Orthopaedic Nursing • September/October 2009 • Volume 28 • Number 5 217 subclavian vein, due to its stable connection with the clavicle via the cervical fascia, can also be subjected to injuries (Casbas et al., 2005). Damage to the internal jugular vein, the suprascapular artery, the axillary, and carotid artery after a clavicular fracture has also been reported (Katras et al., 2001). About 50% of injuries to the subclavian arteries are due to fractures of the clavicle because the proximal part is dislocated superiorly by the sternocleidomas- toid, causing damage to the vessel (Sodhi, Arora, & Khandelwal, 2007). If no injury happens during the ini- tial displacement of the fractured part, then it is un- likely to happen later, because the distal segment is dis- placed downward and forward due to shoulder weight, while the proximal segment is displaced upwards and behind the sternocleidomastoid, without coming into contact with the subclavian vessels (Katras et al., 2001). Nevertheless, there have been reports of injury of sub- clavian vessels following nondisplaced fractures such as greenstick fractures or fractures with a mild angulation (Sodhi et al., 2007; see Figure 1). Late damage due to compression by a large callus or nonunion is rare (Casbas et al., 2005). Vascular injuries include traction, occlusion, con- striction, or compression. Damage of subclavian artery appears usually early after the initial injury, while rup- ture of vessels may lead to life-threatening hemorrhage. Meanwhile, arterial thrombosis or occlusion causes limb ischemia. Signs of limb ischemia or hemorrhage should raise a suspicion. The color and temperature of the upper extremity can be normal, while the absence of pulse, the appearance of large hematomas in supraclav- icular region, and the presence of a systolic bruit and a The objective of our literature review was to inform or- thopaedic nurses about the complications of clavicular frac- ture, which are easily misdiagnosed. For this purpose, we searched MEDLINE (1965–2005) using the key words clavicle, fracture, and complications. Fractures of the clavicle are usu- ally thought to be easily managed by symptomatic treatment in a broad arm sling. However, it is well recognized that not all clavicular fractures have a good outcome. Displaced or comminuted clavicle fractures are associated with complica- tions such as subclavian vessels injury, hemopneumothorax, brachial plexus paresis, nonunion, malunion, posttraumatic arthritis, refracture, and other complications related to os- teosynthesis. Herein, we describe what the orthopaedic nurse should know about the complications of clavicular fractures. Introduction It is estimated that fractures of the clavicle represent 4% of total human fractures (Dath, Nashi, Sharma, & Muddu, 2004). These fractures are usually treated con- servatively with a broad arm sling and have a good func- tional outcome (Brinker, Edwards, & O’Connor, 2005). Nevertheless, because of contiguity of the clavicle with vital organs such as lungs, subclavian vessels, brachial plexus, and heart, an injury to these organs after a clav- icular fracture is possible. There are many references in the English literature about the treatment of clavicular fractures and to the factors that may predispose to its two major complications: nonunion and malunion. In this literature review, we reviewed the major com- plications after a clavicular fracture to help the or- thopaedic nurse to recognize these painful situations or even fatal complications. Complications after a fracture of the clavicle are summarized in Table 1. Injury of Subclavian Vessels Injury to the subclavian vessels is rare because these structures are protected by the subclavius muscle, the clavicle, the first rib, and the deep cervical fascia (Kendall, Burton, & Cushing, 2000). Usually, vascular injuries after a clavicular fracture occur at the proximal or middle part of the subclavian artery, where vertebral and thoracic arteries have their origin. In addition, the George Mouzopoulos, MD, MSc, Orthopaedic Department of Evangelismos Hospital, Athens, Greece. Emmanuil Morakis, MD, Orthopaedic Department of Evangelismos Hospital, Athens, Greece. Michalis Stamatakos, MD, PhD, Department of General Surgery, Laiko Hospital, University of Athens, Athens, Greece. Mathaios Tzurbakis, MD, PhD, Orthopaedic Department of Evangelismos Hospital, Athens, Greece. The authors have disclosed that they have no financial relationships related to this article. Complications Associated With Clavicular Fracture George Mouzopoulos ▼ Emmanuil Morakis ▼ Michalis Stamatakos ▼ Mathaios Tzurbakis NOR200061.qxd 9/11/09 1:23 PM Page 217
subclavian vein, due to its stable connection with theclavicle via the cervical fascia, can also be subjected toinjuries (Casbas et al., 2005). Damage to the internaljugular vein, the suprascapular artery, the axillary, andcarotid artery after a clavicular fracture has also beenreported (Katras et al., 2001).
