Complications of fractures of the clavicle

189

Injury, 7, 189-l 93

Complications

of fractures

of the clavicle

D. W. Yates Orthopaedic

Registrar, Chester Royal Infirmary

Summary Most fractures of the clavicle unite without incident. The number and diversity of the methods of treatment in use suggest that in most cases good results are obtained despite medical supervision. Yet occasionally complications do arise. This paper describes two such cases and reviews the literature in search of a common factor to account for these complications. Cases presenting with early and late complications of fractures of the clavicle are described and the literature on the subject reviewed. The incidence of complications is highest in cases of direct violence to the shoulder region producing cornminuted fractures. Surgical management is outlined in general terms. It is suggested that more prolonged and rigorous immobilization of cases ‘at risk’ may reduce the incidence of non-union and prevent late neurovascular complications.

HISTORICAL

REVIEW

EQUESTRIAN accidents produced most of the early documented cases of fracture of the clavicle. William III sustained such a fracture when his horse shied at a molehill while he was out riding in Kensington on 21 February, 1702. He gradually deteriorated over the next 3 weeks and died on 8 March-hence the Jacobite toast to ‘the little gentleman in the dark velvet coat’. The case of Sir Robert Peel is probably the most famous and tragic example of a complicated fracture of the clavicle. He fell from his horse on his way from Parliament in the summer of 1850 and lapsed into unconsciousness as a pulsatile swelling rapidly developed behind a fracture of the left clavicle. The arm was paralysed. Sir Benjamin Brodie supervised treatment and in his records (Holmes, 1898; Dickson, 1952) described in detail the character of the ‘diffuse false venous aneurysm’. The national mourning which followed Sir Robert’s death 3 days later soon gave way to medical argument. Criticism was levelled

at the diagnosis-‘must have been epilepsy’, ‘failed to diagnose chest injury’-and the treatment-‘too few and too late’, (a reference to the application of 20 leeches at 36 hours). Indeed the editor of The Lancet (1850) thought it prudent to write in support of Brodie’s handling of the case. Many remained sceptical that such a trivial fracture could have lethal complications. Baron Dupuytren was the first to plead for a more rational approach to the treatment of fractures of the clavicle. At a lecture at the H&e1 Dieu in Paris in 1839 he described the types of apparatusincurrent use which attempted, with varying degrees of success, to reduce and hold the fracture. ‘A great many patients could not support the constriction of the chest which they involved without experiencing a sense of suffocation more or less distressing. In other instances this pressure occasioned inflammation and even sloughing, but almost invariably it was attended with intolerable pain.’ He described a case of fracture of the right clavicle treated with such an apparatus and by the application of leeches to the shoulder. Dupuytren was called in when the bleeding could not be arrested. ‘When I was summoned I merely removed the apparatus (the pressure of which was the cause of the mischief) and placed the arm on a pillow. The bleeding immediately ceased.’ Indeed this was his standard regime. Splints were not used. The arm was rested on a pillow until union occurred at about one month. Despite his astute clinical judgement, Dupuytren’s ideas were not universally accepted. His flamboyant and unconventional manner made him unpopular in some quarters-not least amongst contemporary surgical appliance makers. Yet 200 types of splint were still in use 90 years later (Kreisinger, 1927). Thereafter no detailed studies are to be found in the literature until Berkheiser (1937) drew

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attention to the complications of ununited fractures of the clavicle. Four years later Ghormley et al. (1941) reviewed 20 such cases. Since the last war there have been many reports of early and late complications involving the brachial plexus (Campbell et al., 1949; Mital and Aufranc, 1968; Miller and Boswick, 1969), the subclavian artery (Watson-Jones, 1957; Gryska, 1962; Penn, 1964; DeBakey et al., 1965), the common carotid artery (Howard and Shafer, 1965)or a combinationof these structures(Aycock et al., 1971; Iqbal, 1971). Howard and Shafer (1965) emphasized the relationship between the type of trauma and the incidence of complications. Falconer and Weddell (1943) drew attention to the critical space between the clavicle and the first rib, and showed that when soldiers carried heavy packs the neurovascular bundle could be trapped at this site. Wright (1945) demonstrated that hyperabduction of the arm could abolish the radial pulse in over half the population, and that compression occurred either at the level of the first rib or at the lower border of the pectoralis minor. These studies and the recognition of the scalenus anticus and cervical rib syndromes have served to increase awareness of the important posterior relations of the clavicle. CASE

