Extension osteotomy in malunited clavicular fractures

Extension

osteotomy

in malunited

Ulrich Bosch, MD, Michael l-lant-wer, Germany

Skutek, MD, Gabriele

The association

clavicular

paffern

of a ma/united

of disabiliv

that

impairmenf

of shoulder

where

such

an association

icular

deformiv

We

report

fracture

union

pain

and

deformiv function.

occurred

ipsilareral

A// patients clavicle

grab

of follow-up 1 case.

was

All patients

osreoromy

and

fhe shortening 0.9

and

2.2

osteofomy

and was

Universiv

crest-

6 weeks with

of California-Los

in

the

Ange-

pain relief after

of the deform+.

Shoulder

and funcrional

oufcome

cuses of shoulder clavicular

bined

wifh

good

results.

function impairment

ussociuted

fractures,

osfeotomy

autogenous (J Shoulder

bone

extension grahing

Elbow

Surg

is likely

with com-

to produce

1998;71402-51

M

ost c i.ift avrcu ar rat ures will heal with minimal treatment.3~9~’ 1 Complications such as symptomatic malunions and nonunions are rare.‘JJ!*rll,r* Although clavicular fractures often heal with some deformity, associated disability is uncommon. In a small number of patients, however, posttraumatic clavicular deformity can result in painful impairment of upper extremity function.‘* Local compression of the subclavian vessels or brachial plexus may be an From the Department of Traumasurgery, Hannover Medical School, Hannover, Germany. Reprint requests: Uirich Bosch, MD, Department of Traumasuraerv, Hannover Medical School. Postbox 61 01 80, D30;2i’Hannover, Germany. ’ Copyright @ 1998 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/98/$5.00 + 0 32/l/88996

402

METHODS

results, radiographs, and a history were obtained for all patients. The preoperative radiographs included an anteroposterior

view,

a 45’

cephalic-tilt

anteroposterior

view, and an anteroposterior panorama shoulder girdle. In 2 cases a 3-dimensional tion

was

in 3 of the 4 patients.

ma/united

AND

extension osteotomy for symptomatic of the clavicle after fracture was performed on 4 male patients. The operations occurred between January 1991 and December 1993. Physical exam

The length

and

MD,

Clavicular shortening

of the

evaluored

Tscherne,

cm

iliac

screws.

immediate

improved

of

fractures

indication for surgical intervention. Malunited clavicular fractures with shortening of the clavicle can also produce glenohumeral and scapulothoracic dysfunction related to the biomechanical significance of the clavicle for normal upper extremity function.3JTl* In such cases extension osteotomy represents a reconstructive procedure to restore clavicular anatomy and function. We report on 4 cases treated by clavicular extension osteotomy with interposition of an autogenous bone graft for symptomatic shortening of the clavicle after fracture. MATERIALS

in 3 cases

oufcome had

The dys-

clavicle.

a plate

corn&on

funcrion rapidly

dysfuncrion.

between

I to 4 years and

ussociared

of an aurogenous

The funciional

of rhe

neurovascular

cm extension with

les scales.

In

with

radiographs

inrerposirion secured

fracture

In all 4 pafienfs shorrening

fhe conrralareral

Consfonf-Mur/ey

good

with

was

underwent

with

a

of the clav-

a malunired

glenohumeral

clavicle with

with but also

Buf in cases

correction

freufmenf.

On preoperafive

compared

bone

with

was nor associared

the ma/united

Peters, MD, and Harald

be considered.

nonoperofive had

pain

is rare.

