ununited fractures of the clavicle

7
UNUNITED FRACTURES OF THE CLAVICLE RALPH K. GHORMLEY, M.D. JOHN R. BLACK, M.D. Section on Orthopedic Surgery,The Mayo Clinic FeIIow in Orthopedic Surgery,The Mayo Foundation AND JAMES H. CHERRY, M.D. Fellow in Orthopedic Surgery, The Mayo Foundation ROCHESTER, MINNESOTA I T is unusuaI for a fracture of the clavicIe to resuIt in nonunion. This statement in itself expresses the com- monIy accepted opinion that cIavicuIar fractures wiI1 unite whatever the type of treatment empIoyed and sometimes in spite of it. Since the cIavicIe is one of the most diffIcuIt bones in the body to immo- biIize properIy, this wouId appear para- doxica1. NevertheIess, this diffIcuIty is readiIy reflected by the muItitude of splints which have been designed for the purpose of its immobiIization and recommended to the profession. In a review of the Iiterature, we were unabIe to find many reports of the occur- rence of nonunion in clavicuIar fractures. As a matter of fact, we were able to find onIy one authoritative articIe appearing in the medica Iiterature in English during recent years, and this was the one recorded by Berkheiser in 1937. Berkheiser reported a series of nine cases in which nonunion occurred. In addition, he reviewed the anatomy of the shoulder and indicated how the association of Iesions of the brachial pIexus and vascuIar impairment in the adjacent arm in fractures of the cIavicIe couId be accounted for by the proximity of the brachial pIexus and the bIood vessels of the arm, particuIarIy the subcIavian vein, to the most frequent site of fracture. This he has found to be at the junction of the middIe and outer thirds of the cIavicIe. He pointed out certain axioms which appIy to old cases of ununited fractures of the cIavicIe. Among these he mentioned that the severity of the initia1 injury and faiIure to obtain adequate immobiIization are the two most common factors. Berkheiser aIso expressed the opinion that the surest method by which to obtain union in un- united fractures of this nature is by means of the autogenous bone graft. It is our purpose to report an additiona series of ununited fractures of the cIavicIe and at the same time determine the best means of preventing and correcting this condition. CLINICAL DATA We wish to report a tota of twenty cases of fractures of the cIavicIe with nonunion which were examined at the Mayo CIinic during the years from January, 1913, to October, 1939, incIusive. In TabIe I, we have incIuded a brief synopsis of each case. As may be seen, eIeven of the twenty patients were maIe and nine were femaIe. The average age was 35 years, the youngest being 2 years and the oIdest, 60 years. In attempting to ascertain the severity of the injuries which were responsible for these particuIar fractures, we categoricaIIy di- vided the type of fracture force into severe and moderate. Of the severe types, there were ten, and of the moderate, five. Frac- tures resulting from automobiIe accidents were usuaIIy cIassified as severe, whiIe simple faIIs were heId to be responsibIe for the moderate types. In two cases, the type of fracture force was definiteIy not known, while in three others, the question of congenita1 pseudarthrosis entered into the picture; we were, therefore, unable to ascertain the compIete etioIogic circum- stances. This particuIar group of cases wiI1 be discussed in further detai1 later. It is we11 to mention, in connection with the severity of fracture force, that there were no cases 343

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UNUNITED FRACTURES OF THE CLAVICLE

RALPH K. GHORMLEY, M.D. JOHN R. BLACK, M.D.

Section on Orthopedic Surgery, The Mayo Clinic FeIIow in Orthopedic Surgery, The Mayo Foundation

AND

JAMES H. CHERRY, M.D.

Fellow in Orthopedic Surgery, The Mayo Foundation

ROCHESTER, MINNESOTA

I T is unusuaI for a fracture of the clavicIe to resuIt in nonunion. This statement in itself expresses the com-

monIy accepted opinion that cIavicuIar fractures wiI1 unite whatever the type of treatment empIoyed and sometimes in spite of it. Since the cIavicIe is one of the most diffIcuIt bones in the body to immo- biIize properIy, this wouId appear para- doxica1. NevertheIess, this diffIcuIty is readiIy reflected by the muItitude of splints which have been designed for the purpose of its immobiIization and recommended to the profession.

