Nonunion Of The Clavicle - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes nonunion of the clavicle, its etiology, signs and symptoms, diagnostic tests, and treatment options.
What is non-union?
Nonunion means that a bony union will not occur without help.
Surgery is usually required for union of the bone.
Impending nonunion could occur, meaning the fracture will not heal without help.
Established nonunion could occur, meaning a good amount of time has passed (usually about 4 months) and the fracture did not heal.
Timing of surgery is debatable, most of the clavicle fractures will heal without surgery.
Conservative treatment has about an 85% success rate.
The rate of nonunion is about 15%.
Nonunion may be difficult to diagnose due to superimposition of the ends of the clavicle which gives the false impression of healing.
CT scan may be needed for the diagnosis of nonunion in clavicle fractures.
There are no orthogonal views (such as AP and lateral x-rays).
One view of the clavicle alone may not give an idea about the status of the fractures clavicle healing.
Risk factors of nonunion:
Female
Advanced age
Displacement of the fracture
Communication of the fracture
Overlapping of the fracture (more than 2 cm)
Fracture in the lateral third of the clavicle
Smoking
Treatment:
If the nonunion is painless, then leave it alone.
If the nonunion is painful, then the patient will require surgical treatment of the nonunion.
The typical patient will have painful range of motion.
Patient may also have thoracic outlet syndrome or brachial plexus compression.
Surgical treatment of the clavicle nonunion has about a 90%- 95% good to excellent result.
There are 3 types of nonunion of the clavicle:
1- Atrophic
2- Hydrotrophic
3- Nonunion with shortening: compare both sides of the shoulder with the same radiographic view.
Tactics of treatment:
For the nonunion to heal, you will need vascularity and stability of the nonunion.
The vascularity will come from a bone graft:
• Local bone graft
• Iliac crest bone graft
Stability: the stability will come from a stable fixation, usually done with superior anatomic plate with at least three cortical screws on each side.
Sometimes as interfragmentary lag screw is used, then a neutralization plate is used.
Types of nonunion explained:
1- Atrophic:
Will need bone graft and plate fixation.
The bony ends are cleaned, prepared and roughened.
Sometimes the medullary canal is entered.
2- Hypertrophic:
Will need stability.
Usually stability is obtained by a plate.
May trim the extra hypertrophic bone graft and use it locally.
3- Nonunion with shortening:
Compare the length of both clavicles preoperatively by having one film that shows both clavicles.
Check the amount of shortening and overlap between the bony ends.
If the shortening is more than the overlap, then you will probably need to have a bicortical or tricortical interposition graft if the shortening is more than 10 mm.
Need to fill this gap to restore the length and probably will need a strong graft.
4- Patient had plate fixation/ stabilization with failure of fixation and nonunion
Rule out infection
Get CRP and sedimentation rate
Check the clinical appearance of the wound
Try to get intraoperative culture
Adequately debride the bone
May need 1 of 2 approaches:
• Debride now, then close the wound and fix the fracture later, operation is done in 2 stages.
• Deride now, then plate and cancellous bone graft now, operation is done in 1 stage.
Both approaches are a judgment call of the surgeon depending on the appearance of the wound, the clinical experience of the surgeon as well as the circumstances of the patient.
• Bone morphogenetic proteins (BMPs)
I do not use it in this area near the chest because the fluid may travel and may be unpredictable.



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