Neurovascular Complications Associated With Clavicle Fractures: A Report of Three Cases and Recommendations

Abstract

Neurovascular complications associated with clavicular shaft fractures can manifest at presentation, develop gradually over time, or potentially be iatrogenically induced. Conducting a thorough neurovascular examination and, when warranted, pursuing further investigation through modalities such as CT angiogram, MRI, and nerve conduction studies (NCS) are crucial for early diagnosis and pre-operative planning. This comprehensive approach enhances patient outcomes by facilitating timely intervention and addressing any underlying neurovascular issues associated with the fracture. Delayed fixation raises the risk of brachial plexus injury, highlighting the importance of timely intervention. This study aims to explore neurovascular complications associated with clavicle fractures through case presentations and provide management recommendations.

Keywords: brachial plexus; clavicle; fracture; subclavian vessels; thoracic outlet syndrome.

Figure 1. Case 1: Initial shoulder X-ray showing a right midshaft clavicle fracture, which appears to be non-displaced

Figure 2. Case 1: Two-week (a and b) and three-month (c and d) follow-up X-ray revealing additional displacement and shortening, with medialization of the lateral clavicle fragment

a and c depict the anterior-posterior shoulder X-ray, while b and d show the 20° cephalic tilt shoulder X-ray, highlighting notable medialization and shortening.

Figure 3. Case 1: Pre-operative shoulder CT scan depicting nonunion and abundant callus at the fracture site, with the axillary vein closely situated

a (coronal cut) and b and c (axial cut) highlight these features. d displays the CT angiogram, indicating compression of the axillary vein by the lateral segment at the fracture site.

Figure 4. Case 1: Post-operative shoulder X-ray illustrating a healed fracture with a satisfactory position

Figure 5. Case 2: Left shoulder X-ray, including initial AP (a) and cephalic tilt (b), revealing significant displacement and shortening, and six-week (three months) (c and d) follow-up X-ray indicating nonunion

AP: anterior-posterior

Figure 6. Case 2: CT angiogram illustrating florid callus formation, resulting in a marked reduction in the subclavicular space

a shows the coronal view, while b shows the sagittal view.

Figure 7. Case 2: Intra-operative fluoroscopic evaluation revealing good reduction of the left clavicle midshaft fracture

Figure 8. Case 3: Initial left shoulder X-ray exhibiting significant displacement, shortening, and a butterfly fragment

a displays the AP view, while b shows the cephalic tilt view. AP: anterior-posterior

Figure 9. Case 3: Plexus MRI revealing direct compression of the plexus by both the lateral fracture end and the butterfly fragment

a, b, and c show the coronal, axial, and coronal views, respectively. The arrow indicates the site of compression.

Figure 10. Case 3: a displaying intra-operative fluoroscopic evaluation, indicating satisfactory reduction, and b showing post-operative MRI, revealing the plexus appearing in continuity