of avascular necrosis with gross destruction and fibrosis of the sterno- clavicular joint. There was no evidence of metastatic bone disease.

Discussion and Conclusions

The syndrome of sterno-clavicular joint enlargement fol- lowing neck dissection is rarely reported in the literature. The subsequent progression from enlargement to fracture is even less well documented. In 1954 Temesvari and Vandor described three cases of hypertrophy of the medial end of the clavicle. They postulated that avascular necrosis due to poor blood supply following resection of the sterno-cleido- mastoid muscle, division of the accessory nerve, or abnor- mal stresses on the clavicle may be involved in the aetiology. Pfeifle et al. (1974) described three cases, and Lamb (1976) four Cases, one of which was bilateral. Neither of the above authors subscribe to the view that avascular necrosis due to muscle stripping is important. Stripping of the sterno- cleidomastoid muscle alone is unlikely to cause avascular necrosis, as the clavicle receives a nutrient artery from the suprascapular artery. However, the suprascapular artery lies in front of the prevertebral fascia anterior to the phrenic nerve and could be ligated in the lower part of a neck dissection. Whether a combination of radiotherapy and muscle stripping will lead to avascular necrosis is debatable. In six out of the seven cases, reported above, and our case no radiotherapy was given. Also Short et al. (1984) found that patients receiving whole neck radiation without neck dissection had little pain, and insignificant functional dis- ability. It appears more probable that a combination of altered muscle balance due to trapezius denervation and flexural stresses on the clavicle are important in causing the clavicu- lar dislocation. The lack of trapezius action causes shoulder droop, and the weight of the unsupported arm allows

anterior subluxation or luxation of the clavicular head through the stretched sterno-clavicular joint capsule. Under continued stress Lamb (1976) postulates that peri-articu/ar fibrosis occurs, followed by bone remodelling, osteophyte formation and synovial proliferation. Fracture of the cla- vicle is more unusual, but probably represents a progression of the factors causing subluxation and enlargement of the clavicular head. PfeilCle et al. (1974) laid emphasis on the mechanical strains exerted on the clavicle following its anterior subluxation. In all three of their cases they described dense subcutaneous cicatricial cords, inserting via bony exostoses into the clavicle. They felt the cicatricial cords offered a stabilising effect on the clavicle against the muscle imbalance due to loss of trapezius action. Clavicular stress fractures were said to occur due to a disproportion in overload of the clavicle and the stabilising effects of the cords. Radiotherapy may play a role in clavicular fracture as Schramm and Myers (1981) reported two cases, and Cummings and First (1975) one case of stress fracture of the clavicle following neck dissection plus radiotherapy. Finally Lamb (1976) adds an alternative neurogenic theory which may play a part in the gross destruction of the clavicular head. He suggests that the supraclavicular nerves C3 and C4 may be cut in radical neck dissection removing the sensory supply to the sterno-clavicular joint. Repetitive injury could then lead to joint disorganisation and destruc- tion as occurs in the Charcot's joints of tertiary syphilis. The clinical and radiological appearances of the swollen clavicle may be diagnosed as radiation necrosis, inflammat- ory joint disease or a metastatic lesion. Indeed surgical excision of the medial third of the clavicle was carried out in this case to exclude metastasis. However, if the condition is recognised the management is conservative, with analgesics and physiotherapy. It is surprising that the condition is not more frequently reported if muscle imbalance which occurs after all radical neck dissections is the primary initiating factor. Dominant handness or excessive use of the arm post-neck dissection have not been shown to play a significant role. It may be that the reported cases are just the florid manifestations of lesser bony changes that occur more often in the sterno- clavicular joint due to varying degrees of functional disabil- ity. Support for this theory comes from Pfeifle and Koch (1973) who found cicatricial cords inserted into clavicular exostoses in 20 % of their postoperative patients. Interest- ingly Schuller et al. (1983) in a review of 243 patients found no difference in return to work postoperatively between patients having the accessory nerve sacrificed and those having the accessory nerve preserved during neck dissec- tion. This would support the contention that functional changes are only rarely significant enough to cause clinical problems.

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John D. Langdon Dept. of Oral and Maxillo-Facial Surgery King's College School of Medicine and Dentistry Denmark Hill GB-London SE5 8RX