exists,

on 4 patients after

fracture

nor only

fun&on

should

clavicle with

includes

clavicular

of

the

tomography

shoulder

was

created

(CT) scans. Clavicle

with

shortenin

view of the reconstruccomputerized

was calcu-

anorama radiograp lated by using the it s. Clavicle cf on radiograph in centimeters from length was measure the lateral end of the clavicle to the sternoclavicular (oint. Calculations of clavicle shortening that relied on CT scans corresponded well with the calculations based on radiograph. After operation, the extent of clavicle correction in each patient was determined from the anteroposterior radiographs. Surgical technique. All patients were placed in the “beach chair” position. A sagittal approach along Langer’s lines was used to preserve the cutaneous supraclavicular nerves crossing the anterior border of the clavicle. The malunion was exposed by careful subperiosteal dissection. An osteotomy of the malunion was performed through the plane of deformity with a small oscillating saw and ice water. The clavicle was lengthened and realigned in accordance with plans that were made from the preoperative radio raphs and calculations of clavicular shortening. A?t er realignment, the resultant gap in the clavicle was filled by interposition of a tricortical iliac crest-bone autograft. Additional cancellous bone graft from the iliac crest was added to the intercalary raft. The slightly oversized bone graft was remove If form the ipsilateral iliac crest with the aid of a small oscillating saw. During fixation an appropriately contoured A0 3.5 compression or reconstruction plate (S nthes Germany, Bochum, Germany) was applied tot K e superior

1 Shodcfer Volume

7,

Elbow

Surg

Number

4

Table I Patient

Bosch

Table

demographics

II

Ciavicujar

length

measured

et al

403

on the panorama

view Time Case

1 z 4

be

25 Y 55Y 23~ 233Y

interval

(iniury to osteotomy)

3Y 'Y 'Y 1 mo

Follow-up Clavicular

after surgery

4Y 'Y 3Y 6w

surface of the clavicle. A minimum of 3 screws were placed in each main fragment. Ideally, the graft was secured with an additional screw. After completion of the plating procedure the wound was closed over a suction drain. Postoperatively, the arm was immobilized in Gilchrist dressing. Postoperative rehabilitation. Supervised passive and active assisted exercises up to 9V of flexion and isometric deltoid strengthening were allowed from the first day after operation. After 6 to 8 weeks range of motion was increased and resistive exercises instituted. Once radiographic union was achieved, full active use of the extremity was allowed. Follow-up examination. All 4 patients were available for review. The final follow-up examination was performed on 3 patients 1, 3, and 4 years after operation, respectively. The fourth patient was examined for the last time 6 weeks after operation (Table I). The Constant-Murley and University of California-Los Angeles (UCLA) s h ou Id erscoring systems were used to assess the patients.2 The results of the UCLA test were graded as excellent, good, fair, and poor in the manner of Hawkins and Switlyk .5 Active range of motion was measured with a handheld goniometer. RESULTS Patient demographics Four patients (age range 20 to 55 years) had painful glenohumeral dysfunction after malunion of a clavicular fracture (Table I). All 4 patients had sustained a fracture in the middle third of the left clavicle during athletic activities (cycling, hockey, handball) and were treated nonoperatively by immobilization with a figure-of-eight bandage for 4 weeks. Each of these fractures healed with shortening of the fracture site that required revision. The main reason the patients sought medical attention was activity-related pain in the shoulder girdle, especially during overhand or overhead activities. One patient had intermittent pain at night. Clavicular shortening led to symptomatic unilateral shortening of the shoulder girdle with forward and medial displacement of the ipsilateral shoulder and winging of the ipsilateral scapula. Additionally, 1 patient had supraclavicular soft tissue swelling and another patient had tenting of the skin caused by angular deformity of the clavicle. Signs and symptoms of neurovascular compression were not

length of malunited Case

1 2 i

clavicle

side

'5.0 '4.7 '5.0 '4.8

'6.9 '5.6 17.2 16.2

All measurements

Table Ill Overa/] Case

length on contralateral Shortening

1.9 0.9 2,2 1.4

in centimeters.

score UCLA

score

results

at fo/jow-up Constant-Murley

score

1 z

z: 30

'00 100 93

4

'8

63

observed, however, in any of the patients. Palpation of the malunited fracture sites did not result in patient pain, nor did it yield any other clinical signs of nonunion. In 2 patients, a limited range of motion was observed. One was not able to move the ipsilateral hand behind the head or up the back, and the other’s glenohumeral mobility was restricted to 60’ of abduction and 40’ of elevation. On preoperative radiograph the malunited clavicles of the 4 patients were on average 1.6 cm shorter (range 0.9 to 2.2 cm) than the respective contralateral clavicles (Table II). Osteotomy and correction of shortened clavicles was performed in 2 patients at 1 year after trauma and in 1 patient at 3 years after trauma (Table I). In 1 patient the extension osteotomy was done 1 month after a comminuted fracture of the clavicle. In this case, in which the clavicle had shortened by 2.2 cm, persistent shoulder dysfunction with pain was anticipated. Because of the original fracture pattern, the insertion of a iliac crest-bone graft was necessary to restore the proper length of the clavicle. Outcome At follow-up all patients reported immediate pain relief and rapid improvement of shoulder function after correction of the clavicular deformity. The osteotomies healed without complications (Figure 1). The shape of the shoulder girdle was normal and winging of the ipsilateral scapula was corrected in all patients. Review of the radiographs revealed restoration of normal clavicle length and shoulder anatomy.

