Nonunion of the Fractured Clavicle: Evaluation, Etiology, and Treatment

Grant L. Jones, MD, George M. McCluskey III, MD, David T. Curd, MS, Hughston Clinic PC,
the Hughston Shoulder Service, and the Hughston Sports Medicine Foundation Inc, Columbus,
Ga (Dr. Jones is now with the Department of Orthopaedic Surgery, Ohio State University,
Columbus, Ohio.)
J South Orthop Assoc. 2000;9(1)
Abstract
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.
Introduction
From 5% to 10% of all fractures are clavicular fractures,[1,2] and the incidence has increased over
the past decades.[3] Clavicular fractures are often viewed as entirely benign lesions with a high
rate of healing and excellent functional results. However, from the time the fracture initially
occurs to the time the fracture heals, many complications can occur. Berkheiser[4] showed the
problem of complications after clavicular fractures. He reported nine cases of nonunion (six with
brachial plexus injury) and attributed this high complication rate to the increased energy of the
initial trauma. Other authors[2,5-8] have also reported potential problems with these fractures.
Clinicians use various criteria to define a nonunion. Nonunion usually describes a fracture that
has not adequately healed between 6 and 9 months after injury; delayed union, a fracture that has
not healed after 3 to 6 months.[9,10] However, some clinicians believe that a clavicular fracture is
nonunited if the fracture has not adequately healed 4 months after injury.[1,8,11,12]
The nonunion rate after closed fracture treatment has been reported to be from 0.1% to 15% (Fig
1).[2,13] Rowe[5] and Neer[2] discovered that the nonunion rate was even higher in patients treated
with surgery than in patients treated without surgery (3.7% versus 0.8% and 4.6% versus 0.1%,
respectively). Significant disability can result from nonunion-related problems, such as pain,
altered shoulder mechanics, and neurovascular injury; thus, surgical treatment may be necessary
to achieve union. Successful treatment of a clavicular nonunion is often a difficult task and

requires a thorough understanding of the anatomy and function of the clavicle, the etiology and
the symptomatology of nonunion, and the wide array of treatment options.

Figure 1.

Nonunion clavicular fracture.

The purpose of this paper is to review the current and past literature on the etiology and
treatment of clavicular nonunions. We also present our series of 14 clavicular nonunions treated
with plate and screw osteosynthesis and tricorticocancellous bone grafting.
The clavicle is the only long bone to ossify by the intramembranous process and is the first bone
to ossify (fifth week of fetal life).[14] The ossification commences at a centrally situated
ossification center. Secondary centers of ossification develop at both ends of the growing bone,
with the medial ossification center ultimately accounting for up to 80% of the longitudinal
growth.[1]
The clavicle's configuration is a double curvature with a convex anterior curve medially and a
convex posterior curve laterally.[14] The distal and proximal ends of the clavicle are secured
firmly by strong ligaments and muscle attachments, whereas the central section is relatively free
of protective attachments.[5] The weight of the arm and the pull of the pectoralis major muscle
produce an inferior and medial force to the lateral clavicle, while the sternocleidomastoid muscle
creates a superior force vector medially (Fig 2).[15] During elevation of the arm, the clavicle
angles upward by 30 and posteriorly by 35 and rotates about its longitudinal axis as much as
50.[1] These motions combine to produce bending moments in the coronal and sagittal planes,

which are largely concentrated at the middle section of the clavicle.[1] Anatomically, the middle
third of the clavicle has relatively sparse cancellous bone. These large forces concentrated in an
area of sparse cancellous bone and few soft tissue attachments explain why the middle third is
the most commonly fractured section of the clavicle and why it is more prone to nonunion than
other sections of the clavicle.[15]

Figure 2.

