Nonunion of the fractured clavicle: evaluation, etiology, and treatment

Although often viewed as benign injuries, clavicular fractures can lead to complications, particularly nonunions. The nonunion rate has been reported to be between 0.1% and 15%. 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. A clavicular nonunion is rarely asymptomatic and often results in disability from pain at the site of nonunion, altered shoulder mechanics, or a compression lesion involving the underlying brachial plexus or vascular structures. Treatment options include nonsurgical management, salvage procedures, and reconstructive procedures. The present goal is to obtain union with reconstructive procedures. The fixation methods described range from external fixation to plate and screw osteosynthesis. We prefer open reduction and internal fixation with plates and screws and with intercalary tricorticocancellous grafts to obtain union and restore the clavicle to its normal length.