In a review of the Iiterature, we were unabIe to find many reports of the occur- rence of nonunion in clavicuIar fractures. As a matter of fact, we were able to find onIy one authoritative articIe appearing in the medica Iiterature in English during recent years, and this was the one recorded by Berkheiser in 1937. Berkheiser reported a series of nine cases in which nonunion occurred. In addition, he reviewed the anatomy of the shoulder and indicated how the association of Iesions of the brachial pIexus and vascuIar impairment in the adjacent arm in fractures of the cIavicIe couId be accounted for by the proximity of the brachial pIexus and the bIood vessels of the arm, particuIarIy the subcIavian vein, to the most frequent site of fracture. This he has found to be at the junction of the middIe and outer thirds of the cIavicIe. He pointed out certain axioms which appIy to old cases of ununited fractures of the cIavicIe. Among these he mentioned that the severity of the initia1 injury and faiIure to obtain adequate immobiIization are the two most common factors. Berkheiser aIso

expressed the opinion that the surest method by which to obtain union in un- united fractures of this nature is by means of the autogenous bone graft.

It is our purpose to report an additiona series of ununited fractures of the cIavicIe and at the same time determine the best means of preventing and correcting this condition.

CLINICAL DATA

We wish to report a tota of twenty cases of fractures of the cIavicIe with nonunion which were examined at the Mayo CIinic during the years from January, 1913, to October, 1939, incIusive. In TabIe I, we have incIuded a brief synopsis of each case. As may be seen, eIeven of the twenty patients were maIe and nine were femaIe. The average age was 35 years, the youngest being 2 years and the oIdest, 60 years. In attempting to ascertain the severity of the injuries which were responsible for these particuIar fractures, we categoricaIIy di- vided the type of fracture force into severe and moderate. Of the severe types, there were ten, and of the moderate, five. Frac- tures resulting from automobiIe accidents were usuaIIy cIassified as severe, whiIe simple faIIs were heId to be responsibIe for the moderate types. In two cases, the type of fracture force was definiteIy not known, while in three others, the question of congenita1 pseudarthrosis entered into the picture; we were, therefore, unable to ascertain the compIete etioIogic circum- stances. This particuIar group of cases wiI1 be discussed in further detai1 later. It is we11 to mention, in connection with the severity of fracture force, that there were no cases

343

344 American Journal of Surgery GhormIey, et aI.-Ununited Fractures

TABLE I UNUNITED FRACTURES OF THE CLAVICLE; CASE REPORTS

-

_.

_~

_.

_.

_~

__

._

._

._

._

_

._

._

._

._

._ I

._

1 ._

,

T 1

1

I

I

I

I

F

I

I

._

I

_

I

I _ F

_

I

I

_

I

_

F

_

F _

F -

F

-

[

1

I

5

I

_-

I :

1

_-

3 ‘

1

) :

I

I

-

Fracture Site

Symptoms*

Remarks

SCX nnd Date

Age, See”

Years

Operation

at the

Mayo Clinic

._~

None

None ___

None

N”“C

N”“t2 __--

Bone graft

Bone graft

Open red., wiring

Bone graft

N”“‘Z

Bone graft

None

N”“t?

None

None

None

None

Bone graft

Bone graft

Open red.,

CatgUt

Cause of

FractLIre

Bandaging and i- + + operation

____------

? + . . -_--__

Duration

I yr.

16 mans.

5 mans.

I yr.

5 moos.

2 yrs.

-__

4 mans.

I yr.

14 mans.

4 mans.

2” mans.

I” yrs.

__-

8 mans.

45 Yrs.

.>( yrs.

lo/Kg/36

’ fell 2

days be-

fore

n infancy

.8 mans.

5% yrs.

_~

_.

_~

_.

. .

__

. .

._

._

._

._

._

.~

.