Weight of arm and pull of pectoralis major muscle produce inferior and medial force vector to
lateral aspect of clavicle, while sternocleidomastoid muscle creates superior force vector
medially.
The clavicle serves several important purposes.[14] First, it acts as a rigid base for muscular
attachments. Next, it forms a strut holding the glenohumeral joint in the parasagittal plane, thus
increasing the range of motion of the shoulder joint and the range of grasp in three-dimensional
space for the hand. It increases the power of the arm-trunk mechanism above the shoulder level.
The clavicle also provides a protective mechanism for the brachial plexus and the vascular
structures of the neck and extremity. Finally, it serves a cosmetic function by providing a gentle

curve to the base of the neck. Absence of the clavicle results in a foreshortened appearance to the
shoulder girdle. Therefore, fracture, loss, or shortening of the clavicle can result in significant
disability. That is why it is important to try to restore the continuity and normal length of the
clavicle when treating a clavicular nonunion.
Many factors leading to nonunion have been discussed in the literature. These factors include
severe initial trauma, marked initial displacement and shortening, soft tissue interposition,
inadequate initial immobilization, primary open reduction and internal fixation, refracture, open
fractures, and polytrauma.[2,4-8,11-13,16-21] Berkheiser[4] first discussed the concept that the severity of
the injury and resultant initial displacement of the fracture contribute to the development of
nonunion. Similarly, Ghormley et al[6] attributed nonunion to severe initial displacement in 10 of
20 cases. Manske and Szabo[12] discovered during surgery that 50% of their patients with
displaced atrophic nonunions had interposed trapezius muscle at the fracture site, which
contributed to nonunion. More recently, in a retrospective study of 242 displaced middle-third
fractures, Hill et al[13] found that initial shortening of the fracture of 2 cm had a highly
significant association with nonunion.
Many authors have attributed the development of nonunion to inadequate initial immobilization.
Ghormley et al[6] stated that the most important way to prevent nonunion is through adequate
external immobilization. Rowe[5] wrote that the figure-of-eight splint is often inadequate because
the strap can slide laterally and actually increase the deformity. Therefore, he often used a
modified half-shoulder spica to treat displaced fractures. Sakellarides[8] and Wilkins and
Johnston[11] suggested that decreased immobilization time can contribute to nonunion, but they
could not define a significant relationship between a specific duration of immobilization and the
development of nonunion. Other studies, however, have noted no difference in outcomes with the
various types of conservative treatment. Andersen et al[22] found similar union rates, alignment of
fractures, functional results, and cosmetic results in patients treated with figure-of-eight
immobilization compared with the results in patients treated with only a simple sling for comfort.
Many studies have cited primary operative intervention for closed fractures as a leading cause of
nonunion.[2,5,8,17] As mentioned previously, Neer[2] noted a 0.1% nonunion rate in closed fractures
treated conservatively and a 4.6% nonunion rate in those treated with primary open reduction
and internal fixation. Similarly, Rowe[5] cited a 0.8% nonunion rate with closed treatment and a
3.7% nonunion rate with open treatment. More recent studies have also noted a high
complication rate with primary open reduction and internal fixation. Bostman et al[23] discovered
a 23% complication rate with primary open procedures, including nonunion (3%), delayed union
(3%), and malunion rates (12%). Similarly, Poigenfurst et al[24] reported four plate fractures
before union and four refractures after plate removal among 102 patients treated with primary
open reduction and internal fixation. Finally, Schwarz and Hocker[25] noted a 12% failure rate
with primary open reduction and internal fixation of 36 clavicular fractures.
Authors of other studies, however, have reported that the procedure of primary open reduction
and internal fixation does not necessarily predispose the fracture to nonunion.[26-28] These
surgeons believe that primary open reduction and internal fixation should be done on
significantly shortened and displaced fractures to prevent nonunion or malunion and the resultant
disability. Two large studies of conservatively treated clavicular fractures point out the problems