REPORTS

Case 1

A 53-year-old woman was admitted to hospital after the car in which she had been a back-seat passenger had hit a lamp post at speed after a ‘blow out’ of a tyre. She had not been unconscious at any time. There was extensive bruising of the right side of the face and she complained of pain in both shoulders, especially the right, with occasional ‘shooting pains’ down the right arm. There were no long tract signs and her distal pulses were good. The only radiological abnormalities were fractures of the mid-shafts of both clavicles. After two days of symptomatic treatment she was discharged home with a figure-of-eight bandage. The pain in the shoulder subsided: 3 weeks later the bandage was removed and she resumed light work. However, the occasional ‘shooting pains’ in the right arm persisted. Two months later, while sitting in a chair, she experienced a sudden flushing of the right arm followed by severe pain in the supraclavicular fossa radiating into the upper arm. The appearance of a bruise at the fracture site supported the initial diagnosis of refracture. However, the pain persisted and she was admitted the next day. On examination there was a pulsatile mass with a loud bruit in the right supraclavicular fossa. Biceps power was grade 2 and the biceps jerk was absent. Sensation on the outer aspect of the right arm and forearm was blunted. The peripheral circulation was good with

equal radial pulses and the blood pressure on both sides was 160/100. Plain X-ray films showed no bony union of the fracture of the clavicle. Arteriography showed a well-marked narrowing of the right subclavian/axillary junction, with a small local leak of contrast medium (Fig. 1).

Fig. 1. Case I. Arch aortogram at 3 months, showing narrowing of right subclavian/axillary junction. Fracture of mid-shaft, both clavicles. Her symptoms slowly settled without operation, and after 10 days she was allowed home. Although she no longer experienced the ‘shooting pains’, a general ache in the upper limb persisted and the muscle weakness was slow to resolve. She returned to work after 10 weeks. After a relatively quiescent period the dull ache reappeared in a more severe form and the supraclavicular swelling increased in size (Fig. 2). Arteriography now showed the subclavian artery to be pushed downwards but no longer narrowed (Fig. 3). Phlebograms were normal. At operation 18 months after the accident, using a supraclavicular approach, the cords of the brachial plexus were found to be intimately involved in the wall of a false aneurysm

Fig. 2. Case I. The enlarged

pulsatile supraclavicular mass 18 months after injury.

Fig. 3. Case 1. Arch aortogram at 18 months. The narrowing is no longer evident but the subclavian artery is displayed downwards. Fig. 5. Case2. Comminuted fracture of the mid-shaft of the right clavicle with right pneumothorax. expanded well after the insertion of a pleural drain and gave no further trouble. Immobilization of the clavicle was difficult initially because of cerebral irritation, but subsequently he was treated in a figure-of-eight bandage and sling for 3 weeks. When last reviewed 4 months after the accident the clavicular fracture had united and he had not developed any neurovascular complications. The chest X-ray was then normal.

