Although most clavicular fractures in adults heal with no
or minimal persistent symptoms, the rate of symptomatic malunion
or nonunion of displaced fractures of the clavicle has ranged from
3% to 5% in a number of reports1-5.
In a previous study of fifteen clavicular nonunions and malunions2, the senior one of us (J.F.C.) found
that seven patients experienced intermittent or chronic symptoms
associated with impingement on the thoracic outlet. These symptoms occurred
most often when the patient abducted the shoulder or elevated the
arm to an overhead position. Such patients are sometimes treated
for cervical disc disease or, as in this case report, managed with
resection of the first rib without relief of symptoms.
We and others3,5-7 have observed
that the diagnosis and the surgical correction of thoracic outlet
syndrome secondary to clavicular malunion may be delayed. Because
clavicular fractures usually heal without sequelae, patients who
present with late symptoms may be considered malingerers or compensation
seekers7-10. Also, some physicians
may advise against surgical correction because of the long-standing
tradition of nonoperative treatment of clavicular fractures11,12 and because of an appropriate
concern that operative treatment of the malunited fracture is associated
with a risk of damage to the underlying neurovascular structures12,13. Fatal subclavian vascular injuries
from a fractured clavicle have been occasionally reported13-16.
The purpose of this report is to present a case of thoracic outlet
syndrome produced by a clavicular malunion and to illustrate our
technique of clavicular osteotomy to correct the problem.
A thirty-six-year-old man who operated heavy equipment sustained
a fracture to the right clavicle and subsequently was diagnosed
as having thoracic outlet syndrome. Because of persistent pain,
numbness, and inability to use his arm in the performance of his
job, the patient underwent resection of the first rib to decompress
the thoracic outlet. Subsequent herniation of the lung through the
incision required a secondary operative repair with mesh graft over
the site of resection of the first rib.
We saw the patient five years after the resection of the first rib,
at which time he reported persistent shooting pain and numbness
along the ulnar aspect of the right elbow, forearm, and hand. He
also experienced weakness of the hand and arm and persistent pain
in the shoulder in the area of the fractured clavicle. He stated
that the symptoms of pain and weakness caused considerable difficulty
when he had to work a full day as a heavy equipment operator.
The health of the patient had been good. On physical examination,
a visible and palpable prominence was detected over the middle third
of the right clavicle. The patient demonstrated a full range of
active and passive motion of the right shoulder but experienced
pain and weakness when the arm was abducted or elevated in a forward
position beyond 90° or when the limb was exercised in that position.
Plain roentgenograms showed a shortened malunited clavicle and absence
of the first rib (Fig. 1). Magnetic resonance images of
the shoulder showed abnormal signal on the T2-weighted image of
the right brachial plexus. Electrodiagnostic tests demonstrated
that ulnar nerve conduction was decreased in velocity and amplitude
as measured from Erb’s point to the axilla. In addition,
the right medial cutaneous antebrachial nerve demonstrated prolonged distal
sensory latency compared with the normal side. Because of these
persistent symptoms and findings, a corrective osteotomy of the
clavicle was carried out.
With the patient under general anesthesia, a transverse incision
was made distal to the clavicle and was extended 2.5 cm medially
and laterally beyond the prominence of the malunion. The soft tissues
and the trapezius muscle were elevated off the clavicle superiorly
by sharp dissection. A double osteotomy was performed through the
anterosuperior aspect of the clavicle 2 cm medial and 2 cm lateral
to the malunion (Fig. 2-A). The segment was then lifted superiorly
away from the subclavian region, and a complete dissection was carried
out from medial to lateral (Fig. 2-B). The entire malformed section
of bone was dissected with use of manual and sharp dissection, with
care taken to protect and palpate the underlying clavipectoral fascia.
The dissected segment of bone was removed in its entirety, and a
power saw was used to excise the excess callus and to create a more
normally shaped middle-third clavicular segment. The remodeled segment
was then reinserted into the clavicular defect and fixed with an
eight-hole reconstruction plate (Fig. 3-A). Callus from the malunion mass
was applied to the superior surface of the segment. The reconstruction
plate was applied anteriorly, with the screws directed from anterior
to posterior to avoid impinging on the subclavian neurovascular
structures.
After the operation, the right arm was supported in a sling for three
weeks, after which range-of-motion exercises were instituted. The
sites of the clavicular osteotomies healed both clinically and radiographically
(Fig. 3-B).
Twelve months after the operation, the patient reported relief of
the symptoms of thoracic outlet syndrome. He was able to work without
the disabling pain that he had experienced previously. Although
he still had some aching in the shoulder from the long-standing
area of scarring, the radiating neurologic pain in the upper extremity
had not recurred.
To our knowledge, double clavicular osteotomy has not been described
for correction of thoracic outlet syndrome produced by hypertrophic
clavicular malunion. This method follows the surgical principle
of beginning any dissection involving scar well away from the site
of the scar tissue for the purpose of identifying normal bone and
soft tissues as well as ascertaining safe planes for the dissection
of the undersurface of the clavicle.
In a thorough review of thoracic outlet syndrome, Leffert and Perlmutter17 pointed out that the diagnosis is
made on the basis of the history and physical examination. There
is no reliable laboratory diagnostic test for confirming or excluding
the diagnosis. Leffert and Perlmutter reported that the symptoms
of four of their patients with thoracic outlet syndrome and a malunited
clavicular fracture were relieved by resecting the first rib without correcting
the clavicular malunion. They17 and
others10 pointed out that the
surgery has substantial risks; the complication rate is high; and
the outcome, particularly among patients receiving Workers’ Compensation,
has been described as dismal9,10.
A clavicular malunion in bayonet apposition at the junction of the
medial and middle thirds of the clavicle virtually obliterates the
available space between the clavicle and the second rib and may
cause an unsatisfactory result18.
We propose that this loss of available space can lead to thoracic
outlet syndrome. It is our hypothesis that resection of the first
rib by itself would be unlikely to adequately alleviate the compression
of the neurovascular outlet produced by such a hypertrophic malunion.
Although some authors6,14,19-22 have
recommended merely resecting the clavicular segment for the treatment
of a clavicular malunion or for a direct surgical approach to the
subclavian structures, we and others2,7 advise
against this approach. Two of our previous patients who underwent
resection of the middle third of the clavicle subsequently had recurrence
of symptoms because the mobile lateral segment partially regrew
and developed a bone spike that impinged on the subclavian plexus
whenever the shoulder was flexed and adducted.
Symptomatic compression of the thoracic outlet can occur between
the middle third of the clavicle and the second rib as a result
of clavicular malunion. Corrective clavicular osteotomy and plate
fixation can effectively alleviate persistent symptoms. We suggest
that this operative approach be considered in preference to resection
of the first rib.