Open reduction and internal fixation with bone grafting of clavicular nonunion

Although clavicular fractures are common, nonunion of the clavicle is a rare complication. However, it can be disabling, presenting mainly with pain, limitation of shoulder movement, and/or compression of the brachial plexus. The technical difficulty in securing adequate skeletal stabilization and the unique anatomic features of the clavicle pose a challenge for the orthopedic surgeon.

Sixteen patients with symptomatic nonunion of the clavicle were studied. They were nine men and seven women with a median age of 34 years (range, 15-52 years). The average follow-up was 12.9 months (range, 9-24 months). The nonunion was hypertrophic in 11 cases, atrophic in five cases, and showed pseudoarthrosis in one case. The primary indication for performing the operation was pain in all cases. Five of the 16 cases had previous operations. All cases were treated with open reduction and internal fixation using a reconstruction plate or a dynamic compression plate. Double plating was used in three cases. Autogenous bone grafting was applied in 14 cases and corraline hydroxyapatite in one case.

Fifteen of the 16 fractures eventually healed with complete resolution of the preoperative pain, except in two cases who had persistent mild pain. The hardware was removed after union in one case. One hardware failure required revision and eventually went on to heal. Another hardware failure required removal because of pain. The pain subsided despite the persistent nonunion. The same patient had hematoma at the site of the bone graft and continued to have pain until the last follow-up.

Plating and bone grafting of the clavicle is an effective method of management of painful nonunion, and it has minimal complications.