DISCUSSION Fig. 4. Case 1. Operative photograph showing the false aneurysm opened to reveal the small communication with the subclavian artery.

arising from a small defect in the first part of the axillary artery (Fig. 4). The aneurysmal sac and a cuff of the artery were excised and an end-to-end anastomosis performed. The un-united fracture of the clavicle was internally fixed with wire. The patient made a good recovery and 3 months later had lost her preoperative pain. There was now a good radial pulse but the neurological signs were unaltered. Case 2 A 14-year-old schoolboy was admitted after being knocked off his bicycle by a car. He had a moderately severe head injury without focal signs and posttraumatic amnesia lasting for 5 days. Bruises and abrasions were noted over the right side of the face and right shoulder. The vascular supply to both arms was normal and there were no long tract signs. An X-ray film revealed a comminuted fracture of the middle third of the right clavicle and a right pneumothorax (Fig. 5). There was no evidence of direct injury of the chest wall and no fractured ribs were seen on initial or subsequent chest films. The lung

In both these cases the initial injury was a direct blow on the shoulder and side of the face. The mechanism of the injury is not always described in the cases reported in the literature-and of course it is sometimes impossible to obtain an accurate history. But where it is known, the injury appears to follow a similar pattern, namely direct violence to the shoulder region as shown by local bruising of the skin with similar softtissue damage to the chest wall or head and neck. The resultant fracture is transverse, cornminuted or oblique. It is less common to find the long spiral fracture (produced by high torque applied at a distance from the clavicle) to be associated with injuries of the underlying vital structures. The force of the initial direct blow may be sufficient to sever or compress a vessel or nerve or, as in Case 2 above, to puncture the parietal pleura. Fracture or dislocation of the medial end of the clavicle may damage the common carotid artery. Non-union usually results from depression of the lateral fragment, which reduces the critical space behind the middle third of the clavicle and predisposes to progressive compression of the neurovascular bundle. The incidence of nonunion is highest in cornminuted fractures. These

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Injury

are usually produced by direct violence. Previously undetected damage may have been inflicted on deep structures at the time of injury (DeBakey et al., 1965) and the increased mobility afforded by the non-union could add to this damage over a variable period of time and thus explain the sudden appearance of vascular complications which have been described as occurring from 2 weeks to 10 years after trauma. It is suggested that this mechanism was responsible for the changing symptoms in Case 1. The initial shooting pains were caused by and due to brachial

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plexus irritation, and the late complications were a leak from the previously damaged artery, the resulting false aneurysm pressing on the plexus. Neurovascular complications, however, are infrequent after fractures of the clavicle, yet many patients complain of pain, instability and weakness. While total excision of the clavicle leaves little disability (Abbott and Lucas, 1954) the fibrous union which may follow a cornminuted, unsplinted fracture is frequently troublesome. The patient whose fracture is shown (Fig. 6) was unable to do housework for 18 months, and 2

6. A typical comminuted fracture of the mid-shaft of the right clavicle with incipient non-union. outer third of the clavicle is depressed thus reducing the costoclavicular space.

Fig.

FRACTURE OF MIDDLE THIRD OF CLAVICLE Usually commtnuted or transverse and arroctared with soft-tissue damage IMtlEDlATF

LATE

Distal irchaemia

Haemorrhage phenomena

false aneurysm

on brachial plWS

Fig. 7.

Aetiological factors in complications

of fractures of the clavicle.

The

Yates : Fractures

of the Clavicle

193

years later her chief complaints were of weakness and a drooping shoulder. Excessive callus may similarly produce a bad cosmetic result, and in addition to reducing the costoclavicular space and predisposing to the compression of posterior structures (Enker and Murthy, 1970), it can trap the overlying supraclavicular cutaneous nerves resulting in troublesome paraesthesia and pain in the pectoral region. The various aetiological factors are summarized in Fig. 7. MANAGEMENT Vascular complications evident at the time of injury must be explored. Initial arteriography is essential. A supraclavicular approach is used but proximal control of the major vessels may be necessary via the third rib space or a median sternotomy. Primary end-to-end repair is more desirable than vein graft. The fracture is then internally fixed, or part or all of the clavicle excised. Little benefit has followed exploration and attempted repair of associated acute brachial plexus lesions. The late onset of symptoms due to reduction of the costoclavicular space can be relieved by extraperiostal resection of the first rib or of the clavicle. The latter does not result in weakness or instability of the arm. Surgical treatment of a late false aneurysm is more hazardous. Precise localization of the lesion by arteriography is mandatory. Careful dissection of the sac after proximal control of the main vessel may reveal a surprisingly small tear, amenable to direct suture. When there is no clinical evidence of immediate complications but the mechanism of injury suggests the patient is ‘at risk’, it is prudent to maintain a careful follow-up over a longer period than is usual. Some writers have suggested prophylactic internal fixation in these cases. The maintenance of external splintage until union has occurred is an alternative. Acknowledgements I am grateful to Mr P. H. Corkery and Mr E. G. Hardy for permission to review cases under their care and wish to thank Mr Edgar Parry for his advice on the preparation of this paper. REFERENCES