About 50% of injuries to the subclavian arteries aredue to fractures of the clavicle because the proximalpart is dislocated superiorly by the sternocleidomas-toid, causing damage to the vessel (Sodhi, Arora, &Khandelwal, 2007). If no injury happens during the ini-tial displacement of the fractured part, then it is un-likely to happen later, because the distal segment is dis-placed downward and forward due to shoulder weight,while the proximal segment is displaced upwards andbehind the sternocleidomastoid, without coming intocontact with the subclavian vessels (Katras et al., 2001).Nevertheless, there have been reports of injury of sub-clavian vessels following nondisplaced fractures such asgreenstick fractures or fractures with a mild angulation(Sodhi et al., 2007; see Figure 1). Late damage due tocompression by a large callus or nonunion is rare(Casbas et al., 2005).
Vascular injuries include traction, occlusion, con-striction, or compression. Damage of subclavian arteryappears usually early after the initial injury, while rup-ture of vessels may lead to life-threatening hemorrhage.Meanwhile, arterial thrombosis or occlusion causeslimb ischemia. Signs of limb ischemia or hemorrhageshould raise a suspicion. The color and temperature ofthe upper extremity can be normal, while the absence ofpulse, the appearance of large hematomas in supraclav-icular region, and the presence of a systolic bruit and a
The objective of our literature review was to inform or-thopaedic nurses about the complications of clavicular frac-ture, which are easily misdiagnosed. For this purpose, wesearched MEDLINE (1965–2005) using the key words clavicle,fracture, and complications. Fractures of the clavicle are usu-ally thought to be easily managed by symptomatic treatmentin a broad arm sling. However, it is well recognized that notall clavicular fractures have a good outcome. Displaced orcomminuted clavicle fractures are associated with complica-tions such as subclavian vessels injury, hemopneumothorax,brachial plexus paresis, nonunion, malunion, posttraumaticarthritis, refracture, and other complications related to os-teosynthesis. Herein, we describe what the orthopaedic nurseshould know about the complications of clavicular fractures.
IntroductionIt is estimated that fractures of the clavicle represent 4%of total human fractures (Dath, Nashi, Sharma, &Muddu, 2004). These fractures are usually treated con-servatively with a broad arm sling and have a good func-tional outcome (Brinker, Edwards, & O’Connor, 2005).Nevertheless, because of contiguity of the clavicle withvital organs such as lungs, subclavian vessels, brachialplexus, and heart, an injury to these organs after a clav-icular fracture is possible. There are many references inthe English literature about the treatment of clavicularfractures and to the factors that may predispose to itstwo major complications: nonunion and malunion.
In this literature review, we reviewed the major com-plications after a clavicular fracture to help the or-thopaedic nurse to recognize these painful situations oreven fatal complications. Complications after a fractureof the clavicle are summarized in Table 1.
Injury of Subclavian VesselsInjury to the subclavian vessels is rare because thesestructures are protected by the subclavius muscle, theclavicle, the first rib, and the deep cervical fascia(Kendall, Burton, & Cushing, 2000). Usually, vascularinjuries after a clavicular fracture occur at the proximalor middle part of the subclavian artery, where vertebraland thoracic arteries have their origin. In addition, the
George Mouzopoulos, MD, MSc, Orthopaedic Department ofEvangelismos Hospital, Athens, Greece.
Emmanuil Morakis, MD, Orthopaedic Department of EvangelismosHospital, Athens, Greece.
Michalis Stamatakos, MD, PhD, Department of General Surgery, LaikoHospital, University of Athens, Athens, Greece.
Mathaios Tzurbakis, MD, PhD, Orthopaedic Department ofEvangelismos Hospital, Athens, Greece.