._

._

._

._

-

Auto collision tight middle )< ‘ositive reaction for syphilis

1 I

F _-

L

L

I

L

L

F

_-

F

_-

L

F

F

F

_-

F

F

_-

L

_-

L

_-

L

A

R

-

light middle $4

.eft outer >$ N”“C until 3 weeks, T splint

._

.-

.~

.-

._

Not recorded

xft middle $6

_----_

Immediate “p- _. + + eration

Gght outer $6

.eft middle >$

? . . + -_____--__

3 open? opera- + + + + tions

.eft middle 4_5 Bandaging 7 ., ._ ++ + weeks

tight middle !b Manipulation- + + + bandage

____

Gght “u ter fS Velpeau band- _. + + age

.eft middle $6

~_____ Immediate “p- + +

eration

light middle $5

light middle f$

Splint andoper- _. + + ation

~__

Early? - “per- + + ation ‘16

light middle f$ Fraction ++..++ +

light middle f$

:ight outer $6

.eft outer $6

eft outer f<

eft middle f$

:ight middle f$

Light middle $6

? ,.

1 +

__~ Velpeau band- +

age

Vane . . . .

? + -_--__

Vane + --_____--__

? + . .

F 49 3/4/3” ‘unction excellent

Hit by an

auto

‘ositive reaction for syphilis; head in-

jury __-- F 57 g/21/32

Fig 2 Ieclined grafting

Auto collision ‘arkinson’s disease

Falling crane

Auto collision

_____

Fall

<esult: failure

<es”lt: union

iesult: failure

Fall <esult: union M 16 6/z/26 Fig. 4

_____

M 34 10/33/z: Auto collision >eclined grafting

F 38 I 1/22/j: Fig. 3

Fall <esult: union

Horse fell on part

‘ositive reaction for

syphilis

Truck ran

over

?

:unction fair

-

‘unction excellent

M 24 7/5/38 Fig. I

Football in-

iory

‘unction excellent

Train and auto COIL

__-

M 33 16/13/ag

F 3 / 7/a/+9

‘sychosis

‘unction excellent

lesult: union

lesult: union

Cesult: unknown

Congenital ?

? congenital 7

7 congenital ?

Fall in bath-

tub F 8 6/7/13

* Legend of symptoms: Neuritis: Symptoms of nerve irritation in adjacent arm. Sagging: Sagging of adjacent shoulder girdle. Vein Press.: Signs of

interference with venous circulation. Pain: Tenderness on pressure at fracture site. Motion: False motion at fracture site. Limitat. Shou. Mot.: Limitation of motion in adjacent shoulder.

t including bone graft.

NEW SERIES VW. LI. No. 2 Ghormley, et aI.-Ununited Fractures A merican Journal of Surgery 345

of pathoIogic fracture inchrded in this syphihs. The test was not performed on series of twenty cases. three patients, whiIe in the remaining

According to Berkheiser, the majority of fourteen the resuIt was negative.

FIG. I. Ununited fracture of the outer third of the clavicIe.

ununited fractures of the cIavicle occur in the middIe and outer thirds. We found this to hoId true in our series. (Figs. I and 2.)

In fourteen cases, the fracture was in the middIe third, whiIe in six it was in the outer third. In no case did it occur in the inner third. TweIve of the fractures occurred on the right side and eight on the Ieft. There were no cases of biIatera1 invoIvement.

In reviewing the signs and symptoms which the patients in this series presented on examination, the most significant find- ings were as foIIows: faIse motion at the site of the fracture, pain on pressure at the site of the fracture, sagging of the shouIder girdIe on the affected side, irritation of the nerves Ieading to the arm on the affected side, Iimited motion in the adjacent shoul- der joint and interference with the return circuIation of the arm on the affected side. In thirteen cases, faIse motion was present; in eight there was pain on pressure at the site of the fracture; five cases showed sagging of the shouIder; three gave symp- toms which suggested neuritis in the adjacent arm; five cases showed Iimited motion in the shouIder joint, and one case gave evidence of vascuIar changes. In one case, there were no complaints or signs of dysfunction.