ABBOTTL. C. and LUCAS D. 3. (1954) The function of the clavicle. Ann. Sung. 140, 583. Requests for Chester.

reprints should

be addressed to: D.

W. Yates, Orthopa

AYCOCK T. M., I~OM W., CRENSHAWC. A. and REHFELDT F. C. (1971) Monoplegia and false aneurysm. South. Med. J. 64, 1165. BERKHEISERE. J. (1937) Old ununited clavicular fractures in the adult. Surg. Gynecol. Obstei. 64, 1064. CAMPBELLE., HOWARDW. P. and BURKLUNDC. W. (1949) Delayed brachial plexus palsy due to ununited fracture of the clavicle. JAMA 139, 91. DEBAKEY M. E., BEALL A. C. and WOKASCHD. C. (1965) Developments in vascular surgery. Am. J. Surg. 109, 134.

DICKSON J. W. (1952) Death following fractured clavicle. Br. Med. J. 2, 666. DUPUYTRENLe Baron (1839) Legons Orales de Clinique Chirurgical, 2nd ed., vol. 7. Paris, BailliBre, p. 110. Translated in: LE GROS CLARK (1847) On the Injuries and Diseases of Bone. London, Sydenham Society, p. 97. ENKER S. H. and MURTHY K. K. (1970) Brachial plexus compression by excessive callus formation secondary to a fractured clavicle. A Case Report. Mt Sinai J. Med.

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FALCONERM. A. and WEDDELL G. (1943) Costoclavicular compression of the subclavian artery and vein. Lancer 2, 539. GHORMLEYR. K., BLACK J. R. and CHERRY J. H. (1941) Ununited fractures of the clavicle. Am. J. Surg. 51, 343.

GRYSKA P. F. (1962) Major vascular injuries. N. Engl. J. Med. 266, 38 1. HOLMEST. (1898) The Life of Sir Benjamin Collins Brodie. London. T. Fisher Unwin. HOWARD F. M. and SHAFERS. J. (1965) Injuries to the clavicle with neurovascula; complications. J. Bone Joint Surg. 47A. 1335. IQBALQ. M. (1971)Axilla;y artery thrombosis associated with fracture of the clavicle. Med. J. MaZaya 26, 68.

KREISINGERV. (1927) Sur le traitement des fractures de la clavicle. Rev. Chir. Orthop. 65, 396. LANCET (1850) Editorial: Sir Robert Peel’s Death. Lancet 2, 19. MILLER D. S. and BOSWICKJ. A. (1969) Lesions of the brachial plexus associated with fractures of the clavicle. Clin. Orthop. 64, 144. MITAL M. A. and AUFRANC 0. E. (1968) Venous occlusion following greenstick fracture of clavicle. JAMA 206, 1301. PENN I. (1964) The vascular complications of fractures of the clavicle. J. Trauma 4, 819. STEINBERGI. (1961) Subclavian vein thrombosis associated with fractures of the clavicle. N. Engl. J. Med. 264, 686.

WATSON-JONES R. (1957) Fractures and Joint Injuries, 3rd ed., vol. 1. Edinburgh, E. & S. Livingstone, p. 112. WRIGHT I. S. (1945) The neurovascular syndrome produced by hypcr-abduction of the arms. Am. Heart J. 29, 1. edit

Registrar, Chester Royal Infirmary, St Martin’s Fields,