in the nonoperative management of displaced fractures. Hill et al[13] reviewed 52 patients who
had displaced fractures of the middle third of the clavicle. Fifteen percent of these patients had a
nonunion, and 31% reported unsatisfactory results. These authors found a significant correlation
between initial shortening of 2 cm and nonunion and between final shortening of 2 cm and
unsatisfactory results. Eskola et al[16] reported that 30% of patients with clavicular fractures had
neurologic symptoms after the fracture healed, and there was a significant correlation between
shortening >1.5 cm on follow-up examination and the degree of pain.
Zenni et al[26] used open reduction and internal fixation with a threaded intra-medullary wire or
pin to treat 25 clavicular fractures. They reported a 100% union rate with no hardware migration.
The authors' indications for surgery were as follows: (1) neurovascular compromise, (2) fracture
of the distal third of the clavicle with disruption of the coracoclavicular ligament, (3) severe
angulation and comminution of middle-third fractures, (4) the patient's inability to tolerate
prolonged immobilization, and (5) symptomatic nonunion. Two other studies looked specifically
at surgically treated acute fractures. Khan and Lucas[27] achieved a 100% union rate with open
reduction and internal fixation of 20 acute fractures. They noted that patients had pain relief
within 20 hours of the operation, compared with the usual 3 weeks of pain and disability of those
treated with conservative measures, as described by Rowe.[5] Their indications for surgery
included the following: (1) gross displacement of the fragments with soft tissue interposition, (2)
neurovascular complications, (3) multiple injuries or coma, and (4) severe prolonged pain.
Similarly, Faithfull and Lam[28] reported a 100% union rate with open reduction and internal
fixation of 18 acute midclavicular fractures. Their indications for surgery were gross
displacement and comminution or shortening >1.5 cm. They noted that malunion with shortening
of midclavicular fractures, especially in young patients, is not a benign entity.
Another indication for primary open reduction and internal fixation of a clavicular fracture is the
presence of a concomitant displaced scapular fracture, or the "floating shoulder" injury.[29] In this
injury, the entire superior suspension complex of the shoulder is disrupted, resulting in an
extremely unstable shoulder girdle, with sequelae such as drooping shoulder and limited range of
motion.[30] Open reduction and internal fixation of the clavicle restores the superior suspension
complex.
Before proceeding to surgery for a nonunion, a careful history and physical examination must be
done to discern what type of symptoms and disability, if any, the patient is experiencing.
According to Wilkins and Johnston,[11] a nonunion may be asymptomatic, particularly an atrophic
nonunion. In their study, only 3 of 11 patients who had atrophic nonunions were symptomatic
enough to require surgery, as compared with 16 of 22 patients who had hypertrophic nonunions.
They noted that the absence of callous in an atrophic nonunion can diminish the grating and
crepitation that may be responsible for pain at the site of the nonunion. They suggested that
patients with atrophic nonunions be followed for at least 6 months before surgery is
contemplated, since they believe that many patients will become asymptomatic during that time
interval.
Most studies, however, have shown that patients who have clavicular nonunions do have some
form of disability. Olsen et al[21] showed that atrophic nonunions do not become asymptomatic.
Disability may result from pain at the site of nonunion, altered shoulder mechanics (either in

response to pain or because of malposition of the fracture fragments), "ptosis" of the shoulder, or
a compression lesion involving the underlying brachial plexus or vascular structures.[1] Manske
and Szabo[12] found pain to be the prominent symptom in all 10 of their patients with nonunion,
whereas Wilkins and Johnston[11] reported that 17 of 19 patients who had symptomatic nonunions
reported moderate to severe pain. Boehme et al[15] also reported that pain was the prominent
symptom in most of their patients with nonunion (18 of 21).
Neurologic symptoms can develop in the acute phase as a result of stretch injury or bone
fragment compression, in the chronic phase as a result of compression from healing of the
fracture with inferior and posterior displacement of the distal fragment or massive callous, or
from motion of the nonunion.[31-37] Kay and Eckardt[37] noted that acute traction neuropathies most
commonly involve the lateral cord of the brachial plexus, while delayed compressive
neuropathies most commonly involve the medial cord. Compressive neuropathies affect the
medial cord because of entrapment from hypertrophic callous in the costoclavicular space, as
described by Berkheiser[4] to be between the clavicle nonunion site above and the first and
second ribs below. The medial cord consistently crosses the first rib in this area.[4] A compressive
neuropathy can develop anywhere from 3 weeks to 10 years after injury. Therefore, it is
important to follow a patient's neurologic status for an extended period.[37]
Patients may also present vascular complications. According to Lim and Day,[33] several factors
play a role in preventing vascular injury. One factor is the direction of displacement of the
fracture, with the distal fragment being pulled inferiorly and anteriorly by gravity and the
proximal fragment being pulled superiorly and posteriorly into the trapezius muscle by the
trapezius and sternocleidomastoid muscles, thus preventing the major vascular structures from
being compressed between the bone ends. Also, the subclavius muscle and the deep cervical
fascia act as barriers between the bone ends and vessels. Nonetheless, vascular injuries ranging
from subclavian vein compression or thrombosis to arterial ischemia have been reported.[20,31-34]
The reported incidence of neurovascular complications varies. Neer[2] reported no neurovascular
symptoms in his 18 cases of nonunion, and Ghormley et al[6] noted only one case of
neurovascular injury in 20 nonunions. Similarly, Wilkins and Johnston[11] (2 of 33 nonunions)
and Sakellarides[8] (3 of 20 nonunions) reported relatively low neurovascular complication rates.
Conversely, Berkheiser[4] reported a relatively high rate of neurovascular compromise: 6 of 9
nonunions. More recently, Connolly and Dehne[34] and Jupiter and Leffert[20] have noted high
rates of neurovascular injury from nonunion: 7 of 15 nonunions and 9 of 23 nonunions,
respectively. Connolly and Dehne[34] stated that nonunion of the clavicle was the most common
cause of thoracic outlet syndrome in their clinic.
Indications
The main indication for surgery is symptomatic nonunion. Pain at the nonunion site is the most
frequent symptom and thus the most common reason for operative intervention. Static or
progressive neurovascular compromise is another indication for surgery, as well as extremity
dysfunction due to ptosis, stiffness, or weakness.
Procedure Options

