What is the treatment for a nonhealing green stick (incomplete) fracture of the clavicle?

Treatment of Nonhealing Greenstick Clavicle Fracture

A nonhealing greenstick clavicle fracture requires surgical intervention with open reduction and internal fixation using plate and screw fixation combined with bone grafting to achieve union and restore clavicular length. 1

Understanding the Clinical Problem

A greenstick fracture that fails to heal represents a nonunion, which is rarely asymptomatic and typically causes significant disability from pain, altered shoulder mechanics, or potential neurovascular compression. 1 While the overall nonunion rate for clavicle fractures ranges from 0.1% to 15%, contributing factors include severe initial trauma, marked displacement, soft tissue interposition, inadequate initial immobilization, and open fractures. 1

Surgical Management Algorithm

Primary Treatment Approach

• Open reduction and internal fixation with plate and screw osteosynthesis is the preferred reconstructive procedure for clavicular nonunion. 1
• Intercalary tricorticocancellous bone grafts should be used to obtain union and restore the clavicle to its normal length. 1

Plate Selection and Positioning

• Use manufacturer-contoured anatomic clavicle plates, which have lower rates of implant removal or deformation compared to non-precontoured plates. 2
• Consider anterior inferior plating over superior plating, as it may lead to lower implant removal rates. 2
• Intramedullary nailing provides equivalent long-term clinical outcomes to plate fixation with similar complication rates, though plate fixation may be more beneficial in the presence of fracture comminution. 2, 3

Critical Assessment Before Surgery

Radiographic Evaluation

• Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and nonunion characteristics. 2, 3
• Assess for displacement >100% (no cortical contact between fragments), which indicates urgent need for intervention. 2

Patient Risk Factors

• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes; counsel patients on smoking cessation before and after surgery. 2
• Evaluate for polytrauma, which may have contributed to the initial nonunion. 1

Expected Outcomes

Surgical treatment of nonunion provides higher union rates and better patient-reported outcomes compared to continued conservative management. 2 The goal is to achieve bony union while restoring normal clavicular length and shoulder mechanics, which nonsurgical management cannot accomplish in established nonunions. 1

Common Pitfalls to Avoid

• Do not attempt continued conservative management for established nonunion, as it rarely resolves spontaneously and causes ongoing disability. 1
• Avoid using non-precontoured plates, which have higher rates of hardware-related complications requiring removal. 2
• Do not overlook the need for bone grafting, as simple fixation without grafting may not achieve union in established nonunions. 1