Case Reports in Orthopedics

Case Reports in Orthopedics / 2017 / Article

Case Report | Open Access

Volume 2017 |Article ID 5105670 | 4 pages | https://doi.org/10.1155/2017/5105670

Successful Treatment of a 15-Year-Old Nonunion of a Midshaft Clavicle Fracture Causing Brachial Plexus Compression

Academic Editor: Zbigniew Gugala
Received23 Apr 2017
Revised27 Jun 2017
Accepted03 Aug 2017
Published10 Sep 2017

Abstract

A 49-year-old man with a 15-year-old nonunion of a midshaft clavicle fracture suffered from progressive tingling in his entire arm and fingers for two years, due to irritation of the brachial plexus in the costoclavicular space, especially upon elevation of the arm. After open reduction and internal plate fixation, all symptoms were resolved and complete consolidation of the fracture was achieved at one-year follow-up. This case demonstrates two things: brachial plexus compression can occur even many years after a nonunion of a clavicle fracture and union can be still achieved, even in a longstanding nonunion.

1. Introduction

Clavicle fractures account for 3–10% of all fractures, with an incidence of 30 per 100.000 inhabitants in adults [1, 2]. Fractures of the midshaft are the most common (over 69%) [2].

Nonunion after a midshaft fracture occurs in 5–20% of cases after conservative treatment [3]. A meta-analysis on operative versus conservative treatment of midshaft clavicle fractures reports a 14% incidence of brachial plexus involvement after conservative treatment [4]. Brachial plexus injury following clavicular fracture is a rare condition, occurring in less than 1% of cases [5]. A brachial plexus injury arising from callus formation following clavicular nonunion is even rarer. Acute brachial plexus injuries usually arise within a few weeks to months. However, there is one previously mentioned case which describes a delayed onset [6]. We add a further case of delayed onset of brachial plexus compression, 13 years after the injury.

We describe the successful treatment of a patient with progressive complaints of a delayed brachial plexus compression due to a 15-year-old nonunion midshaft clavicle fracture.

2. Case Report

A 49-year-old man presents with progressive complaints in his left arm over the past two years. He experiences a tingling and a numb feeling in his entire arm especially when walking or driving. These complaints initiate in the hand, digits two to four in particular, and progress proximally over time.

Furthermore, the patient has an annoying sensation of two rubbing clavicular fracture parts. Fifteen years ago he fell from a height of five meters during work. As a result of this accident he sustained a midshaft clavicle fracture on the left side, which was treated conservatively.

Physical examination revealed a drooping left shoulder, a visible thickening, and an abnormally shaped clavicle. Active and passive full range of motion of the shoulder was found.

Neurological examination showed symmetrical low reflexes and a normal sensibility. When raising the arm and keeping it elevated, tingling and numbness occurred.

X-rays showed a nonunion of a midshaft clavicle fracture with extension callus formation (Figure 1).

An MRI showed granulation tissue around the brachial plexus, without revealing an injury of the plexus itself (Figure 2).

The diagnosis was therefore a hypertrophic nonunion of a midshaft clavicle fracture causing compression of the brachial plexus, without damage to the plexus. We decided to perform an open reduction and internal fixation of the clavicle, using a precontoured locking plate (Perilock, Smith & Nephew, Warsaw, USA) (Figure 3).

Intraoperatively, extensive preparation to free both ends of the clavicle from scar tissue was performed, both ends were trimmed to fit as well as possible, an autologous bone graft was performed (obtained from the resected parts), the medullary canal was opened, and the plate was fixed. At the first postoperative visit (six weeks) the tingling sensation had gone almost completely. Six months postoperatively, the patient reported no pain, and he had obtained a full range of motion. Despite these satisfactory results, complete healing of the fracture was not yet seen on the X-rays (Figure 4). However, during the final check-up, 12 months after treatment, a complete healing of the clavicula fracture was observed (Figure 5).

3. Discussion

We presented a patient with progressive compression of the brachial plexus which arose 13–15 years after a nonunion midshaft clavicle fracture, which was treated successfully with plate osteosynthesis of the clavicle. This case shows that even 15 years after a clavicle fracture, compression of the brachial plexus can still occur and union can be achieved with a nonunion repair (plate osteosynthesis and autologous bone graft).

