Posttraumatic Pseudoarthrosis of a Clavicle Fracture
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An 11-year-old girl presented to our A&E department after a fall on an outstretched arm with immediate pain experienced at the right shoulder. The X-ray demonstrated a nondisplaced fracture of the middle to the proximal third of the right clavicle (Figure 1). There were no other injuries, and the neurovascular examination of the upper extremity was normal. The fracture was managed conservatively with sling immobilization for 6 weeks, and on clinical follow-up, it appeared to be healing well. The patient had no pain nor functional limitation, with the adequate progression of periosteal reossification and callus formation seen on radiological examination. The patient was an amateur junior javelin thrower and was restricted from all sporting activity for a total of 3 months and until there was radiographic confirmation of callus formation (Figure 2).

The patient remained completely asymptomatic for 12 months, after which time she presented with new swelling at the callus midline, associated pain, and shoulder function loss, in the absence of additional trauma. The X-ray at 12 months confirmed the clinical suspicion of a pseudoarthrosis. Following a multidisciplinary discussion, they decided to investigate the suspected nonunion and the need for surgical intervention using CT and MRI. The initial topographic examination was important to validate the pseudoarthrosis, which clearly identified two areas of hypertrophy without signs of bridging. The MRI was useful in excluding an entrapment of surrounding articular structures and in evaluating the involvement of the neurovascular bundle with respect to the bone.

Following a discussion with the patient’s parents, they opted for a surgical approach with open reduction and internal fixation and iliac crest bone graft from the ipsilateral hip . The nonunion was confirmed intraoperatively with debriding of the fracture site, with a loss of bone substance of 2 cm. The bone sample taken from the iliac crest was customised, molded, and inserted into the remaining gap. Following bone tissue transplant, the clavicle was reduced and internal fixation performed with a 3.5 mm seven-hole locking compression plate (LCP) (Synthes) in compression.Following a normal postoperative course, clinical and radiological follow-up showed complete isometric anatomical healing at 1 year from the operation. The clinical examination showed no pain during shoulder movement, with a range of motion in antepulsion of 180°, abduction of 180°, internal rotation up to X thoracic vertebra, and external rotation of 80°


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