Clavicle nonunion and plate breakage after locking compression plate fixation of displaced midshaft clavicular fractures

Abstract

Open reduction and plate fixation have been widely used for the treatment of displaced midshaft clavicular fractures (DMCF). The nonunion rate after plate fixation of DMCF has been reported to be between 0.1 and 15% and the construct failure rate is approximately 5%. Few studies have discussed the risk factors of construct failure. The aim of the present study was to identify possible risk factors of construct failure in plate fixation of DMCF and discuss the subsequent treatment strategies. Six patients who experienced plate breakage and clavicle nonunion between 2015 and 2017 were evaluated. All these patients were treated with open reduction and plate fixation of DMCF using a 3.5-mm locking compression plate. The plate breakage occurred 3-6 months after the initial injury. After the diagnosis of plate breakage, four patients underwent surgical management and two patients underwent nonoperative treatment. Potential risk factors for construct failure and efficacy of the subsequent treatment strategies were analyzed. We found that a risk factor for plate breakage was the increased stress in free hole area around the fracture zone. A second surgery for plate renewal and bone grafting may be necessary in a large percentage of these individuals. Based on the results of this study, our recommendation is that monocortical screws or simple obturators for the holes around the fracture zone should be used to protect the comminuted fragment for further damage and enhance plate strength. If a clavicle nonunion and plate breakage does occur, surgical repair and bone grafting provide high union rates and should be a necessary remedy.

Keywords: clavicle nonunion; displaced midshaft clavicular fractures; locking compression plate; plate breakage.

Figure 1.

A case with plate breakage and clavicle nonunion after open surgery was treated with plate renewal and bone grafting. (A) CT scanning of the right clavicle in the emergency department showing the clavicle fracture zone (white arrow). (B) X-ray AP view of the right clavicle 2 days after open surgery showing good fracture reduction. (C) X-ray AP view of the right clavicle 5 months after open surgery showing clavicle nonunion and plate breakage (white arrow). (D) X-ray AP view of the right clavicle 2 days after the renewal of plate and bone grafting (white arrow. (E) Intraoperative image showed the plate breakage point was at the free hole area around the fracture zone. (F) X-ray AP view of the right clavicle 3 months after the revision surgery showing union of the fracture. AP, anteroposterior.

Figure 2.

A case with plate breakage and clavicle nonunion after open surgery was treated with plate renewal. (A) X-ray AP view of the right clavicle in the emergency department showing the clavicle fracture zone (white arrow). (B) X-ray AP view of the right clavicle 2 days after open surgery showing the good fracture reduction. (C) X-ray AP view of the right clavicle 5 months after open surgery showed the clavicle nonunion and plate breakage (white arrow). (D) X-ray AP view of the right clavicle 2 days after renewal of the plate (white arrow). (E) X-ray AP view of the right clavicle 3 months after the revision surgery showing union of the fracture (white arrow). AP, anteroposterior.

Figure 3.

A case with plate breakage and clavicle nonunion after open surgery was treated with nonoperative management. (A) X-ray AP view of the right clavicle in the emergency department showing the clavicle fracture zone (white arrow). (B) X-ray AP view of the right clavicle 2 days after open surgery showing the good fracture reduction. (C) X-ray AP view of the right clavicle 6 months after open surgery showing the clavicle nonunion and plate breakage (white arrow). (D) CT scan of the right clavicle 12 months after the open surgery showing little union of the fracture (white arrow), and the possible need for revision surgery in the near future. AP, anteroposterior.

Figure 4.

A case with plate breakage and clavicle nonunion after open surgery was treated with nonoperative management. (A) X-ray AP view of the right clavicle in the emergency department showing the clavicle fracture zone (white arrow). (B) X-ray AP view of the right clavicle 2 days after open surgery showing good fracture reduction. (C) X-ray AP view of the right clavicle 4 months after open surgery showing the clavicle nonunion and plate breakage (white arrow). (D) X-ray AP view of the right clavicle 6 months after open surgery showing the clavicle nonunion and plate breakage (white arrow). (E) X-ray AP view of the right clavicle 9 months after open surgery (white arrow). (F) CT scan of the right clavicle 12 months after open surgery showed partial fracture union (white arrow). AP, anteroposterior.