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Home , Cervical spinal nerve 4, Clavicle, Clavicle fracture, Suprascapular artery

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Complications Associated With Clavicular Fracture

George Mouzopoulos ▼ Emmanuil Morakis ▼ Michalis Stamatakos ▼ Mathaios Tzurbakis

The objective of our literature review was to inform or- subclavian , due to its stable connection with the thopaedic nurses about the complications of clavicular frac- via the cervical , 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 , 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 are in a broad 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- paresis, , 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 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 , subclavian vessels, brachial striction, or compression. Damage of 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 , the Michalis Stamatakos, MD, PhD, Department of General Surgery, Laiko clavicle, the first , and the 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.

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ture is occlusion after compression of 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 (Casbas et al., —hemothorax 2005). It is followed in frequency by damage to brachial Late complications plexus and subclavian artery. Subclavian vein injury Symptoms include distension of and an- Ulnar neuropathy terior thoracic wall , 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 , 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 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 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 apex and pleura, pneumothorax or hemo- bolic phenomena, and compression of brachial plexus can occur from bony spiculae of a displaced clav- (Watanabe & Matsumura, 2005). The most common icular fracture (Steenvoorde, van Lieshout, & Oskam, late vascular 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. subclavian artery spasm. and middle branches in the costoclavicular space in

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adults (Derham, Varghese, Deacon, Spencer, & Curley, intramedullary fixation of the fracture with Kirschner 2007). The distal segment of the fractured clavicle is dis- wires (Ring & Holovacs, 2005). placed because of shoulder weight downward and back- Symptoms can appear either from lesions of the ward, resulting in the formation of a callus by com- whole brachial plexus or from injury to a part of it. pressing the brachial plexus (Kitsis, Marino, Krikler, & Patients often complain of paresthesias or pain of the Birch, 2003). upper limb for a long time after the clavicular fracture. Symptoms usually involve the distribution of the Symptoms are aggravated by abduction, external rota- ulnar and appear weeks or years after a clavicular tion of shoulder, weight lifting, or other activities, fracture (Jupiter & Leibman, 2007). In children, the which require the elevation of upper limb over the head, production of a large callus rarely results in a decrease while symptoms subside with rest (Kitsis et al., 2003). of costoclavicular space, so the brachial plexus is usu- Symptoms can also emerge during sleep. Isolated injury ally not compressed. In addition, in children, the size of of the anterior interosseous, musculocutaneous, and the callus diminishes over the years as the remod- suprascapular nerve after refracture of the clavicle has els; therefore, brachial plexus compression is extremely been described with accompanying sympathetic algody- rare (Krishnan, Mucha, Gupta, & Schackert, 2008). strophy of anterior thoracic wall (Jupiter et al., 2007). Late injuries of brachial plexus in adults can also Diagnosis of brachial plexus injury is made after his- occur because of compression by the fractured seg- tory, physical examination, and the electromyography ments of the clavicle after nonunion or because of for- (EMG) and magnetic resonance imaging (MRI) results mation of a subclavian artery aneurysm (Jupiter & (Middleton, Foley, & Foy, 1995). In addition, displace- Leibman, 2007). In nonunion, especially that of hyper- ment of more than 1 cm in a simple x-ray result may trophic type, the distal fractured segment is displaced suggest a brachial plexus lesion (Kitsis et al., 2003). downward and backward, resulting in compression of Patients should be informed of the possibility of this the brachial plexus between the fractured segment and complication, especially when they have a displaced clavi- first rib (Krishnan et al., 2008; see Figure 2). cle fracture, so that they can inform their doctor of any Although the periosteum in the posterior aspect of new or worrisome symptoms. Special attention is required the clavicle, the subclavius muscle, and the clavicle pro- for closed reduction of clavicular fractures because dis- tect the brachial plexus, direct injury can occur espe- placed bony spiculae can cause a direct injury to brachial cially after a displaced or comminuted fracture of the plexus (Muller, Al-Maiyah, Hui, & Adedapo, 2005). The co- middle part of the clavicle (Derham et al., 2007). existence of clavicular fractures with brachial plexus le- Acute lesions occur most commonly on the posterior sions is suggestive of injury to subclavian vessels. Early ap- branch of the brachial plexus and rarely on the whole pearance of neuropathy carries a better prognosis than a brachial plexus. They manifest as neuroapraxia usually, late appearance (Muller et al., 2005). due to avulsion rather than from direct pressure by the Treatment of acute neuropathy consists of removing fractured ends of clavicle, which are displaced back- the bony fragments from brachial plexus and performing ward (Kitsis et al., 2003). Forces that cause acute in- open reduction and internal fixation. While in late neu- juries of brachial plexus have a downward or posterior ropathy, excision of the large callus or removal of a clavic- direction, resulting in tension of the brachial plexus, ular segment is required (Watanabe & Matsumara, 2005). which is compressed against the transverse processes of . In addition, brachial plexus can be avulsed over the clavicle or directly from the Nonunion of Fractures (Watanabe & Matsumura, 2005). Acute injury of Clavicular fracture nonunion is defined as the absence of brachial plexus can also occur after immobilization of a obvious healing either clinically or radiologically 4–6 clavicular fracture with figure-of-8 bandage or after months after the injury (Havet et al., 2008; see Figure 3).