Brachial plexus injury or compression may occur, both in the acute and in the chronic phases [7]. In the majority of cases, plexus neuropathy based on pressure may develop from three weeks to seven years after the damage [6, 7] (Table 1). Only one case with a delayed onset of 7–10 years is known; however, this case is dated from several decades ago (1949) [6]. Both our case and Campbell et al.’s [6] describe a favorable outcome with a complete recovery, despite the substantial delay. This shows that there is no reason not to operate when there is a considerable delay in the onset of brachial plexus complaints resulting from a nonunion clavicular fracture in the past.


Date of publicationStudy sample(Delayed) time span/onset of symptomsTreatment strategyLaboratory dataPostoperative course

Our case report

Teunis et al.13 yrssurgical decompression + ORIFX-ray, MRIComplete recovery after 1 year

Available literature (full text)

Berkheiser [8]19373 months to 1 yearPlexus brachial involvement arose after the first operationX-rayFull recovery after a second operation

Storen [9]19463 yrsResection + metal sutureX-rayAfter 5 months a second operation, because of pain. New suture, after that full recovery in 14 months

Campbell et al. [6]19497 yrsRemoving of the callus and scar tissueX-rayComplete recovery after 4 weeks

Neviaser [10]19633 monthsResection of the middle part of the clavicleX-rayComplete recovery after 2 months

Miller and Boswick [11]19693, 4, 12, and 5 wkClaviculectomy, exploration, ORIF, explorationX-rayComplete recovery in 1 year, unknown, 6 months, and 4 months

Wilkins and Johnston [12]198312 and 14 wkResection of 1/3 of clavicle, ORIFUnknownPain when lying on the affected side, complete recovery

Kay and Eckardt [7]1986 3 wkORIFX-ray + EMGComplete recovery after 10 months

Connolly and Dehne [13]19898, 18, 8, and 4 monthsResection, resection, resection, pinningX-rayThe patient with pinning technique recovered completely, the other cases unknown

Derham et al. [14]20078 wkSurgical decompression + ORIFX-ray, MRI, EMGComplete recovery after 3 months

Thavarajah and Scadden [15]2013Directly after first procedure (8 months)ORIF first operation, surgical decompression second operationX-rayMRC grade 4/5 power from C5–T1

British Medical Research Council (MRC).

Compression of the brachial plexus in patients who have not been operated on is reported to be 14% [4]. This circumstance is almost exclusively caused by hypertrophic bone growth with a nonunion midshaft clavicle fracture [7]. Herein compression of the brachial plexus takes place within the costoclavicular area, which is formed by the middle one-third of the clavicle and the first rib. Often there is persistent pressure on the root inferior trunk, medial fasciculus [16]. Patients may experience pain in the shoulder or armpit and a numb or tingling feeling in (parts of) the arm or hand [17]. In the current case the patient experienced tingling and numbness in the hand, radiating to the shoulder, without loss of function.

The prognosis of compression of the brachial plexus is generally poor; however, it does depend on the severity of the lesion. For acute plexus injuries, most improvement can be expected in the first six months after neurolysis [18]. Known cases do not provide a clear time scale during which the brachial plexus should be operated upon; however, based on neurobiology knowledge it is important to treat an injury as soon as possible [14].

In this case, the patient already showed signs of improvement within six weeks and recovered completely after six months. Based on the articles mentioned in Table 1, a positive outcome for a delayed onset can be expected (even after years).

To conclude, this case demonstrated a delayed brachial plexus compression due to a 15-year-old nonunion of a midshaft clavicle fracture, which resolved completely after open reduction and plate fixation.