The various procedures can be divided into two main categories: salvage and reconstructive.[1]
Salvage procedures attempt to alleviate symptoms or deformities without achieving bone union.
Reconstructive procedures, however, are designed to achieve bone union. Within each category,
there are multiple procedures.
Salvage procedures involve removing a bony prominence or performing a partial or total
claviculectomy to provide relief from painful grating or to release entrapped neurovascular
structures. Abbott and Lucas[38] pointed out that the middle third of the clavicle may be removed
without significant disability as long as the distal and proximal portions are left intact. Rowe[5]
noted that removal of the entire clavicle results in a "surprisingly good functional and cosmetic
appearance" but stated that this should be done only after a patient has had several unsuccessful
bone-grafting procedures and is "sufficiently" disabled. Connolly and Dehne,[34] however, wrote
that resection of the midclavicle should be avoided because it is likely to lead to delayed
problems. They stated that patients in general are not satisfied with their result or appearance
after resection. Overall, taking into account the important functional role of the clavicle and the
successful reconstructive options available, an attempt should be made to achieve bone union in
an anatomic position for nonunited symptomatic clavicular fractures.
Reconstructive procedures include a wide array of fixation methods for the treatment of
clavicular nonunions, ranging from external fixation[18] and threaded and unthreaded pins[11,39,40]
to plate and screw osteosynthesis.[12,15,19-21,41-45] Schuind et al[18] used a Hoffman external fixator
(Howmedica, Rutherford, NJ) to treat both acute fractures and nonunions and had a 100% union
rate. Two pins were placed in the medial fragment in an ascending anterior-posterior or almost
horizontal direction to avoid the pleural dome, and two pins were inserted in the lateral fragment
in a superior-inferior and anterior or almost vertical direction. The external fixator was used for
an average time of 51 days. According to Schuind et al,[18] indications for this type of fixation are
an open fracture or a septic nonunion, in which the risk of deep infection is high if internal
fixation is used.
Another form of surgical treatment is intramedullary pin fixation and autogenous bone grafting.
Boehme et al[15] described a technique in which a skin incision is made in the Langer line,
centered directly over the nonunion site; a modified Hagie pin (Zimmer, Warsaw, Ind) is inserted
into the intramedullary canal after excising the fibrous nonunion. The pin is drilled from the
nonunion site out through the intra-medullary canal of the distal fragment. A small skin incision
is made over the pin at the posterolateral aspect of the shoulder. The pin is then retracted from
the clavicle until its end is at the level of the nonunion site. The fracture is then reduced, and the
pin is drilled across the fracture site and into the medial fragment. The tip of the pin is left
palpable in the subcutaneous tissue laterally to allow for its removal under local anesthesia after
the fracture is healed. Autogenous bone graft is then placed around the nonunion site.
Boehme et al[15] achieved a 95% healing rate in 21 patients using the preceding technique.
Capicotto et al[40] obtained a 100% union rate with a similar procedure using Steinmann pin
(Richards, Memphis, Tenn) fixation. Boehme et al[15] noted that the advantages of intramedullary
pinning over other forms of fixation, particularly plate and screw osteosynthesis, include a
cosmetically acceptable incision; less dissection of the soft tissues; and, after healing, easy
removal of the pin through a small incision under local anesthesia. In addition, the

intramedullary pin is a load-sharing device, as compared with plates and screws, which are loadbearing devices. Therefore, osteoporosis (which occurs under a plate as a result of stress
shielding) is less severe with an intramedullary pin, and the likelihood of refracture through
osteoporotic bone after hardware removal is diminished. One disadvantage of this technique,
however, is the lack of rotational control with the pin.[12,20] Boehme et al[15] recognized this, and in
their early postoperative regimen, they limited forward flexion to a maximum of 90 to
"eliminate" rotational forces. Another disadvantage of pin fixation is the potential for pin
breakage and pin migration, which results in serious neurologic and pulmonary complications.[4648]