The authors have disclosed that they have no financial relationshipsrelated to this article.
palpable pulsatile mass should lead to the diagnosis of aserious vascular injury (Stokkeland, Soreide, &Fjetland, 2007). According to Sturm and Cicero (1983),criteria for performing an angiography to exclude asupraclavicular artery injury comprise fracture of firstrib, reduction or absence of radial artery pulses, palpa-ble hematoma in supraclavicular region, mediastinumwidening in chest x-ray, and injury of brachial plexus.Angiography is the method of choice for the diagnosisof a subclavian artery injury but is not always helpfulfor the diagnosis of a posttraumatic aneurysm, espe-cially in cases where the vascular lumen is narrow andno adequate amount of contrast medium can enter(Watanabe & Matsumura, 2005). In addition, Dopplerultrasonography is not useful because the interferenceof clavicle and ribs results in a poor imaging of the ves-sels (Garnier et al., 2003).
Constriction of vessels can be complicated later withthrombosis. Differential diagnosis of arterial constric-tion following an arterial rupture is difficult, but re-gional blockade of the sympathetic nervous system canhelp (Weh & von Torklus, 1980). Damage of the vascu-lar wall can result in aneurysm formation, thromboem-bolic phenomena, and compression of brachial plexus(Watanabe & Matsumura, 2005). The most commonlate vascular complication following a clavicular frac-
ture is occlusion after compression of subclavian veinbetween the fractured clavicle and the first rib(Davidovic et al., 2001). Obstruction occurs where thesubclavian vein traverses the first rib and passes belowthe subclavius muscle and costoclavicular ligament andis compressed by the clavipectoral fascia (Casbas et al.,2005). It is followed in frequency by damage to brachialplexus and subclavian artery.
Symptoms include distension of upper limb and an-terior thoracic wall veins, which is minimized withdownward shoulder movement (Kochhar, Jayadev,Smith, Griffiths, & Seehra, 2008). The presence of veinthrombosis is not dangerous for limb viability but canresult in pulmonary embolism. In these situations, sud-den dyspnea, pleuritic chest pain, hemoptysis, syncopeor shock, and tachypnea can indicate the presence ofpulmonary embolism (West, Goodacre, & Sampson,2007). In addition, fractures of the proximal part of theclavicle can be complicated by carotid artery obstruc-tion, caused either by compression from a fracturedbony segment or by production of a large callus, causingsyncopal episodes (Hanby, Pasque, & Sullivan, 2003).Initially, vascular injury could be asymptomatic and bemissed, resulting later in worsening symptoms of sub-clavian artery occlusion, and pose a danger to the limb’sviability. Arterial pressure of both upper extremitiesshould be measured, and if there is any difference, thelimb should be investigated by angiography.
Initial therapy of arterial injury should include man-agement of hypovolemia and associated injuries (he-mopneumothorax), and later an end-to-end suturing ofthe lesion or a venous grafting should be performed.Finally, the fracture of clavicle should be fixed surgically(Casbas et al., 2005). Treatment of subclavian vein in-jury consists of removal of the callus, which is responsi-ble for the compression (Kochhar et al., 2008).
Pneumothorax—HemothoraxBecause of contiguity of the middle part of the claviclewith the lung apex and pleura, pneumothorax or hemo-thorax can occur from bony spiculae of a displaced clav-icular fracture (Steenvoorde, van Lieshout, & Oskam,2005). Pneumothorax also has been observed after inter-nal fixation of a clavicular fracture (Hegemann, Kleining,Schindler, & Holthusen, 2005; Kochhar et al., 2008).
Almost 60% of injuries are caused by low-energy in-juries of the shoulder (Taitsman, Nork, Coles, Barei, &Agel, 2006). These complications have been observed in3% of clavicle fractures, and the coexistence of scapularor upper ribs fractures should increase the suspicion oftheir existence (Weening et al., 2005). Treatment con-sists of drainage of the hemothorax and conservativetreatment or operative fixation of the fracture.
