Large defect after multiple clavicular resections

10.1055/b-0034-86376

Large defect after multiple clavicular resections

René K Marti

Case description

A 33-year-old woman presented with a 5.5 cm defect non-union after multiple interventions to stabilize a fracture of the clavicle. She complained about pain, limited shoulder function, and the cosmetic appearance.

This type of nonunion can occur after a clavicular resection for a thoracic outlet syndrome or after inadequate treatment of chronic infections.

Indication

Any type of clavicular resection causes problems and should be avoided. Most patients complain about pain, loss of function, and strength of the shoulder. Reconstruction by internal fixation and iliac crest autogenous cancellous bone grafts can lead to excellent functional results.

A large-gap nonunion of the clavicular shaft with a small lateral fragment.

Preoperative planning

In this particular case a standard plate fixation is difficult as the lateral fragment is small, atrophic and does not provide sufficient hold for a plate by itself.

All basic principles have to be applied:

Multiple intercalary bone grafts
Intramedullary splinting with K-wires
Plate fixation
Tension band secures only the fixed lateral part of the plate

Equipment

Dynamic compression plate (DCP) 3.5(locking plates may be used alternatively)
K-wires (elastic nails may be used alternatively)
Cerclage wires

(Size of system, instruments, and implants may vary according to anatomy.)

Patient preparation and positioning

The patient is placed in a beach-chair position.

A single-dose 2nd generation cephalosporin should be administered as a prophylactic antibiotic.

The anterior iliac crest is prepared for bone-graft harvesting.

The principle of internal fixation of nonunions with large defects: • Multiple intercalary bone grafts • Intramedullary splinting with two K-wires • Wave plate • Lateral tension band around the tip of the third screw

Surgical approach

Incision is performed along the inferior or superior border of the clavicle to the acromioclavicular (AC) joint, whenever possible using and excising former incisions. Removal of the interposed scar tissue, decortication and opening of the medullary canal of the sclerotic medial fragment of the nonunion are performed. The AC joint is identified with a needle.

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