Connolly and Dehne[34] described a technique using Knowles pin (DePuy, Warsaw, Ind) fixation,
which the authors believe is particularly suitable for hypertrophic nonunions. A small Knowles
pin is inserted from the anterior cortex of the medial fragment into the lateral fragment under
fluoroscopic guidance. According to the authors, the Knowles pin locks against the anterior
cortex and permits good fracture fixation and compression. One main advantage of this
technique is that, as in intramedullary pin fixation, there is minimal periosteal stripping.
Advantages over intramedullary pin fixation include avoidance of the often difficult placement
of intramedullary pins because of the sigmoid shape of the clavicle and avoidance of the
loosening and migrating of Steinmann pins.
The final method of fixation is plate and screw osteosynthesis (Fig 3). Edvardsen and Odegard[41]
described a technique consisting of debridement and trimming of the bone ends, placement of a
cortical bone transplant posteriorly and metal plate anteriorly, and fixation of the plate to the
clavicle and cortical bone transplant with screws. A 100% union rate was achieved in 6 patients
with posttraumatic nonunion. With the cortical bone graft posteriorly and plate anteriorly, the
construct is stable, but an extensive amount of soft tissue stripping anteriorly and posteriorly is
needed. Manske and Szabo[12] treated 10 nonunions with an AO 3.5-mm dynamic compression
plate (Synthes, Paoli, Penn) and iliac crest cancellous bone graft. Radiographically, all the
clavicles united at an average of 19 weeks after surgery, and all the patients had full, painless
range of motion.

Figure 3.

Open reduction and internal fixation of clavicular nonunion with plate and screw osteosynthesis.
Jupiter and Leffert[20] reported on an 89% union rate after plate fixation and bone grafting in 18
nonunited fractures of the middle third of the clavicle. The authors emphasized the importance of
restoring the normal length of the clavicle because shortening can cause abduction weakness and
can increase the moments and forces at the site of the fracture.[16,20] Seiler and Jupiter[42]
specifically addressed the restoration of clavicular length in a more recent study; they used
intercalary tricortical iliac crest bone grafts to treat clavicular nonunions with bony defects.
Preoperatively, the authors obtained a view of the contralateral clavicle to establish the normal
length of the clavicle, and they determined the size of the bone graft by comparing the
anteroposterior radiographs of each clavicle. The nonunion site was debrided, and the medullary
canals were opened medially and laterally with a drill bit. They procured a tricortical iliac crest
that was 1.5 times larger than the calculated defect. The graft was then placed in the defect and
secured to the medial and lateral fragments with a limited contact dynamic compression plate,
compressing both the medial and lateral junctions. The authors reported union in all eight
patients treated with this technique within 3 months of surgery. Olsen et al[21] also emphasized the
importance of reestablishing native clavicular length. These authors, however, just used
autologous cancellous bone graft to fill the defect rather than a tricorticocancellous graft.
More recently, Ballmer et al[49] emphasized the importance of restoring clavicular length. These
authors treated 37 delayed union and nonunion fractures with decortication, plate osteosynthesis,
and bone grafts, and they achieved a 95% union rate. Nine patients required tricorticocancellous
grafts to restore clavicular length. The authors' indication for using the tricorticocancellous graft
was clavicular shortening >1.5 cm compared with the contralateral clavicle.
Boyer and Axelrod[45] described a technique that entailed shortening the clavicle. The nonunion is
excised by cuts at 45 to the long axis of the clavicle, and either a pelvic reconstruction or
dynamic compression plate with a lag screw (to provide interfragmentary compression) is used
for fixation. Cancellous bone is then placed at the nonunion site. The authors stated that their
technique respects AO principles for the treatment of nonunions, allows early mobilization, and
minimizes morbidity at the donor site (ie, cancellous bone graft is procured rather than
tricorticocancellous graft). In their study, all seven patients with clavicular nonunions healed and
returned to normal function. The average reduction in length of the clavicle was 1.5 cm.
However, according to the authors, the resultant lack of restoration of the shoulder width proved
to be cosmetically acceptable and gave excellent function.
The final issue for plate and screw fixation is the type of plate used. Bradbury et al[44] compared
the results of an AO dynamic compression plate (Synthes, Paoli, Penn) and an AO pelvic
reconstruction plate for treatment of clavicular nonunion. The authors reported a 97% union rate
(31 of 32 nonunions) and noted no significant differences between the two plates. They stated,
however, that the reconstruction plate was much easier to contour to the sigmoid shape of the
clavicle.
Mullaji and Jupiter,[19] on the other hand, prefer a 3.5-mm low-contact-dynamic compression
plate (LC-DCP). The authors reported a 100% union rate in six patients treated with the LC-DCP.
Valuable features of the LC-DCP include a structured under-surface that preserves the blood