Brachial Plexus InjuryAbout 1% of brachial plexus injuries occur following afracture of the clavicle, and symptoms can appear earlyor late (Ring & Holovacs, 2005). Most common is thelate presentation of a brachial plexus injury due to cre-ation of an oversized callus that entraps the posteriorand middle branches in the costoclavicular space in
adults (Derham, Varghese, Deacon, Spencer, & Curley,2007). The distal segment of the fractured clavicle is dis-placed because of shoulder weight downward and back-ward, resulting in the formation of a callus by com-pressing the brachial plexus (Kitsis, Marino, Krikler, &Birch, 2003).
Symptoms usually involve the distribution of theulnar nerve and appear weeks or years after a clavicularfracture (Jupiter & Leibman, 2007). In children, theproduction of a large callus rarely results in a decreaseof costoclavicular space, so the brachial plexus is usu-ally not compressed. In addition, in children, the size ofthe callus diminishes over the years as the bone remod-els; therefore, brachial plexus compression is extremelyrare (Krishnan, Mucha, Gupta, & Schackert, 2008).
Late injuries of brachial plexus in adults can alsooccur because of compression by the fractured seg-ments of the clavicle after nonunion or because of for-mation of a subclavian artery aneurysm (Jupiter &Leibman, 2007). In nonunion, especially that of hyper-trophic type, the distal fractured segment is displaceddownward and backward, resulting in compression ofthe brachial plexus between the fractured segment andfirst rib (Krishnan et al., 2008; see Figure 2).
Although the periosteum in the posterior aspect ofthe clavicle, the subclavius muscle, and the clavicle pro-tect the brachial plexus, direct injury can occur espe-cially after a displaced or comminuted fracture of themiddle part of the clavicle (Derham et al., 2007).
Acute lesions occur most commonly on the posteriorbranch of the brachial plexus and rarely on the wholebrachial plexus. They manifest as neuroapraxia usually,due to avulsion rather than from direct pressure by thefractured ends of clavicle, which are displaced back-ward (Kitsis et al., 2003). Forces that cause acute in-juries of brachial plexus have a downward or posteriordirection, resulting in tension of the brachial plexus,which is compressed against the transverse processes ofcervical vertebrae. In addition, brachial plexus can beavulsed over the clavicle or directly from the spinal cord(Watanabe & Matsumura, 2005). Acute injury ofbrachial plexus can also occur after immobilization of aclavicular fracture with figure-of-8 bandage or after
intramedullary fixation of the fracture with Kirschnerwires (Ring & Holovacs, 2005).
Symptoms can appear either from lesions of thewhole brachial plexus or from injury to a part of it.Patients often complain of paresthesias or pain of theupper limb for a long time after the clavicular fracture.Symptoms are aggravated by abduction, external rota-tion of shoulder, weight lifting, or other activities,which require the elevation of upper limb over the head,while symptoms subside with rest (Kitsis et al., 2003).Symptoms can also emerge during sleep. Isolated injuryof the anterior interosseous, musculocutaneous, andsuprascapular nerve after refracture of the clavicle hasbeen described with accompanying sympathetic algody-strophy of anterior thoracic wall (Jupiter et al., 2007).
Diagnosis of brachial plexus injury is made after his-tory, physical examination, and the electromyography(EMG) and magnetic resonance imaging (MRI) results(Middleton, Foley, & Foy, 1995). In addition, displace-ment of more than 1 cm in a simple x-ray result maysuggest a brachial plexus lesion (Kitsis et al., 2003).
Patients should be informed of the possibility of thiscomplication, especially when they have a displaced clavi-cle fracture, so that they can inform their doctor of anynew or worrisome symptoms. Special attention is requiredfor closed reduction of clavicular fractures because dis-placed bony spiculae can cause a direct injury to brachialplexus (Muller, Al-Maiyah, Hui, & Adedapo, 2005). The co-existence of clavicular fractures with brachial plexus le-sions is suggestive of injury to subclavian vessels. Early ap-pearance of neuropathy carries a better prognosis than alate appearance (Muller et al., 2005).
Treatment of acute neuropathy consists of removingthe bony fragments from brachial plexus and performingopen reduction and internal fixation. While in late neu-ropathy, excision of the large callus or removal of a clavic-ular segment is required (Watanabe & Matsumara, 2005).
