Injury to the Brachial Plexus by a Fragment of Bone After Fracture of the Clavicle

Abstract

Clavicular fractures are occasionally responsible for lesions of the brachial plexus. The symptoms are usually delayed and due to compression by hypertrophic callus, nonunion or a subclavian pseudoaneurysm.We describe a patient in whom a displaced bone fragment was pressing on the retroclavicular part of the brachial plexus, leading to early symptoms of a lesion of the posterior cord. Internal fixation of the clavicle and external neurolysis of the brachial plexus gave an almost full recovery. CASE REPORTA 32-year-old, right-handed man sustained a closed comminuted fracture of the right clavicle in a fall. He was treated conservatively with a figure-of-eight bandage and sling. Three weeks later he was referred to us, complaining of continuous pain in the shoulder and right arm. He reported that immediately after the injury he had been aware of numbness in the distribution of the radial nerve in the forearm and hand, with weakness of the deltoid, triceps and wrist extension. These observations were confirmed by clinical examination, but there was no evidence of vascular injury. A plain radiograph (Fig. 1) and CT (Fig. 2) showed a sagittally orientated, intermediate bone fragment, and narrowing of the costoclavicular space. MRI confirmed impingement of the clavicular lesion on the brachial plexus (Fig. 3). EMG showed a lesion of the posterior cord, with signs of denervation in the radial and axillary nerves. Operation was undertaken one week later. A sharp fragment of bone, 2.5 cm long, was found to be pressing directly on the proximal part of the posterior cord (Fig. 4).Since there was no obvious sign of perineural injury, Fig. 1 Anteroposterior radiograph of the right clavicle, three weeks after injury, showing a displaced multisegmental fracture of the middle third. Three-dimensional reconstruction of a CT scan of the right clavicle showing the displaced bone fragment (arrow) narrowing the costoclavicular space.

Delayed union of a fracture of the middle third of the clavicle presenting with a late subclavian pseudoaneurysm

“…Clavicular fractures are occasionally responsible for lesions of the brachial plexus. The symptoms are usually delayed and are attributable to compression by the hypertrophic callus, the non-union or a subclavian pseudoaneurysm [4]. Fortunately, no neurological symptoms were recorded in our case.…”

Fixation of fractures of the midshaft of the clavicle with Kirschner wires

“…4,15 Pressure from a displaced fragment on the retroclavicular part of the brachial plexus may cause symptoms after conservative treatment. 16 We found our technique very useful for the management of displaced fractures of the middle third of the clavicle, especially in the presence of multiple rib fractures when fixation of the clavicle may help to stabilise the hemithorax.…”

Operative Treatment for Midshaft Clavicle Fractures in Adults: A 10-Year Study Conducted in a Korean Metropolitan Hospital

“…(7) In combination with brachial plexus injuries the lateral fragment of a clavicle fracture is subject to greater downward force, causing displacement and increasing the chance of nonunion. Several studies (20)(21)(22)(23)(24) imply that clavicle fractures with associated neurovascular injuries provide an indicator for surgery. In this study, 3 out of total of 4 cases of brachial plexus injury had initially resulted in nonunion, where the patients later sought treatment in the hospital where this study was conducted.…”