supply beneath the plate, avoidance of stress risers after implant removal, and oblique undercuts
to the screw holes that allow for insertion of lag screws up to an angle of 40. Also, the plate is
made of titanium, which is twice as flexible as steel, thus rendering it less prone to fatigue failure
when used to span a defect. A feature that is specifically valuable to treatment of clavicular
nonunions is the uniformly placed screw holes without a solid middle section, which facilitates
introduction of a screw or screws into the intercalary bone graft. Also, the uniform bending
stiffness of the plate allows easier contouring in multiple planes, important in the clavicle
because of its complex shape. Finally, the LC-DCP has universal screw holes that allow
compression in either direction and thus permit compression of the intercalated graft to both the
medial and lateral fragments.
Overall advantages of plate and screw osteosynthesis over other methods of fixation include
excellent control of rotation and the ability to restore the normal length of the clavicle. Also,
according to Jupiter and Leffert,[20] the apex of deformity in a clavicular nonunion is superior;
therefore, a plate applied to the superior surface can act as a tension band, which enhances
compression across the fracture. Disadvantages to plate fixation include the need for wider
exposure and increased periosteal stripping, which can disturb the blood supply to the healing
fragments. Also, a larger exposure is required for hardware removal, necessitating another
surgical procedure. The potential for refracture after plate removal is increased because of
osteoporosis below the plate and stress risers at the empty screw holes (Fig 4).

Figure 4.

(Top) Healed clavicular nonunion after open reduction and internal fixation with plate and screw
osteosynthesis and intercalary bone grafting. (Center) Hardware was removed 54 weeks after
open reduction/internal fixation procedure. (Bottom) Refracture of clavicle 54 weeks after
hardware removal.
Using plate and screw osteosynthesis with intercalary tricorticocancellous graft, we treat
symptomatic nonunions to achieve union of the clavicle and to restore normal length. The patient
is given general anesthesia with endotracheal intubation and then is placed in the 50 beach chair
position, with the head secured to a Mayfield headrest (Wiggins Medical Inc, Sunnyside, Fla).

The injured upper extremity and the ipsilateral or contralateral iliac crest region are prepared and
draped.
We make a lazy S type of incision over the involved clavicle, ensuring that the midpoint is at the
site of the nonunion. As dissection is carried down sharply, the platysma muscle is divided.
While protecting the neurovascular structures, we accomplish a subperiosteal exposure of the
fracture and the medial and lateral fragments (Fig 5). After the fracture is exposed, the fibrous
nonunion is debrided and bony prominences at the site of nonunion are trimmed. After restoring
the clavicle to its normal length, we measure the resulting defect (Fig 6).

Figure 5.

Nonunion site is exposed, and ends of fragments are found to be atrophic. Lateral aspect of
clavicle is displaced inferiorly and medially with respect to medial aspect.

Figure 6.

