NOR200061.qxd 9/11/09 1:23 PM Page 217 Complications Associated With Clavicular Fracture George Mouzopoulos ▼ Emmanuil Morakis ▼ Michalis Stamatakos ▼ Mathaios Tzurbakis The objective of our literature review was to inform or- subclavian vein, due to its stable connection with the thopaedic nurses about the complications of clavicular frac- clavicle via the cervical fascia, can also be subjected to ture, which are easily misdiagnosed. For this purpose, we injuries (Casbas et al., 2005). Damage to the internal searched MEDLINE (1965–2005) using the key words clavicle, jugular vein, the suprascapular artery, the axillary, and fracture, and complications. Fractures of the clavicle are usu- carotid artery after a clavicular fracture has also been ally thought to be easily managed by symptomatic treatment reported (Katras et al., 2001). About 50% of injuries to the subclavian arteries are in a broad arm sling. However, it is well recognized that not due to fractures of the clavicle because the proximal all clavicular fractures have a good outcome. Displaced or part is dislocated superiorly by the sternocleidomas- comminuted clavicle fractures are associated with complica- toid, causing damage to the vessel (Sodhi, Arora, & tions such as subclavian vessels injury, hemopneumothorax, Khandelwal, 2007). If no injury happens during the ini- brachial plexus paresis, nonunion, malunion, posttraumatic tial displacement of the fractured part, then it is un- arthritis, refracture, and other complications related to os- likely to happen later, because the distal segment is dis- teosynthesis. Herein, we describe what the orthopaedic nurse placed downward and forward due to shoulder weight, should know about the complications of clavicular fractures. while the proximal segment is displaced upwards and behind the sternocleidomastoid, without coming into contact with the subclavian vessels (Katras et al., 2001). Introduction Nevertheless, there have been reports of injury of sub- It is estimated that fractures of the clavicle represent 4% clavian vessels following nondisplaced fractures such as of total human fractures (Dath, Nashi, Sharma, & greenstick fractures or fractures with a mild angulation Muddu, 2004). These fractures are usually treated con- (Sodhi et al., 2007; see Figure 1). Late damage due to servatively with a broad arm sling and have a good func- compression by a large callus or nonunion is rare tional outcome (Brinker, Edwards, & O’Connor, 2005). (Casbas et al., 2005). Nevertheless, because of contiguity of the clavicle with Vascular injuries include traction, occlusion, con- vital organs such as lungs, subclavian vessels, brachial striction, or compression. Damage of subclavian artery plexus, and heart, an injury to these organs after a clav- appears usually early after the initial injury, while rup- icular fracture is possible. There are many references in ture of vessels may lead to life-threatening hemorrhage. the English literature about the treatment of clavicular Meanwhile, arterial thrombosis or occlusion causes fractures and to the factors that may predispose to its limb ischemia. Signs of limb ischemia or hemorrhage two major complications: nonunion and malunion. should raise a suspicion. The color and temperature of In this literature review, we reviewed the major com- the upper extremity can be normal, while the absence of plications after a clavicular fracture to help the or- pulse, the appearance of large hematomas in supraclav- thopaedic nurse to recognize these painful situations or icular region, and the presence of a systolic bruit and a even fatal complications. Complications after a fracture of the clavicle are summarized in Table 1. George Mouzopoulos, MD, MSc, Orthopaedic Department of Injury of Subclavian Vessels Evangelismos Hospital, Athens, Greece. Emmanuil Morakis, MD, Orthopaedic Department of Evangelismos Injury to the subclavian vessels is rare because these Hospital, Athens, Greece. structures are protected by the subclavius muscle, the Michalis Stamatakos, MD, PhD, Department of General Surgery, Laiko clavicle, the first rib, and the deep cervical fascia Hospital, University of Athens, Athens, Greece. (Kendall, Burton, & Cushing, 2000). Usually, vascular Mathaios Tzurbakis, MD, PhD, Orthopaedic Department of injuries after a clavicular fracture occur at the proximal Evangelismos Hospital, Athens, Greece. or middle part of the subclavian artery, where vertebral The authors have disclosed that they have no financial relationships and thoracic arteries have their origin. In addition, the related to this article. Orthopaedic Nursing • September/October 2009 • Volume 28 • Number 5 217 NOR200061.qxd 9/11/09 1:23 PM Page 218 ture is occlusion after compression of subclavian vein TABLE 1. POTENTIAL COMPLICATIONS ASSOCIATED WITH between the fractured clavicle and the first rib CLAVICULAR FRACTURES (Davidovic et al., 2001). Obstruction occurs where the Early complications subclavian vein traverses the first rib and passes below Subclavian or carotid artery injury the subclavius muscle and costoclavicular ligament and Neuroapraxia of posterior branches of brachial plexus is compressed by the clavipectoral fascia (Casbas et al., Pneumothorax—hemothorax 2005). It is followed in frequency by damage to brachial Late complications plexus and subclavian artery. Subclavian vein injury Symptoms include distension of upper limb and an- Ulnar neuropathy terior thoracic wall veins, which is minimized with Nonunion downward shoulder movement (Kochhar, Jayadev, Malunion Smith, Griffiths, & Seehra, 2008). The presence of vein Posttraumatic arthritis thrombosis is not dangerous for limb viability but can Refracture result in pulmonary embolism. In these situations, sud- Complications of surgical treatment den dyspnea, pleuritic chest pain, hemoptysis, syncope or shock, and tachypnea can indicate the presence of pulmonary embolism (West, Goodacre, & Sampson, 2007). In addition, fractures of the proximal part of the palpable pulsatile mass should lead to the diagnosis of a clavicle can be complicated by carotid artery obstruc- serious vascular injury (Stokkeland, Soreide, & tion, caused either by compression from a fractured Fjetland, 2007). According to Sturm and Cicero (1983), bony segment or by production of a large callus, causing criteria for performing an angiography to exclude a syncopal episodes (Hanby, Pasque, & Sullivan, 2003). supraclavicular artery injury comprise fracture of first Initially, vascular injury could be asymptomatic and be rib, reduction or absence of radial artery pulses, palpa- missed, resulting later in worsening symptoms of sub- ble hematoma in supraclavicular region, mediastinum clavian artery occlusion, and pose a danger to the limb’s widening in chest x-ray, and injury of brachial plexus. viability. Arterial pressure of both upper extremities Angiography is the method of choice for the diagnosis should be measured, and if there is any difference, the of a subclavian artery injury but is not always helpful limb should be investigated by angiography. for the diagnosis of a posttraumatic aneurysm, espe- Initial therapy of arterial injury should include man- cially in cases where the vascular lumen is narrow and agement of hypovolemia and associated injuries (he- no adequate amount of contrast medium can enter mopneumothorax), and later an end-to-end suturing of (Watanabe & Matsumura, 2005). In addition, Doppler the lesion or a venous grafting should be performed. ultrasonography is not useful because the interference Finally, the fracture of clavicle should be fixed surgically of clavicle and ribs results in a poor imaging of the ves- (Casbas et al., 2005). Treatment of subclavian vein in- sels (Garnier et al., 2003). jury consists of removal of the callus, which is responsi- Constriction of vessels can be complicated later with ble for the compression (Kochhar et al., 2008). thrombosis. Differential diagnosis of arterial constric- tion following an arterial rupture is difficult, but re- gional blockade of the sympathetic nervous system can Pneumothorax—Hemothorax help (Weh & von Torklus, 1980). Damage of the vascu- Because of contiguity of the middle part of the clavicle lar wall can result in aneurysm formation, thromboem- with the lung apex and pleura, pneumothorax or hemo- bolic phenomena, and compression of brachial plexus thorax can occur from bony spiculae of a displaced clav- (Watanabe & Matsumura, 2005). The most common icular fracture (Steenvoorde, van Lieshout, & Oskam, late vascular complication following a clavicular frac- 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 in 3% of clavicle fractures, and the coexistence of scapular or upper ribs fractures should increase the suspicion of their existence (Weening et al., 2005). Treatment con- sists of drainage of the hemothorax and conservative treatment or operative fixation of the fracture. Brachial Plexus Injury About 1% of brachial plexus injuries occur following a fracture of the clavicle, and symptoms can appear early or late (Ring & Holovacs, 2005). Most common is the late presentation of a brachial plexus injury due to cre- ation of an oversized callus that entraps the posterior FIGURE 1. Clavicle fracture subclavian artery spasm. and middle branches in the