404

Bosch et al

J Shoulder July/August

Figure 1 Standard sition of autogenous lined

anteroposterior iliac crest-bone

radiograph graft and

The results of the shoulder scores are shown in Table Ill. Two patients attained the highest possible score on the Constant-Murley scale. Though no patient had the highest possible score on the UCLA scale, the results were good for 3 of the 4 patients. The patient who was evaluated only 6 weeks after operation still had limited shoulder function. He had a Constant-Murley score of 63 points and a UCLA score of 18 points.

DISCUSSION In the present study clavicular fracture in 4 patients had healed with shortening associated with pain and ipsilateral glenohumeral dysfunction. There were no signs of neurovascular compression. Extension osteotomy of the malunited clavicle proved to be an effective procedure both for pain relief and improvement of upper extremity function. Because most patients with malunited clavicular fracture are asymptomatic and function well in their daily activities, correction osteotomy is generally not indicated. If there are persistent symptoms of neurovascular compression as a result of either clavicular deformity or massive callus formation after fracture, then correction by osteotomy or callus resection, respectively, is a reliable solution.12 Little is known, however, about the treatment of shortened clavicles that have no signs of neurovascular compression but that are associated with functional impairment resulting from pain and limitation of shoulder mobility. Functionally, the clavicle serves as the only bony strut laterally supporting the shoulders and contributes to the power and stability of the upper extremity, especially in overhead activities.12 In such cases of posttraumatic shortening of the clavicle, cases in which no signs of neurovascular compression are present, ipsilateral gienohumeral and scapulothoracic dysfunction may be attributed to forward and medial displacement of the shoulder that is in turn the result of shortening of the ipsilateral shoulder girdle. Few studies have been published in the last 10 years on this particular complication. Wilkies and

after restoration of clavicular plate fixation. Well-incorporated

length bone

Elbow

Surg 1998

by interpograft is out-

Halawal3 reported on a patient who had sustained a fracture of the clavicle and the scapula. The patient’s clavicle healed 3 months after fracture with 60’ of superior bowing. The patient presented with abnormal shoulder contour and limited abduction in the glenohumeral ioint despite intensive physiotherapy. After osteotomy of the clavicle and the scapula, shoulder function and contour could be restored. Herbsthofer et al6 described successful correction of a clavicular fracture that healed with 3 cm of shortening. Mulliai and Jupiter’0 published a case of clavicular shortening and deformity in which the fragments overlapped 4 cm in a patient with multiple trauma. The patient had pain, limited should mobility, and positive impingement and apprehension signs. CT arthrogram revealed a Bankart lesion. The patient underwent an extension osteotomy with interposition of an autogenous iliac crest graft. Through the same surgical approach an anterior capsulorrhaphy was also performed. Simpson and Jupiter’2 reported on clavicular osteotomy in 4 patients for deformity associated with ipsilateral glenohumeral dysfunction either alone or in combination with scapulothoracic dysfunction. In all 4 patients, the functional outcome was satisfactory. Although extension osteotomy with interposition of an autogenous bone graft in malunited clavicular fractures may produce favorable results, indication for this invasive procedure should be assessed carefully in each patient. During surgery particular care is needed to avoid neurovascular complications and attention should be paid to plate fixation. Fixation and healing of fractures and osteotomies in the middle third of the clavicle can be strongly affected by anatomic and biomechanical conditions of the clavicle. Complex torsional forces act on the middle section of the clavicle during abduction of the arm.9,‘0,‘2 Having reviewed the literature and our case work, we maintain that extension osteotomy should be considered in the treatment of patients with symptomatic clavicular deformity after fracture. Even in

Bosch

J Shoulder Elbow Surg Volume 7, Number 4

patients who only have symptomatic shortening of the clavicle and no symptoms of neurovascular compression, favorable outcomes can be expected with this procedure.

trven behandlung 1994;24:263-7. 7.

8.

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