Nonunion of FracturesClavicular fracture nonunion is defined as the absence ofobvious healing either clinically or radiologically 4–6months after the injury (Havet et al., 2008; see Figure 3).
However, 0.13–15% of nonunion occurs in displacedfractures of the middle part of the clavicle (Brinker et al., 2005; Jones, McCluskey, & Curd, 2000).
About 22–23% of nonunion occurs in fractures of thedistal segment of the clavicle. Finally, fractures of theproximal clavicle demonstrate only a 1% nonunion rate(Rosenberg, Neumann, & Wallace, 2007).
Usually 60–80% of nonunions of the middle part ofthe clavicle are symptomatic, causing mild to severesymptoms (Rosenberg et al., 2007). Pain at the fracturesite, which radiates to neck, forearm, and hand, is usu-ally reported, especially when the brachial plexus isstimulated. Sometimes there is poor function of theshoulder and a diminished range of motion but thesesymptoms may also imply injury to the shoulder joint,the subacromial space, or soft tissue rather than tononunion of the clavicle. With nonunion, the patientcomplains of a limited sense of motion or crepitation ofthe fractured clavicle. The arm is clasped to the chest toprevent movement. The proximal fractured part of theclavicle can be palpated inside the trapezius muscle(Jeray, 2007). Usually 25% of patients have symptomsdue to trapping of brachial plexus from the oversizedcallus or due to compression of the subclavian veinfrom the callus, which results in thoracic outlet syn-drome (Derham et al., 2007).
The examiner finds sensitivity and motion of thefractured parts in the site of nonunion. The atrophicnonunion may initially present with severe symptoms,but as time passes by, symptoms subside (Denard,Koval, Cantu, & Weinstein, 2005).
On the contrary, 80% of the cases with distal claviclenonunion are asymptomatic (Nowak, Holgersson, &Larsson, 2005). Symptoms of posttraumatic arthritis ofacromioclavicular or sternoclavicular joint can imitatethat of nonunion, so a careful assessment should bemade keeping in mind that symptoms of arthritis ap-pear many years after the injury (Denard et al., 2005).
The following are risk factors for the development ofnonunion of a clavicular fracture (see Table 2): fracturesite, displacement more than 20 mm, severe injury,refracture, previous surgery, and inadequate shoulderimmobilization.
Fracture displacement more than 20 mm is the mostimportant factor for nonunion occurrence because it isfollowed by interposition of soft tissues, which preventhealing (Kabak, Halici, Tuncel, Avsarogullari, &Karaoglu, 2004).
Almost 85% of nonunions occur in midshaft claviclefractures because these are the most common fractures
(Brinker et al., 2005). On the contrary, distal claviclefractures develop nonunion because they are more un-stable. These fractures are displaced easily due to shoul-der weight and are difficult to immobilize. Manynonunions result from severe injury to soft tissue struc-tures, which in turn affect the vascularity of the site(Kabak et al., 2004).
Because of severe injury of the soft tissue, there is adecreased blood supply to the fracture site. It is reportedthat open fractures have a higher incidence of nonunion(Jones et al., 2000). For the same reason, appearance ofrefracture in a site of a previous healed fracture predis-poses to nonunion possibly due to damage in blood sup-ply of the area (Jones et al., 2000).
About 3.7–4.5% of nonunions occur in displacedfractures, which are reduced with an open method(Marti, Nolte, Kerkhoffs, Besselaar, & Schaap, 2003).
A higher incidence of nonunion occurs when semi-tubular plates are used for fixation or when a plate isfixed with few screws (Chen et al., 2008).
In addition, in cases of conservative treatment,shoulder immobilization should remain until completehealing is achieved (Simpson & Jupiter, 1996). The pe-riod required for stabilization of fractures of middleshaft of clavicle is 2 weeks for the newborn, 3 weeks forchildren, 4–6 weeks for adolescents, and 6 weeks foradults (Khan et al., 2008). Radiologically confirmedhealing appears much later when compared with clini-cally assessed healing, and it can take 12 weeks.