Fracture is reduced after debriding fibrous nonunion tissue and removing atrophic, sclerotic bone
ends. Resultant defect is measured, and appropriately sized tricorticocancellous bone graft is
obtained from iliac crest.
Next, we make an incision over the anterior one third of the iliac crest and accomplish a
subperiosteal exposure of the iliac crest. Using straight and curved osteotomes, we remove a
piece of tricorticocancellous bone graft that is the size of the clavicular defect. Then, we harvest
a cancellous bone graft from the inner table of the ilium. The wound is copiously irrigated, and a
Hemovac drain (Baxtor Healthcare Corp, Deerfield, Ill) is placed deep to the muscle and fascial
layer. We close the wound in layers with interrupted sutures and the skin with running
subcuticular stitch.
The tricorticocancellous bone graft serves as an interpositional graft between the proximal and
distal clavicle fragments. The cortical surfaces lie superiorly and inferiorly to allow for screw
fixation. We contour a 3.5-mm pelvic reconstruction plate and use bone-holding clamps to attach
it to the superior surface of the clavicle (Fig 7). The plate is secured to the clavicle with one or
two cortical screws placed in the interpositional fragment and three or four cortical screws placed
in each of the medial and lateral fragments. After plate and screw placement, the cancellous bone
graft is packed around the nonunion site. Closure begins with reapproximating the periosteum
and fascia over the plate. We close the subcutaneous tissue with interrupted sutures and the skin
with a running subcuticular stitch. We apply sterile dressings and place the patient's extremity in
a sling. On the day after surgery, the Hemovac drain is removed, and the patient is discharged
from the hospital.

Figure 7.

(Top) Plate is secured to superior surface of clavicle with 3 or 4 screws proximal and distal to
fracture site and 1 or 2 screws in interposed graft. (Bottom) Plain radiograph of plate and screw
fixation with intercalary tricorticocancellous bone grafting.
One of us (G.M.M.) has treated 14 patients (14 nonunions) with the preceding technique. The
average duration of delayed union or nonunion from the time of injury to surgery was 30 months
(range, 3 to 260 months). Twelve of the 14 nonunions were atrophic, and two were hypertrophic.
The average time to union was 15.6 weeks (range, 7 to 34 weeks). Average follow-up was 33
months (range, 21 to 61 months). Successful union was achieved in 13 of the 14 patients (93%),
with good functional outcomes after healing. In one patient, the nonunion was determined by
viewing radiographs of the clavicle. The nonunion may have occurred because the patient was
treated with early open reduction and internal fixation rather than with closed measures, as the
others were treated.

There were a few significant complications. The most noteworthy was refracture after hardware
removal in three patients. Two of the refractures, though, were the result of significant trauma: a
bicycle accident and a significant fall on an outstretched arm at 39 weeks and 12 weeks after
hardware removal, respectively. The refractures were managed successfully with repeated open
reduction and internal fixation with 3.5 pelvic reconstruction plates after radiographs showed
lack of healing at an average of 16 weeks after refracture. No bone grafts were required.
For 6 weeks after surgery, the patient wears a sling and performs passive range-of-motion
exercises with passive forward elevation limited to 90. We limit passive forward elevation
during this time to prevent rotational torque on the clavicle and hardware. Beginning at 6 weeks
after surgery, the patient's range-of-motion exercises can include passive forward elevation above
90. The patient can begin active forward elevation and progressive resisted strengthening
exercises at 3 months or when the radiographs reveal good consolidation of the bone graft.
Healing is assessed with antero-posterior radiographs and anteroposterior radiographs at 15
cephalic tilt. If assessing the degree of healing by plain radiographs is difficult, tomograms or
computed tomography scans can be useful.
Although clavicular fractures have a relatively low nonunion rate, they should be treated with
appropriate immobilization and respect for potential healing complications. When a nonunion
does occur, it usually is symptomatic and can cause significant disability. Symptoms include
pain, paresthesia, and extremity weakness from neurovascular entrapment; shoulder weakness
from disturbed shoulder mechanics; crepitation at the fracture site; and unacceptable cosmetic
appearance.
The many treatment options for a clavicular nonunion range from conservative management to
multiple surgical procedures. If the patient is symptomatic, surgery is recommended. Two broad
groups of surgical options exist: salvage and reconstructive procedures. Presently, the emphasis
is on obtaining union in an anatomic position to restore normal shoulder mechanics and provide
the best possible functional outcome. Therefore, reconstructive procedures are recommended.
We agree with Seiler and Jupiter[42] that open reduction and internal fixation with plates and
screws and with intercalary bone graft as needed best achieves this goal.
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Reprint requests to George M. McCluskey III, MD, The Hughston Clinic PC, 6262 Veterans
Parkway, PO Box 9517, Columbus, GA 31908-9517.
J South Orthop Assoc. 2000;9(1) 2000 Southern Medical Association
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