FIGURE 2. Clavicle fracture nonunion. FIGURE 3. Malunion of clavicular fracture.

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However, 0.13–15% of nonunion occurs in displaced (Brinker et al., 2005). On the contrary, distal clavicle fractures of the middle part of the clavicle (Brinker fractures develop nonunion because they are more un- et al., 2005; Jones, McCluskey, & Curd, 2000). stable. These fractures are displaced easily due to shoul- About 22–23% of nonunion occurs in fractures of the der weight and are difficult to immobilize. Many distal segment of the clavicle. Finally, fractures of the result from severe injury to soft tissue struc- proximal clavicle demonstrate only a 1% nonunion rate tures, which in turn affect the vascularity of the site (Rosenberg, Neumann, & Wallace, 2007). (Kabak et al., 2004). Usually 60–80% of nonunions of the middle part of Because of severe injury of the soft tissue, there is a the clavicle are symptomatic, causing mild to severe decreased blood supply to the fracture site. It is reported symptoms (Rosenberg et al., 2007). Pain at the fracture that open fractures have a higher incidence of nonunion site, which radiates to , , and , is usu- (Jones et al., 2000). For the same reason, appearance of ally reported, especially when the brachial plexus is refracture in a site of a previous healed fracture predis- stimulated. Sometimes there is poor function of the poses to nonunion possibly due to damage in blood sup- shoulder and a diminished range of motion but these ply of the area (Jones et al., 2000). symptoms may also imply injury to the shoulder , About 3.7–4.5% of nonunions occur in displaced the subacromial space, or soft tissue rather than to fractures, which are reduced with an open method nonunion of the clavicle. With nonunion, the patient (Marti, Nolte, Kerkhoffs, Besselaar, & Schaap, 2003). complains of a limited sense of motion or crepitation of A higher incidence of nonunion occurs when semi- the fractured clavicle. The arm is clasped to the chest to tubular plates are used for fixation or when a plate is prevent movement. The proximal fractured part of the fixed with few screws (Chen et al., 2008). clavicle can be palpated inside the muscle In addition, in cases of conservative treatment, (Jeray, 2007). Usually 25% of patients have symptoms shoulder immobilization should remain until complete due to trapping of brachial plexus from the oversized healing is achieved (Simpson & Jupiter, 1996). The pe- callus or due to compression of the subclavian vein riod required for stabilization of fractures of middle from the callus, which results in thoracic outlet syn- shaft of clavicle is 2 weeks for the newborn, 3 weeks for drome (Derham et al., 2007). children, 4–6 weeks for adolescents, and 6 weeks for The examiner finds sensitivity and motion of the adults (Khan et al., 2008). Radiologically confirmed fractured parts in the site of nonunion. The atrophic healing appears much later when compared with clini- nonunion may initially present with severe symptoms, cally assessed healing, and it can take 12 weeks. but as time passes by, symptoms subside (Denard, If there is no sensitivity or movement at the frac- Koval, Cantu, & Weinstein, 2005). ture, then progressively the individual’s physical activ- On the contrary, 80% of the cases with distal clavicle ity can increase even if the healing is not still visible on nonunion are asymptomatic (Nowak, Holgersson, & x-ray results. Larsson, 2005). Symptoms of posttraumatic arthritis of Diagnosis of nonunion is assessed clinically by the acromioclavicular or can imitate motion of the fractured ends and the sensitivity of the that of nonunion, so a careful assessment should be fracture site. Radiographically, it is confirmed with made keeping in mind that symptoms of arthritis ap- simple anteroposterior x-ray result with a cephalic pear many years after the injury (Denard et al., 2005). projection of 45Њ or simple tomography. In case of The following are risk factors for the development of doubt, a computed tomography (CT) can help nonunion of a clavicular fracture (see Table 2): fracture (Rosenberg et al., 2007). site, displacement more than 20 mm, severe injury, When nonunion of clavicle is asymptomatic, there is refracture, previous surgery, and inadequate shoulder no need for treatment. But if nonunion causes pain or immobilization. dysfunction of the shoulder, then operative treatment is Fracture displacement more than 20 mm is the most mandatory and consists of excision of the nonunion tis- important factor for nonunion occurrence because it is sue, internal fixation, and iliac crest grafting (Werner, followed by interposition of soft tissues, which prevent Favre, van Lenthe, & Dumont, 2007). Alternatively, in- healing (Kabak, Halici, Tuncel, Avsarogullari, & tramedullary fixation of the clavicle with K-wires, Karaoglu, 2004). Steinmann pins, Knowles pins, or Hagie pins is possible Almost 85% of nonunions occur in midshaft clavicle (Russo, Visconti, Lorini, & Lombardi, 2007). fractures because these are the most common fractures Malunion Healing of a clavicular fracture with a decrease in TABLE 2. FACTORS PREDISPOSING TO NONUNION OF length by 2 cm or more besides dysmorphy, results in CLAVICULAR FRACTURES poor functionality and persistent pain in adults due to a Displacement of fracture ends for more than 20 mm decrease in muscular strength of the shoulder Fracture of distal part of clavicle (Lazarides & Zafiropoulos, 2006; see Figure 4). Severe injury of soft tissue It seems that a decrease of clavicular length changes Refracture the glenoid position and results in restriction of Open reduction humeral head motion and scapular rotation during Failed internal fixation upper limb movement (Andermahr et al., 2006). At the Inadequate shoulder stabilization same time, angulation of the sternoclavicular joint is observed (Ledger, Leeks, Ackland, & Wang, 2005).