If there is no sensitivity or movement at the frac-ture, then progressively the individual’s physical activ-ity can increase even if the healing is not still visible onx-ray results.
Diagnosis of nonunion is assessed clinically by themotion of the fractured ends and the sensitivity of thefracture site. Radiographically, it is confirmed withsimple anteroposterior x-ray result with a cephalicprojection of 45� or simple tomography. In case ofdoubt, a computed tomography (CT) can help(Rosenberg et al., 2007).
When nonunion of clavicle is asymptomatic, there isno need for treatment. But if nonunion causes pain ordysfunction of the shoulder, then operative treatment ismandatory and consists of excision of the nonunion tis-sue, internal fixation, and iliac crest grafting (Werner,Favre, van Lenthe, & Dumont, 2007). Alternatively, in-tramedullary fixation of the clavicle with K-wires,Steinmann pins, Knowles pins, or Hagie pins is possible(Russo, Visconti, Lorini, & Lombardi, 2007).
MalunionHealing of a clavicular fracture with a decrease inlength by 2 cm or more besides dysmorphy, results inpoor functionality and persistent pain in adults due to adecrease in muscular strength of the shoulder(Lazarides & Zafiropoulos, 2006; see Figure 4).
It seems that a decrease of clavicular length changesthe glenoid position and results in restriction ofhumeral head motion and scapular rotation duringupper limb movement (Andermahr et al., 2006). At thesame time, angulation of the sternoclavicular joint isobserved (Ledger, Leeks, Ackland, & Wang, 2005).
Displacement of fracture ends for more than 20 mmFracture of distal part of clavicleSevere injury of soft tissueRefractureOpen reductionFailed internal fixationInadequate shoulder stabilization
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On the contrary, in children, the healing of the frac-ture with a decrease in length of the clavicle does notresult in severe problems. Thanks to remodeling, chil-dren have the ability to restore the anatomical architec-ture of the bone (Pujalte & Housner, 2008).
Treatment consists of clavicle osteotomy and iliaccrest grafting to achieve initial length and internal fixa-tion (McKee, Wild, & Schemitsch, 2004).
Of course, the patient should be informed about thepossibility of nonunion in case of open reduction and in-ternal fixation and about the postoperative scar forma-tion, which results in more cosmetic problems than doesthe projection of the bone under the skin surface itself.
Posttraumatic ArthritisPosttraumatic arthritis usually appears in fractureswith intra-articular extension into the acromioclavicu-lar joint, after type III fractures that remain undiag-nosed (Beals & Sauser, 2006). In these fractures, symp-tomatic arthritis occurs in 15% of the cases (Buss &Watts, 2003). In 3% of the cases of posttraumaticarthritis after a fracture of the midshaft of the clavicle,there are no evident radiographic lesions (Beals &Sauser, 2006).
In midshaft fractures, possibly the decrease of theclavicular length alters the load on the acromioclavicu-lar joint and results in late degenerative changes of thejoint (Clarke & McCann, 2000). Symptoms arise due topain of the acromioclavicular joint or due to osteophyteformation in the inferior aspect of the clavicular distalend, which by compressing the rotator cuff and sub-acromial bursa result in subacromial impingement syn-drome (Beals et al., 2006). This condition predisposes torupture of rotator cuff, especially when the osteophytessize is more than 2 mm (Noble, 2003).
Radiographically, cystic lesions, osteophytes, steno-sis of the acromioclavicular joint space, and osteolysisof the distal clavicle especially can be observed with thehelp of a “Zanca view,” with cephalic inclination of thebeam at 10–15� (de Abreu, Chung, Wesselly, Jin-Kim, &Resnick, 2005).
CT helps estimate the intra-articular extension of theclavicular fracture in the acromioclavicular joint whileMRI helps diagnose coexistent injuries of rotator cuff orintra-articular disc of the acromioclavicular joint.Besides, symptoms can be due to rupture of the intra-articular disc of the acromioclavicular joint during theinitial injury without radiographic alterations (Buss &Watts, 2003).