Of the twenty patients, onIy three gave positive reactions to flocculation tests for

FIG. Z. Ununited fracture of the middle third of the ctavicle with marked displacement of the outer fragment.

In attempting to analyze the adequacy of therapy given these patients imme- diateIy after the injury and later, we were abIe to demonstrate only two cases in which the treatment couId be dehnitely said to have been inadequate. In one case, the patient had received no form of treat- ment, while in another therapeutic meas- ures had not been instituted unti1 three weeks after the date of the injury. In stiI1 two other cases, the adequacy of treatment was questionabIe. In six cases the type of previous therapy was not determined. Of the eight patients known to have received some form of conservative therapy, with or without subsequent operation before com- ing to the cIinic, two were treated by means of the conventiona T sphnt, two by VeIpeau bandaging, two by simpIe ban- daging (since the detai1 of the immobiliza- tion in the Iatter two cases couId not be fuIIy ascertained from the records, the adequacy of their treatment is question- abIe), one patient was treated by manipula- tion pIus bandage, whiIe another was treated by means of traction to the arm. Of the six patients who had received open oper- ative procedures before examination at the clinic, three had been subjected to some form of conservative treatment before oper- ation. Two of the six had received immedi-

346 Amencan Journal of Surgery Ghormley, et aI.-Ununited Fractures FEBRUARY, ,941

ate open reductions. Three others had been not carried out on one patient, who was suf- operated upon after conservative measures fering from insanity, because of the antici- had failed to produce union. In one other pated dificuIty in the postoperative care.

TABLE II OPERATIVE CASES OF CLAVICULAR FRACTURES WITH NONUNION

-

Graft Type Recumbent Period Int. Fixation

Bed 12-18

Days

Num- ber of Cases

2

Mass. and Osteo.

Osteo- peri- peri- ostea1

osteat

Type of Procedure Par- ham Band

Bed 2

Wks. + Cast

Bed 4-6

Wks.

Bed

9 Days

Cat- gut

Mas- sive

Wire

I- I- -/ Open reduction with fresh-

ening of bone and fixa- tion

--

Results !

‘)

Nonunion.

Unknown.

Bone grafting.

‘Union. ResuIts I

\ Nonunion.

Totals.

I

I

2

I

I-

l- *

I

I-

*

3

l- 2 3 I 2

I

2

I- I-

I-

2 2 2

case, bone grafting had been attempted eIse- where but had not produced union.

Of the tota twenty patients having nonunion, onIy eight were subsequentIy operated upon at the cIinic. For reasons which wiI1 be enumerated, tweIve patients received no further treatment here. Three of the tweIve patients, as has been men- tioned, had strongIy positive reactions for syphiIis, and operation was deferred for the institution of appropriate medica therapy. However, none of the three re- turned for surgica1 treatment. In four of the patients, function was very good and the symptoms were minimaI. For these reasons surgica1 intervention appeared to be op- tional and these four patients decided against further procedures. Two of the eleven patients for whom bone grafting seemed indicated decIined operation for fi- nancia1 and other reasons. Operation was

The same held true in regard to another patient amicted with Parkinson’s disease. In the case of the two-year-oId child with nonunion in the Ieft cIavicIe, it was believed that bone grafting was not indicated at the time of examination because of her age and because of the absence of physica inter- ference with function.

Eight patients were finaIIy operated upon and the detai1 of procedure and resuIt may be seen in Table II. Bone grafting procedures were carried out on six patients, whiIe in two cases, the bone fragments were freshened up and reaIigned without the benefit of grafting. InternaI fixation was secured by means of wire in one of these cases, whiIe in the other, strong cat- gut was used. In the two cases in which bone grafting was not used, subsequent faiIure to unite occurred in one. The resuIt in the other could not be determined.

NEW SERIES VOL. LI, No. z GhormIey, et al-ununited Fractures A me&an Journal of Surgery 347

Union occurred in five of the six patients who received bone grafts. It is sign&ant that the faiIure to unite occurred in the patient who remained the shortest time in bed after operation. *

The tota resuIts of al1 the operative cases showed that union resulted in live patients, nonunion in two, and the result was unknown in one.