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Radiographically, cystic lesions, osteophytes, steno- sis of the acromioclavicular joint space, and of the distal clavicle especially can be observed with the help of a “Zanca view,” with cephalic inclination of the beam at 10–15Њ (de Abreu, Chung, Wesselly, Jin-Kim, & Resnick, 2005). CT helps estimate the intra-articular extension of the clavicular fracture in the acromioclavicular joint while MRI helps diagnose coexistent injuries of or intra-articular disc of the acromioclavicular joint. Besides, symptoms can be due to rupture of the intra- articular disc of the acromioclavicular joint during the initial injury without radiographic alterations (Buss & Watts, 2003). Intra-articular cortisone and lidocaine injection relieves symptoms, but persistent symptoms can be alleviated 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 the coracoclavicular ligament, and the is sutured to the trapezoid fascia (Tytherleigh-Strong, Gill, Sforza, Copeland, & Levy, 2001). But excision of more than 1 cm of the distal clavicle sometimes is ac- FIGURE 4. Clavicle fracture associated with axillary nerve paresis. companied with pain during motion or at rest, due to decreased muscular strength of the shoulder (Edwards, Wilson, Flores, Koh, & Zhang, 2007). On the contrary, in children, the healing of the frac- Excision of 1 cm of the distal clavicle is accompanied ture with a decrease in length of the clavicle does not with anteroposterior instability (Nissen & Chatterjee, result in severe problems. Thanks to remodeling, chil- 2007). dren have the ability to restore the anatomical architec- Rarely, arthritis of the sternoclavicular joint can ture of the bone (Pujalte & Housner, 2008). occur after a fracture of the proximal 1/3 of the clavicle. Treatment consists of clavicle osteotomy and iliac In this case, the proximal end of the clavicle is excised, crest grafting to achieve initial length and internal fixa- and in its place the clavicular insertion of the stern- tion (McKee, Wild, & Schemitsch, 2004). ocleidomastoid is sutured (Mazzocca, Arciero, & Bicos, Of course, the patient should be informed about the 2007). possibility 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 does Refracture the projection of the bone under the surface itself. Almost 4% of cases occur after the removal of an inter- nal fixation plate (Smekal, Oberladstaetter, Struve, & Posttraumatic Arthritis Krappinger, 2008). The plate should remain in place for 12–18 months, and any athletic activity should be Posttraumatic arthritis usually appears in fractures avoided in the 3 first months after the removal. with intra-articular extension into the acromioclavicu- Alcoholism and comminuted fractures are risk fac- lar joint, after type III fractures that remain undiag- tors of refracture (Kim & McKee, 2008). Furthermore, nosed (Beals & Sauser, 2006). In these fractures, symp- clavicle refracture predisposes to nonunion. tomatic arthritis occurs in 15% of the cases (Buss & Watts, 2003). In 3% of the cases of posttraumatic arthritis after a fracture of the midshaft of the clavicle, Complications After Sternal there are no evident radiographic lesions (Beals & Sauser, 2006). Clavicular Fracture Dislocation In midshaft fractures, possibly the decrease of the Sternoclavicular fracture-dislocation is a very danger- clavicular length alters the load on the acromioclavicu- ous situation, as the proximal portion is very close to lar joint and results in late degenerative changes of the vital organs. Many complications have been reported joint (Clarke & McCann, 2000). Symptoms arise due to secondary to the retrosternal fracture-dislocation such pain of the acromioclavicular joint or due to osteophyte as pneumothorax, compression on the subclavian formation in the inferior aspect of the clavicular distal artery, compression of the right , end, which by compressing the rotator cuff and sub- laceration of the superior vena cava, thoracic outlet syn- acromial bursa result in subacromial impingement syn- drome, brachial plexus compression, rupture of esoph- drome (Beals et al., 2006). This condition predisposes to agus, tracheoesophangeal fistula, onset of snoring, rupture of rotator cuff, especially when the osteophytes hoarseness of the voice, stridor, and dysphagia size is more than 2 mm (Noble, 2003). (Macdonald & Lapointe, 2008).