Intra-articular cortisone and lidocaine injectionrelieves symptoms, but persistent symptoms can bealleviated by open or arthroscopic excision of the dis-tal clavicle (Lervick, 2005; Nikolaides, Dermon,Papavasiliou, & Kirkos, 2006). Usually, 2 cm of the dis-tal clavicle is excised, laterally to the insertion of thecoracoclavicular ligament, and the deltoid muscle issutured to the trapezoid fascia (Tytherleigh-Strong,Gill, Sforza, Copeland, & Levy, 2001). But excision ofmore than 1 cm of the distal clavicle sometimes is ac-companied with pain during motion or at rest, due todecreased muscular strength of the shoulder(Edwards, Wilson, Flores, Koh, & Zhang, 2007).Excision of 1 cm of the distal clavicle is accompaniedwith anteroposterior instability (Nissen & Chatterjee,2007).
Rarely, arthritis of the sternoclavicular joint canoccur after a fracture of the proximal 1/3 of the clavicle.In this case, the proximal end of the clavicle is excised,and in its place the clavicular insertion of the stern-ocleidomastoid is sutured (Mazzocca, Arciero, & Bicos,2007).
RefractureAlmost 4% of cases occur after the removal of an inter-nal fixation plate (Smekal, Oberladstaetter, Struve, &Krappinger, 2008). The plate should remain in place for12–18 months, and any athletic activity should beavoided in the 3 first months after the removal.
Alcoholism and comminuted fractures are risk fac-tors of refracture (Kim & McKee, 2008). Furthermore,clavicle refracture predisposes to nonunion.
Complications After SternalClavicular Fracture DislocationSternoclavicular fracture-dislocation is a very danger-ous situation, as the proximal portion is very close tovital organs. Many complications have been reportedsecondary to the retrosternal fracture-dislocation suchas pneumothorax, compression on the subclavianartery, compression of the right common carotid artery,laceration of the superior vena cava, thoracic outlet syn-drome, brachial plexus compression, rupture of esoph-agus, tracheoesophangeal fistula, onset of snoring,hoarseness of the voice, stridor, and dysphagia(Macdonald & Lapointe, 2008).
FIGURE 4. Clavicle fracture associated with axillary nerve paresis.
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Complications From Surgical ProceduresSignificant complications can result following openreduction and internal fixation (see Table 3). Use ofosteosynthesis with short plates (using less than 2 holesto each end of the fracture) may lead to hardware fail-ure and loss of fixation (Proubasta et al., 2002).
In addition, migration of osteosynthesis pins tolungs, aorta, orbit, or spinal column can occur after in-tramedullary fixation of the clavicle (Regel, Pospiech,Aalders, & Ruchholtz, 2002). Excessive grafting of thefracture, especially in the inferior aspect of the clavicle,can result in trapping of brachial plexus or subclavianvein. So these forms of treatment are not recom-mended.
When the incision is performed exactly above theclavicle, then there is a possibility of supraclavicularnerve injury, resulting in hypoesthesia or dysesthesia ofthe region. It is suggested that incision should be madebelow the clavicle to obtain better results (Coupe,Wimhurst, Indar, Calder, & Patel, 2005).
Finally, if the incision is not according to Langer’slines, the possibility for a dysmorphic and hypertrophicscar is common (Der, Davison, & Dias, 2002).
ConclusionClavicle fractures usually heal uneventfully and arerarely complicated by significant morbidity. The clinicalfindings of associated injuries, including injury of sub-clavian vessels, pneumothorax—hemothorax, brachialplexus injury, may be obscured when attention is fo-cused on to the obvious bony disruption. So meticulousphysical examination of chest, neurological and; circu-latory status, and vital signs (number of breaths/minand pulses/min) by the orthopaedic nurse could be help-ful to avoid fatal complications. The orthopaedic nurseshould know the clinical signs of upper limb ischemia,vein thrombosis, pulmonary embolism, pneumothorax,and brachial plexus palsy. Furthermore, the knowledgeof painful conditions after clavicular fracture treat-ment, such as nonunion, malunion, osteoarthritis,hardware failure, and loss of fixation, could help the or-thopaedic nurse to offer appropriate management byordering the appropriate x-rays.
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