Nonunion of the Fractured Clavicle: Evaluation, Etiology, and Treatment

Grant L. Jones, MD, George M. McCluskey III, MD, David T. Curd, MS, Hughston Clinic PC, the Hughston Shoulder Service, and the Hughston Sports Medicine Foundation Inc, Columbus, Ga (Dr. Jones is now with the Department of Orthopaedic Surgery, Ohio State University, Columbus, Ohio.)

J South Orthop Assoc. 2000;9(1) 

In This Article

Abstract and Introduction

Abstract

Although often viewed as benign injuries, clavicular fractures can lead to complications, particularly nonunions. The nonunion rate has been reported to be between 0.1% and 15%. Contributing factors to nonunion include severe initial trauma, marked initial displacement and shortening, soft tissue interposition, primary open reduction and internal fixation, refracture, open fracture, polytrauma, and inadequate initial immobilization. A clavicular nonunion is rarely asymptomatic and often results in disability from pain at the site of nonunion, altered shoulder mechanics, or a compression lesion involving the underlying brachial plexus or vascular structures. Treatment options include nonsurgical management, salvage procedures, and reconstructive procedures. The present goal is to obtain union with reconstructive procedures. The fixation methods described range from external fixation to plate and screw osteosynthesis. We prefer open reduction and internal fixation with plates and screws and with intercalary tricorticocancellous grafts to obtain union and restore the clavicle to its normal length.

Introduction

From 5% to 10% of all fractures are clavicular fractures,[1,2] and the incidence has increased over the past decades.[3] Clavicular fractures are often viewed as entirely benign lesions with a high rate of healing and excellent functional results. However, from the time the fracture initially occurs to the time the fracture heals, many complications can occur. Berkheiser[4] showed the problem of complications after clavicular fractures. He reported nine cases of nonunion (six with brachial plexus injury) and attributed this high complication rate to the increased energy of the initial trauma. Other authors[2,5,6,7,8] have also reported potential problems with these fractures.

Clinicians use various criteria to define a nonunion. Nonunion usually describes a fracture that has not adequately healed between 6 and 9 months after injury; delayed union, a fracture that has not healed after 3 to 6 months.[9,10] However, some clinicians believe that a clavicular fracture is nonunited if the fracture has not adequately healed 4 months after injury.[1,8,11,12]

The nonunion rate after closed fracture treatment has been reported to be from 0.1% to 15% (Fig 1).[2,13] Rowe[5] and Neer[2] discovered that the nonunion rate was even higher in patients treated with surgery than in patients treated without surgery (3.7% versus 0.8% and 4.6% versus 0.1%, respectively). Significant disability can result from nonunion-related problems, such as pain, altered shoulder mechanics, and neurovascular injury; thus, surgical treatment may be necessary to achieve union. Successful treatment of a clavicular nonunion is often a difficult task and requires a thorough understanding of the anatomy and function of the clavicle, the etiology and the symptomatology of nonunion, and the wide array of treatment options.

Figure 1.

Nonunion clavicular fracture.

The purpose of this paper is to review the current and past literature on the etiology and treatment of clavicular nonunions. We also present our series of 14 clavicular nonunions treated with plate and screw osteosynthesis and tricorticocancellous bone grafting.

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