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Beals, R. K., & Sauser, D. D. (2006). Nontraumatic disor- TABLE 3. COMPLICATIONS OF SURGICAL TREATMENT ders of the clavicle. Journal of the American Academy of Nonunion Orthopaedic Surgeons, 14, 205–214. Brinker, M. R., Edwards, T. B., & O’Connor, D. P. (2005). Osteosynthesis device failure Estimating the risk of nonunion following nonoperative Pin migration treatment of a clavicular fracture. Journal of Bone and Trapping of brachial plexus or subclavian vein Joint Surgery. American Volume, 87, 676–677. Paresthesia Buss, D. D., & Watts, J. D. (2003). Acromioclavicular in- Dysmorphic scar juries in the throwing athlete. Clinics in Sports Medicine, 22, 327–341, vii. Casbas, L., Chauffour, X., Cau, J., Bossavy, J. P., Midy, D., Baste, J. C., et al. (2005). Post-traumatic thoracic outlet Complications From syndromes. Annals of Vascular Surgery, 19, 25–28. Chen, C. H., Chen, J. C., Wang, C., Tien, Y. C., Chang, J. K., Surgical Procedures & Hung, S. H. (2008). Semitubular plates for acutely dis- Significant complications can result following open placed midclavicular fractures: A retrospective study of reduction and internal fixation (see Table 3). Use of 111 patients followed for 2.5 to 6 years. Journal of osteosynthesis with short plates (using less than 2 holes Orthopaedic Trauma, 22, 463–466. to each end of the fracture) may lead to hardware fail- Clarke, H. D., & McCann, P. D. (2000). Acromioclavicular ure and loss of fixation (Proubasta et al., 2002). joint injuries. Orthopaedic Clinics of North America, 31, In addition, migration of osteosynthesis pins to 177–187. Coupe, B. D., Wimhurst, J. A., Indar, R., Calder, D. A., & lungs, aorta, orbit, or spinal column can occur after in- Patel, A. D. (2005). A new approach for plate fixation of tramedullary fixation of the clavicle (Regel, Pospiech, midshaft clavicular fractures. Injury, 36, 1166–1171. Aalders, & Ruchholtz, 2002). Excessive grafting of the Dath, R., Nashi, M., Sharma, Y., & Muddu, B. N. (2004). fracture, especially in the inferior aspect of the clavicle, Pneumothorax complicating isolated clavicle fracture. can result in trapping of brachial plexus or subclavian Journal, 21, 395–396. vein. So these forms of treatment are not recom- Davidovic, L., Lotina, S., Kostic, D., Pavlovic, S., mended. Jakovljevic, N., & Djoric, P. (2001). [The upper thoracic When the incision is performed exactly above the outlet vascular syndrome]. Acta Chirurgica Iugoslavica, clavicle, then there is a possibility of supraclavicular 48, 31–36. nerve injury, resulting in hypoesthesia or dysesthesia of de Abreu, M. R., Chung, C. B., Wesselly, M., Jin-Kim, H., & Resnick, D. (2005). Acromioclavicular joint osteoarthri- the region. It is suggested that incision should be made tis: comparison of findings derived from MR imaging below the clavicle to obtain better results (Coupe, and conventional . Clinical Imaging, 29, Wimhurst, Indar, Calder, & Patel, 2005). 