Operative management of clavicular malunion in midshaft clavicular fractures: a report of 59 cases

• Published in: Journal of shoulder and elbow surgery Vol. 28; no. 12; pp. 2343 - 2349
• Main Authors: Strong, David H., Strong, Michael W., Hermans, Deborah, Duckworth, David
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-12-2019
• Subjects: Adolescent; Adult; bone graft; Bone Plates; Bone Transplantation; Child; Clavicle; Clavicle - diagnostic imaging; Clavicle - injuries; Clavicle - surgery; Diaphyses - diagnostic imaging; Diaphyses - injuries; Diaphyses - surgery; Female; fracture; Fracture Fixation, Internal - adverse effects; Fracture Healing; Fractures, Malunited - diagnostic imaging; Fractures, Malunited - surgery; Humans; Infections - etiology; Infections - surgery; Male; malunion; Middle Aged; osteotomy; Osteotomy - adverse effects; Osteotomy - methods; Postoperative Complications - etiology; Postoperative Complications - surgery; Postoperative Period; Radiography; shoulder; Transplantation, Autologous; Treatment Outcome; Young Adult; Treatment Study; Level IV; osteotomy; bone graft; Clavicle; Case Series; malunion; shoulder; fracture
• ISSN: 1058-2746; 1532-6500
• DOI: 10.1016/j.jse.2019.04.058

Nonoperative management has long been the preferred treatment for clavicular fractures; however, good outcomes, particularly with a shortened and malunited clavicle, are not universal. We report on radiographic and patient-based outcomes of a patient cohort with symptomatic clavicular malunions managed with corrective osteotomy, plate fixation, and local bone graft. We hypothesized that local bone graft would be sufficient for achieving union and length of malunion time would not affect the outcome.
Over a 10-year period, 59 cases underwent operative management of symptomatic clavicular malunion. The surgical technique included osteotomy of the malunion, restoration of length, fixation with a plate, and local bone graft. The average length of time between fracture and surgery was 193.42 weeks (range, 8 weeks to 30 years). All patients were followed up postoperatively until radiographic union was achieved. Disabilities of the Arm, Shoulder and Hand scores were obtained and patients completed questionnaires to assess patient-based outcomes postoperatively.
All 59 cases achieved union with an average time of 9.25 weeks (range, 6-38 weeks) and only required local bone graft. All patients improved postoperatively with a mean Disabilities of the Arm, Shoulder and Hand score of 1.81 (range, 0-20.68) at 12 months. In 2 patients, infection developed, requiring revision of fixation, and union was subsequently achieved. Two patients had fractures adjacent to their hardware after union was achieved.
Corrective osteotomy with restoration of length and alignment, soft-tissue preservation, local bone graft, and plate fixation is a reliable treatment option for midshaft clavicular malunion. Union can be achieved, with good clinical outcomes independent of malunion time.