Orthopaedics and Traumato logy

I (1992). 2-7 (No. I), 7© Urban & Vogel, Munich

Surgical Treatment of Non-unions of the Clavicle

Martin Hansis, Siegfried Weller, Christian H. Siebert

Hospital for Trauma Surgery, University of Bonn, and

Berufsgenossenschaftliche Unfallklinik Tfibingen, Germany

Surgical P~nciples A non-union of the clavicle can develop following a fracture, which is conservatively treated with in- sufficient reduction or inadequate immobilisation, as well as after an open reduction and internal fixation in cases with severe soft tissue injury or with poor osseous stabilization. Dynamic compression plating of a non-union of the clavicle provides the mechanical stability required for bone healing; in cases of atrophic non-union or pseudarthrosis with loss of bone, the procedure is supple- mented with an autogenous cancellous bone graft, whereas those with associated shortening are treated with the interposition of a cortico-cancellous block. The (rare) post-traumatic thoracic outlet syndrome can frequently be treated successfully through a stable internal fixation of the pseudarthrosis.

Indications

Hypertrophic and atrophic non-unions of the clavicle, especially when associated with pain, re- duction in strength, loading instability or neurologic symptoms such as peripheral paraesthesia and/or re- striction of the blood supply.

Contraindications

Poor general health.

Advanced age.

Poor soft tissue conditions (such as scar tissue with osteolysis following radiation).

Patient Information

Delayed union and recurrent non-union or pseud- arthrosis (especially when shortening occurred and a block interposition is planned).

Cosmetically unpleasing scars/keloid scar tissue.

First published in: Operat. Orthop. Traumatol. 1 (1989), 139-144 (German Edition).

Symptoms caused by the implants (especially in the presence of atrophic, previously treated skin con- ditions).

Removal of bone graft from the iliac crest.

Paraesthesias following removal of bone graft in the distribution of the lateral cutaneous nerve of the thigh.

Plexus lesions.

Injuries of the subclavian vessels.

Pre-operative Work-up

If indicated neurologic and vascular examinations, using nerve conduction test and Doppler sonography.

Surgical Instruments

- 6 / 7 and 8 hole dynamic (3.5 mm).

- 3.5 mm cortical screws. - 2.5 mm drillbit with guide.

compression plates

Mart in Hansis . Siegfried Wefler . Chris t ian 14 Sicbert : Surgical T rea tmen t ot Non-unions of the Clavicle

Or~hop. T r a u m a t o l 1 ( b)92}, 2 - 7 {No. I )

- 3.5 mm thread tapper. - Bone clamps. - Distractor. - Various chisels such as the Lexer chisel

(decort icat ion) , V-chisel and saw (bone removal) .

P o s i t i o n i n g a n d A n a e s t h e s i a

- The patient is placed supine with slightly elevated upper body; a fiat cushion is placed under the in- volved shoulder.

- The patient 's head is ro ta ted and tilted to the op- posite side.

- Free draping of the arm. The operat ive field encompasses an area medial to the sterno- clavicular joint , lateral to the shoulder, superior and inferior a hand breadth above and below the clavicle respectively.

- Sterile draping of the ipsilateral iliac crest.

Surgical Technique Fig. 1 to 6

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Fig. 1 Sagittat incision (suspender incision) over the non- union. The skin incision extends over the clavicle superiorly and inferiorly by three finger breadths in both directions and is approximately 12 to 15 cm long. The subcutaneous tissue is in- cised in the same direction.

Fig.2 Exposure of the bone in anterosuperior direction. The soft tissues are split along the axis of the clavicle. To protect the soft tissue structures, the wound is only retracted medially or laterally.

Martin Hansis. Siegfried Weller, Christian H. Siebert: Surgical Treatment of N~,m-unions of the Clavicle

Orthop. Traumato l 1 (1992), 2 7 (No. 1)

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Fig. 3 In case of a hypertrophic non-union, decortication of the site with a curved chisel is carried out; the soft tissues are re- leased with their bony insertions attached. The decortication amounts to two thirds of the clavicular circumference anteriorly and posteriorly, as seen from the superior aspect.

Fig. 4 In case of an atrophic non-union, limited exposure of the ends of the fragments with the help of a small, sharp periosteal elevator. Callus and fibrous tissue should (as far as possible) re- main attached to the bone. Distraction of the two ends of the clavicle is carried out with two bone clamps or a distractor. Re- storation to the proper length is required. Determinat ion of the length of the bone block to be interposed. During the release of the bone from the surrounding tissue, care must be taken not to injure the brachial plexus. In patients pre- senting neurologic deficits (paraesthesias) that may be caused by local irritation (for example by callus) of the brachial plexus, a neurolysis must be carried out.

Fig. 5 Contouring of a 3.5 mm compression plate (here a seven hole plate). This plate can be contoured in all three planes. The compression plate should be fitted to the superior or anterosuperior surface. Fixation of the plate with two screws in the fragment which is more difficult to approach. Application of compression device on the opposite end. Compression.

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Orthop. Traumatol. I (1992). 2 - 7 (No. 1)

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Fig. 6 Completion of the internal fixation (medially and laterally a minimum of three screws). In presence of an atrophic non-union supplementation with cortico-cancellous bone grafts (taken from the inner iliac crest with the help of a chisel). Suction drain, subcutaneous sutures, atraumatic skin closure with interrupted sutures or a continuous intracutaneous suture.