273–277. Finally, if the incision is not according to Langer’s Denard, P. J., Koval, K. J., Cantu, R. V., & Weinstein, J. N. lines, the possibility for a dysmorphic and hypertrophic (2005). Management of midshaft clavicle fractures in scar is common (Der, Davison, & Dias, 2002). adults. American Journal of Orthopedics,34, 527–536. Der, T. J., Davison, J. N., & Dias, J. J. (2002). Clavicular fracture non-union surgical outcome and complica- Conclusion tions. Injury, 33, 135–143. Clavicle fractures usually heal uneventfully and are Derham, C., Varghese, M., Deacon, P., Spencer, N., & rarely complicated by significant morbidity. The clinical Curley, P. (2007). Brachial plexus palsy secondary to clavicular nonunion. Journal of Trauma, 63, E105– findings of associated injuries, including injury of sub- E107. clavian vessels, pneumothorax—hemothorax, brachial Edwards, S. L., Wilson, N. A., Flores, S. E., Koh, J. L., & plexus injury, may be obscured when attention is fo- Zhang, L. Q. (2007). Arthroscopic distal clavicle resec- cused on to the obvious bony disruption. So meticulous tion: A biomechanical analysis of resection length and physical examination of chest, neurological and; circu- joint compliance in a cadaveric model. Arthroscopy, 23, latory status, and vital signs (number of breaths/min 1278–1284. and pulses/min) by the orthopaedic nurse could be help- Garnier, D., Chevalier, J., Ducasse, E., Modine, T., ful to avoid fatal complications. The orthopaedic nurse Espagne, P., & Puppinck, P. (2003). [Arterial complica- should know the clinical signs of upper limb ischemia, tions of thoracic outlet syndrome and pseudarthrosis of vein thrombosis, pulmonary embolism, pneumothorax, the clavicle: Three patients]. Journal des Maladies Vasculaires, 28, 79–84. and brachial plexus palsy. Furthermore, the knowledge Hanby, C. K., Pasque, C. B., & Sullivan, J. A. (2003). Medial of painful conditions after clavicular fracture treat- clavicle physis fracture with posterior displacement and ment, such as nonunion, malunion, osteoarthritis, vascular compromise: The value of three-dimensional hardware failure, and loss of fixation, could help the or- computed tomography and duplex ultrasound. thopaedic nurse to offer appropriate management by Orthopedics, 26, 81–84. ordering the appropriate x-rays. Havet, E., Duparc, F., Tobenas-Dujardin, A. C., Muller, J. M., Delas, B., & Freger, P. (2008). Vascular anatomical REFERENCES basis of clavicular non-union. Surgical and Radiologic Andermahr, J., Jubel, A., Elsner, A., Prokop, A., Tsikaras, P., , 30, 23–28. Jupiter, J. et al. (2006). Malunion of the clavicle causes Hegemann, S., Kleining, R., Schindler, H. G., & Holthusen, significant glenoid malposition: A quantitative anatomic H. (2005). [Kirschner wire migration in the contralateral investigation. Surgical and Radiologic Anatomy, 28, lung after osteosynthesis of a clavicular fracture]. Der 447–456. Unfallchirurg, 108, 991–993.

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Jeray, K. J. (2007). Acute midshaft clavicular fracture. ular fracture. Journal of Bone and Joint Surgery. British Journal of the American Academy of Orthopaedic Volume, 87, 568–570. Surgeons, 15, 239–248. Nikolaides, A. P., Dermon, A. R., Papavasiliou, K. A., & Jones, G. L., McCluskey, G. M., III, & Curd, D. T. (2000). Kirkos, J. M. (2006). Coracoclavicular joint degenera- Nonunion of the fractured clavicle: evaluation, etiology, tion, an unusual cause of painful shoulder: A case report. and treatment. Journal of the Southern Orthopaedic Acta Orthopaedica Belgica, 72, 90–92. Association, 9, 43–54. Nissen, C. W., & Chatterjee, A. (2007). Type III acromioclav- Jupiter, J. B., & Leibman, M. I. (2007). Supraclavicular icular separation: Results of a recent survey on its man- nerve entrapment due to clavicular fracture callus. agement. American Journal of Orthopedics, 36, 89–93. Journal of Shoulder and Elbow Surgery, 16, e13–e14. Noble, J. S. (2003). 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