COMMENT

There were four cases in which nonunion occurred during infancy. In onIy one of these cases was a delinite injury of sufh- cient force recorded to have caused the original fracture. It has been our observa- tion that the majority of infants with fracture of the cIavicIe show a greenstick type of fracture with IittIe or no displace- ment. This has also been true in obstetric fractures in this bone. Owing to the elastic- ity caused by the highly cartiIaginous content of the bones at this age, a compIete transverse fracture with dispIacement is the exception rather than the rule. One would think that these factors wouId be conducive to very few nonunions. For this reason one naturalIy wonders why 4 or 20

per cent of our cases should have been nonunions occurring in infants unless there was some congenital weakness or defect originally present. We were Ied to believe that there might have been a congenita1 pseudarthrosis present in the case of the two-year-oId gir1 whom we saw in October, 1939. The parents brought the child be- cause of a faI1 which she had suffered the day before admission. Roentgenograms showed a fracture of the left clavicIe at the junction of the middIe and outer thirds, but this was obviously not a recent’one. Since there was no history of previous injury or disability and because of normal function, it was believed that the deformity was con- genital although one could not be sure. The same may or may not have been true in two other cases.

None of the four patients presented asso- ciated signs or symptoms which would suggest cIeidocrania1 dysostosis, a well

known syndrome in which there is a com- plete or partia1 absence of both cIavicIes. Regardless of the causation of these infant fractures with nonunion, the treatment should be carried out aIong much the same lines as one wouId treat ordinary nonunion in the cIavicIe. SurgicaI intervention wouId appear to be indicated only in those cases in which there is obvious deformity, the presence of untoward physical discomfort and an interference with function. It is preferable to postpone operation until the patient is oId enough to be handled without too much difficuIty, aIthough in the case of our three-year-old patient a bone grafting operation was successful.

AIthough there were ten cases out of the total twenty in which the patient had received severe injuries, there were, never- theIess, live cases in which the fracture force had been of the moderate or average type. It wouId appear that in these five cases the cause of nonunion resided chiefly in the Iack of proper lixation rather than the severity of the initia1 injury. Adequate immobilization is certainly to be empha- sized as one means of preventing nonunion. This fixation should be carried out with the best avaiIabIe means at hand. In cases where we have found it difficuIt to main- tain proper aIignment of the fragments with the conventional T splint, we have employed a Taylor brace with an outrigger attachment in the shoulder regions. This type of sphnt affords a comfortabIe means of puIIing the shoulder girdle backward and hoIding it in place, especiaIIy in those pa- tients who have an increase in the normal kyphosis of the spinal column.

In cases in which the patient has sus- tained severe types of injury to the cIavicle, and in those in which other injuries inter- fere with the proper externa1 splinting of the cIavicle, early open reduction shouId be seriousIy considered. However, com- plete rest in bed with sandbags as an aid may be tried at first, provided the patient is able to cooperate sufficiently to remain flat on his back with the sandbags in place. If open reduction becomes necessary, wire

348 American Journnl of Surgery GhormIey, et aI.-Ununited Fractures FEBRUARY, 194,

appears to be the most suitabIe agent at our disposal for this type of internal fixation.

FIG. 3. Ununited fracture of the middle third of the cIavicIe; Q, before operation; b, union after massive bone graft and wiring; C, photograph of the same patient after bone graft operation wire has been removed.

Contrary to Berkheiser’s findings, we were abIe to demonstrate onIy one case in which an associated injury of the brachiaI pIexus was present, and this was one for which two previous open reductions and one bone grafting operation had been performed. There were two other patients who compIained of pains like those of neuritis in the invoIved arm, but we could not be sure that these were due to actual pressure of the fragments on the brachial pIexus. Patients wearing VeIpeau bandages often complain of the same type of dis- comfort. The patient who showed evidence

of pressure on the brachia1 pIexus aIso pre- sented signs of interference with the venous circuIation in the affected extremity.