Specific Problems

Fig. 7 and 8

Fig.7 Pseudarthroses with loss of bone require the use of a cortico-cancellous graft of predetermined length harvested from the iliac crest. The thickness of the iliac crest is generally similar to that of the clavicle. Wedging into the defect.

Fig.8 Clavicular non-unions in the lateral fourth are stabilized with the help of tension band wiring. Depending on the location of the non-union and the bone quality of the lateral fragment, the temporary inclusion of the acromioclavicular joint in the osteosynthesis may be required (see postoperative man- agement).

Martin Hartsi.s. Siegfried Wetler. Christian H Siebert: Surgical Treatment of Non-unions of the Clavicle

Orthop. Traumatol. 1 (1992), 2 - 7 (No. 1 )

Postoperative Management

Support of the arm in abduction (large pillow) and physical therapy starting the first postoperative day.

In cases of questionable stability (marked osteo- porosis, large cortical bone interposition) and/or in instances with transfixation of the acromioclavicular joint, a Desault bandage should be used for the first two postoperative days followed by a Gilchrist bandage for another two weeks. This bandage permits a limited range of motion while eliminating the forces of gravity.

Abduction and forward flexion are only permitted up to the horizontal level. Unlimited range of motion (above the horizontal plane) is allowed after bony consolidation and removal of the acromio- clavicular fixation (after approximately eight weeks).

Intra- and Post-operative Complications

Intraoperative: Insufficient stability obtained with the compression plate may require the use of a markedly longer plate (splinting effect) or the in- clusion of the acromioclavicular joint in the pro- cedure (see Figure 8).

The injury of the subclavian artery or vein re- quires primary surgical repair (occasionally with interpositional grafts, depending on the type of injury), while injury of the brachial plexus may require primary fascicle sutures.

Postoperative: Skin slough of the incision over the clavicle: Small areas heal spontaneously follow- ing (early) implant removal; larger defects must be covered with a local flap.

Loosening of the implant: Occasionally such loosening can be "caught" with proper, tempo- rary immobilization. Frequently a repeat pro- cedure with the use of a longer compression plate (splinting effect) and less soft tissue trauma- tization will be required.

Errors and Potential Hazards

The reported sagittal skin incision has cosmetic advantages over the longitudinal approach. One must be sure to use the appropriate incision length.

Retractors may only be applied at one side of the wound at a time to avoid pressure necrosis of the skin.

Errors in plate positioning: The anterior position of the plate leads to a higher rate of wound com- plications and pressure necrosis than the superior position. The intraoperative exposure (especially of the medial clavicle) may be limited. Careful posi- tioning of the patient is therefore imperative (see above).

Choice of wrong plate length: Fewer than three screws in each fragment usually do not provide adequate stabilization. Seven hole or eight hole compression plates are preferred to avoid the use of holes in the immediate vicinity of the non-union. Only very large interpositioned bone blocks are se- cured with separate screws.

Instead of soft tissue stripping, a decortication should be performed to assure successful osseous union.

Failure to use the tension device: Considering the usual presence of a diastasis of the fragments, the use of eccentrically placed holes (dynamic com- pression principle) is not enough to properly reduce the fragments and does not achieve an adequate compression at the fracture site.

Injuries of the brachial plexus or the subclavian artery and vein may be caused by careless drilling or by an aggressive subclavicular release of scar tissue.

Results

During the period from 1970 until 1987 40 clavicular non-unions were surgically treated in the Berufsge- nossenschaftliche Unfallklinik Ttibingen, of which 34 were located in the medial third and six in the lateral third. Twenty-one were previously treated conservatively. In 38 instances a dynamic com- pression plate was used, while two other patients (lateral third) were treated with tension band wiring. Thirty-nine of the 40 non-unions healed in four to six months; 37 patients had a normal range of shoulder motion upon the last follow-up ex- amination (usually prior to implant removal). The other three patients showed an abduction and forward flexion of 90 ° to 120 ° and an external rotation of approximately 60 ° with full internal rotation.

Martin Hansis, Siegfried Weller, Christian H Siebert: Surgical Treatment of Non-unions of the Clavicle

Orthop. Traumatol. 1 (1992). 2 - 7 ( N~. I) 7

Local complications: Three haematomas had to be evacuated. Three small wound dehiscences healed spontaneously or following secondary closure. One deep infection was treated with the application of sump drains and early implant removal. One large wound dehiscence (following three previous pro- cedures to stabilize the clavicle) required the use of a local flap. One thoracic outlet syndrome with neurologic deficits improved upon stabilization of the non-union.

3. Hagemann, H., P. J. Meeder: Die Schlfisselbein- pseudarthrose-eine vermeidbare Kornplikation? Un- fallchirurgie 8 (1982), 88.

4. Rabenseifner, L.: Zur Jktiologie und Therapie bei Schlfisselbeinpseudarthrosen. Akt. Traumat. 11 (Z981), Z30.

Key Words:

Non-union of the clavicle • Pseudarthrosis of the clavicle • Clavicle fracture - Thoracic outlet syndrome

References

1. Bl6mer, J., G. Muhr, H. Tscherne: Ergebnisse kon- servativ und operativ behandelter Schliisselbeinbrii- che. Unfallheilkunde 80 (1977), 237.

2. Hackenbruch, W., St. von Gumppenberg: Die opera- tive Therapie der Clavicula-Pseudarthrose. Unfall- heilkunde 85 (1982), 478.

Address all correspondence to: Prof. Dr. Martin Hansis University Hospital for Trauma Surgery Sigmund-Freud-Strafie 25 D-5300 Bonn 1