Midshaft Clavicle Malunion with an Atypical Posterior Apex Deformity

Amro Alhoukail¹ and Ross Leighton²*

Received: May 10, 2018;   Published: May 15, 2018

DOI: 10.32474/OSMOAJ.2018.01.000110

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Abstract

Purpose: We are presenting this pattern of a rare variant of a clavicle malunion with an apex posterior-inferior deformity. This occurred in an elite major junior hockey player during his draft season. This illustrates that such a deformity will most likely result in shoulder weakness, altered shoulder mechanics and may cause brachial plexus neurological findings. In addition, this can cause associated sterno-clavicular deformity which can lead to sternoclavicular joint subluxation secondary to the increased strain placed on the sternoclavicular joint from an apex posterior inferior malunited clavicle. Deformity of > 20 degrees in any direction interferes with normal motion and normal cortical strength even in a young patient.

Introduction: Symptomatic malunion is fortunately less frequently observed (4) since the significant shift to operative treatment for displaced shortened mid shaft clavicle fractures. Symptomatic patients are typically those with marked displacement and significant shortening at the fracture site. Patient’s report weakness of the involved shoulder with rapid fatigability plus an increased deformity comes with an increased risk of recurrent fractures. Although not commonly described in the literature, clavicle malunion usually has a very consistent deformity pattern. As illustrated by McKee et al, the patient usually presents with a complex three dimensional deformity with shortening, an anterior apex at the fracture site and associated joint pain around the shoulder or sternum (6). The influence of the coraco-clavicular and a cromio-clavicular ligaments on the fracture fragments is hypothesized to cause an effect on the displacement of these fractures which involves the lateral segment of the clavicle being carried forward by virtue of its retained a cromio-clavicular and residual coraco-clavicular attachments. Angulations are more acute the closer the break is to these pivot points. This has had associated significant alteration in normal clavico-scapular motion.

Method: Case report and literature review.

Conclusion: Symptomatic clavicular malunion is rare but definitely higher with non-operative management and can cause discomfort and shoulder weakness. Neurological symptoms and signs are more likely to occur in inferior malunited clavicle, particularly with an inferior-posterior deformity. We illustrated the steps necessary to correct all deformities and lengthen the clavicle using a long working length precountored plate construct. This has improved the clinical symptoms of the patient and illuminated the risk of repeat fracture due to deformity. Plate removal is planned but is still an unanswered question.

Keywords: Mid Shaft; Clavicle Symptomatic; Malunion; Nonunion; Deformity

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