AIthough three of our patients with nonunion gave strongIy positive reactions for syphiIis, we do not beIieve that the faiIure to unite was caused by the presence of syphilis aIone. In one case, the patient definiteIy did not receive the proper treat- ment for fracture and in another the ade- quacy of such treatment was open to controversy. Provided the proper medica measures are initiated, we beIieve that the presence of syphiIis is not a contraindica- tion to bone grafting.

In fractures of the cIavicIe with non- union, the procedure of choice is some type of autogenous bone grafting, preferabIy the use of the massive type of graft. (Fig. 3.) OsteoperiosteaI grafts may be used in combination with massive grafts, or they may be used aIone in those cases where the contour of the fractured bone does not aIIow massive grafting. (Fig. 4.)

The means of interna fixation wiI1, of course, depend on the type of graft, the difficuIty in holding the fragments to- gether and the gap which has to be fiIIed in by new bone. Here again wire wouId seem to be the most dependabIe agent (Figs. 3 and 4) aIthough beef bone and vitaIlium screws have been used to advan- tage by others in hoIding the grafts in pIace.

Perhaps the most important part of the treatment of fractures of the cIavicIe with nonunion is the proper immobiIization of the patient folIowing operation. The one patient in our series for whom union was not obtained by grafting remained in bed onIy nine days after operation. This is more than a coincidence since the quickest and best results were obtained in those cases in which the patients were kept in bed from four to six weeks folIowing opera- tion. Even if a shoulder spica cast is appIied, compIete rest of the grafted region cannot be insured unIess the patient is flat in bed.

In reviewing this series of cases and from experience in the treatment of acute

NEW SERIES VOL. LI, No. 2 GhormIey, et aI.-Ununited Fractures A me&an Journal of Surgery 349

cIavicuIar fractures, we are of the opinion the literature have been few. Severe initial now that this period of complete immo- injuries and improper immobihzation bilization shouId be at Ieast live weeks wouId appear to be the chief causes of

FIG. 4. Ununited fracture of the clavicle; a, before operation; b, union after osteoperiosteal bone graft and wiring.

foIIowing grafting. For this reason a certain amount of judgment should be exercised in the selection of patients for this regimen of treatment. One can ob- viousIy envision the diffrcuIty in handIing psychotic and non-cooperative patients under such a regimen. A patient with a psychosis or one with Parkinson’s disease is hardIy a suitabIe subject. On the other hand, we do not hoId that a11 patients with nonunion of the cIavicIe shouId be refused the benefit of a grafting procedure if this period of complete immobilization cannot be carried out. However, it is certainly the idea1 method and shouId be used in the majority of cases if union is to be expected.

After the hospitahzation period, the part shouId stiI1 be supported by bandage or spIintage unti1 union is present cIinicaIIy and roentgenographicalIy. Union should take place within two to three months. If at the time of operation wire or meta has been used internaIIy, its remova shouId be carried out at a Iater date.

SUMMARY

Nonunion in fractures of the cIavicIe is known to occur but the reported cases in

nonunion in this type of fracture. Twenty cases of fracture of the clavicle with non- union are reported. A review of these cases tends to bear out this observation. Eight of the twenty patients were sub- jected to surgical procedures and in five, union was obtained whiIe in two, nonunion resuIted. The resuIt was not known in one case. Of the six patients having bone grafting procedures, union occurred in five and nonunion in one. The importance of prolonged hospitaIization with the patient in bed foIIowing bone grafting is borne out by the resuIts. The best means of prevent- ing nonunion in fractures of the cIavicIe is to be had by the earIy initiation of appro- priate therapeutic measures. Fractures which fail to respond to the proper con- servative measures shouId be reduced by open operative procedures. Autogenous bone grafting is the surest method of correction in instances in which nonunion has occurred.

REFERENCE

1. BERKHEISER, E. J. OId ununited cIavicuIar fractures in the ad&. Surg., Gynec. CY Obst., 64: 1064-1072,

1937.