What are the treatment options for nonunion of a displaced mid left clavicle (collarbone) fracture?

From the Guidelines

Surgical intervention is the recommended treatment for nonunion of a displaced mid left clavicle fracture, as it is associated with higher union rates and better early patient-reported outcomes compared to nonsurgical treatment. According to the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1, surgical treatment of displaced midshaft clavicle fractures in adult patients is associated with higher union rates and better early patient-reported outcomes than nonsurgical treatment.

The standard surgical approach for nonunion of a displaced mid left clavicle fracture is open reduction and internal fixation (ORIF) with plate and screw fixation, which provides stability and promotes bone healing. The procedure typically involves making an incision along the clavicle, reducing the fracture fragments to their anatomical position, and securing them with a contoured plate and multiple screws.

Following surgery, the arm should be immobilized in a sling for 2-4 weeks, with gradual introduction of passive range of motion exercises after the first week, followed by active motion at 4-6 weeks, and strengthening exercises at 6-8 weeks. Full return to activities, especially contact sports, should be delayed until radiographic union is confirmed, usually at 3-6 months.

Some key points to consider when treating nonunion of a displaced mid left clavicle fracture include:

• The importance of achieving anatomical reduction and stable fixation to promote bone healing
• The need for gradual and progressive rehabilitation to avoid complications and promote optimal outcomes
• The potential risks and complications associated with surgical intervention, including infection, hardware irritation, and the possible need for hardware removal after healing, as noted in the study by 1.

It is essential to weigh the potential benefits and risks of surgical intervention and to discuss these with the patient, considering their individual circumstances and preferences. However, based on the current evidence, surgical intervention is the recommended treatment for nonunion of a displaced mid left clavicle fracture, as it offers the best chance of achieving union and optimal functional outcomes 1.

From the Research

Nonunion of a Displaced Mid Left Clavicle Fracture

• The nonunion rate for clavicle fractures has been reported to be between 0.1% and 15% 2.
• Contributing factors to nonunion include severe initial trauma, marked initial displacement and shortening, soft tissue interposition, primary open reduction and internal fixation, refracture, open fracture, polytrauma, and inadequate initial immobilization 2.
• Treatment options for nonunion of a displaced mid left clavicle fracture include nonsurgical management, salvage procedures, and reconstructive procedures 2.
• Open reduction and internal fixation with plates and screws, and with intercalary tricorticocancellous grafts, is a preferred method to obtain union and restore the clavicle to its normal length 2.

Symptoms and Treatment Outcomes

• Clavicular nonunion can be disabling, presenting mainly with pain, limitation of shoulder movement, and/or compression of the brachial plexus 3.
• Open reduction and internal fixation using a reconstruction plate or a dynamic compression plate, with autogenous bone grafting, is an effective method of management of painful nonunion, with minimal complications 3.
• Fifteen of the 16 fractures in one study eventually healed with complete resolution of the preoperative pain, except in two cases who had persistent mild pain 3.

Surgical Intervention

• Open reduction and internal fixation has become a reliable technique to treat complex middle-third clavicle fractures, with the aim of reconstituting the initial curvature and length of the clavicle, restoring a normal connection from the arm to the axial skeleton, and providing stable fixation of the proximal and distal fragments 4.
• The procedure includes steps such as placing the patient in a beach-chair position, making a transverse skin incision, exposing the fracture site, reducing the fragments, and applying a contoured plate to the superior or anterior surface of the clavicle 4.

Complications and Outcomes

• A systematic review of 53 studies reported a mean clinical follow-up of 2.6 years, with 72% of nonunions being of the middle third, and 95% of patients achieving union after the primary nonunion surgery 5.
• The overall complication rate was 17%, with single-plating fixation having significantly faster union time, lower reoperation rate, and hardware removal rate than intramedullary pin fixation 5.
• Bone graft had significantly lower rates of delayed union, but higher complication and reoperation rates than the other groups 5.

Plate Breakage and Nonunion

• The nonunion rate after plate fixation of displaced midshaft clavicular fractures has been reported to be between 0.1 and 15%, with the construct failure rate being approximately 5% 6.
• A risk factor for plate breakage is the increased stress in the free hole area around the fracture zone, and a second surgery for plate renewal and bone grafting may be necessary in a large percentage of these individuals 6.