The patient gave informed consent to the publication of the case study.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

References

  1. F. Postacchini, S. Gumina, P. de Santis, and F. Albo, “Epidemiology of clavicle fractures,” Journal of Shoulder and Elbow Surgery, vol. 11, no. 5, pp. 452–456, 2002. View at: Publisher Site | Google Scholar
  2. C. M. Robinson, “Fractures of the clavicle in the adult. Epidemiology and classification,” Journal of Bone and Joint Surgery, vol. 80, no. 3, pp. 476–484, 1998. View at: Publisher Site | Google Scholar
  3. I. R. Murray, C. J. Foster, A. Eros, and C. M. Robinson, “Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle,” Journal of Bone and Joint Surgery - Series A, vol. 95, no. 13, pp. 1153–1158, 2013. View at: Publisher Site | Google Scholar
  4. R. C. McKee, D. B. Whelan, E. H. Schemitsch, and M. D. McKee, “Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials,” The Journal of Bone & Joint Surgery—American Volume, vol. 94, no. 8, pp. 675–684, 2012. View at: Publisher Site | Google Scholar
  5. C. R. Rowe, “An atlas of anatomy and treatment of midclavicular fractures. Orthop Relat Res,” in Clin Orthop Relat Res, vol. 58, pp. 29–42, 58, 1968. View at: Google Scholar
  6. E. Campbell, W. P. Howard, and C. W. Burklund, “Delayed brachial plexus palsy due to ununited fracture of the clavicle: Report of a case,” Journal of the American Medical Association, vol. 139, no. 2, pp. 91-92, 1949. View at: Publisher Site | Google Scholar
  7. S. P. Kay and J. J. Eckardt, “Brachial plexus palsy secondary to clavicular nonunion,” Case Report and Literature Survey, vol. 206, pp. 219–222, 1986. View at: Google Scholar
  8. E. J. Berkheiser, “Old ununited clavicular fractures in the adult,” in Surg Gynecol Obstet, vol. 64, pp. 1064–1072, 1937. View at: Google Scholar
  9. H. Storen, “Old clavicular pseudarthrosis with late with late appearing neuralgias and vasomotoric disturbances cured by operation,” in Acta Chir Scand, vol. 94, pp. 187–192, 1946. View at: Google Scholar
  10. J. S. Neviaser, “The treatment of fractures of the clavicle,” Surgical Clinics of North America, vol. 43, no. 6, pp. 1555–1563, 1963. View at: Publisher Site | Google Scholar
  11. D. Miller and J. Boswick, “Lesions of the brachial plexus associated with fracture of the clavicle,” Clin. Orthop, vol. 64, p. 144, 1969. View at: Google Scholar
  12. R. M. Wilkins and R. M. Johnston, “Ununited fractures of the clavicle.,” The Journal of Bone & Joint Surgery, vol. 65, no. 6, pp. 773–778, 1983. View at: Publisher Site | Google Scholar
  13. J. F. Connolly and R. Dehne, “Nonunion of the Clavicle and Thoracic Outlet Syndrome,” The Journal of Trauma: Injury, Infection, and Critical Care, vol. 29, no. 8, pp. 1127–1133, 1989. View at: Publisher Site | Google Scholar
  14. C. Derham, M. Varghese, P. Deacon, N. Spencer, and P. Curley, “Brachial plexus palsy secondary to clavicular nonunion,” Journal of Trauma - Injury, Infection and Critical Care, vol. 63, no. 4, pp. E105–E107, 2007. View at: Publisher Site | Google Scholar
  15. D. Thavarajah and J. Scadden, “Iatrogenic postoperative brachial plexus compression secondary to hypertrophic non-union of a clavicle fracture,” Annals of the Royal College of Surgeons of England, vol. 95, no. 3, pp. e55–e57, 2013. View at: Publisher Site | Google Scholar
  16. R. Onstenk, M. J. A. Malessy, and R. G. H. H. Nelissen, “Plexus-brachialisletsel door niet genezen of in afwijkende stand genezen claviculafracturen,” Ned Tijdschr Geneeskd, vol. 145, no. 50, 2001. View at: Google Scholar
  17. M. B. Bromberg, J. M. Shefner, and J. F. Dashe, “Brachial plexus syndromes,” Internet Site up to Date, 2015, http://www.uptodate.com.proxy-ub.rug.nl/contents/brachial-plexus-syndromes?source=machineLearning&search=plexus+brachialis&selectedTitle=1~150&sectionRank=2&anchor=H8#H5. View at: Google Scholar
  18. R. Midha, “Epidemiology of brachial plexus injuries in a multitrauma population,” Neurosurgery, vol. 40, no. 6, pp. 1182–1189, 1997. View at: Publisher Site | Google Scholar

Copyright © 2017 Annemarijn Teunis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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