Congenital Pseudoarthrosis of Clavicle Treatment & Management

  • Author: L Andrew Koman, MD; Chief Editor: Jeffrey D Thomson, MD  more...
 
Updated: Feb 03, 2016
 

Approach Considerations

Indications for intervention include pain, shoulder girdle instability that interferes with function, and altered self-esteem secondary to an unsightly appearance.[17] No major contraindications to intervention exist. However, internal fixation may be compromised by the size of the patient (and the clavicle).

In the future, the true etiology of congenital pseudoarthrosis may be delineated, and its predilection for the right chest will be understood. It is likely that injection with osteoinductive material will convert the pseudoarthrosis to normal membranous ossification or that the application of external bone-stimulating devices will induce osteoprogenitor cells to replace the pseudoarthrosis with normal bone.

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Medical Therapy

Mere observation may be appropriate. No nonoperative techniques achieve union.

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Surgical Therapy

Treatment with resection of the pseudoarthrosis, primary approximation of the ends of the clavicle, or the use of autologous graft (iliac crest and rigid fixation with a plate and screws) have reliable results. Poor results with the use of bovine cancellous xenograft (Tutobone) have been reported[18] ; this should be avoided because of reaction, nonunion, and difficulty achieving union. A case report details salvage with a vascularized bone graft.

Procedural details

After taking a general history and performing a physical examination, evaluate the right upper extremity for range of motion (ROM), stability, and neurovascular function. The patient should be prepared for surgery, and the entire right upper limb prepared free to facilitate mobilization of the clavicle and to observe for neurovascular problems. Prophylactic antibiotics are appropriate if internal fixation is employed. A semisitting or beachchair position may be helpful to obtain exposure.

Surgical steps are as follows:

  • Expose the clavicle through a transverse incision
  • Control bleeding with electrocauterization
  • Expose the medial and lateral clavicle subperiosteally, excise the sclerotic ends, and resect the pseudoarthrosis
  • Determine if end-to-end repair is possible [19] ; if not, use a bone graft; do not use bovine xenograft (Tutobone)
  • Apply an appropriate-sized compression plate [20]
  • Reapproximate the periosteum
  • Close the wound in layers

Postoperatively, the patient is immobilized in a sling and swath; alternatively, a shoulder spica cast may be used for small children if internal fixation is inadequate.[21] The clavicle is protected until union is confirmed clinically and radiographically.

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Complications

The major surgical complication is failure of the clavicle to unite.[22] However, in contradistinction to congenital pseudoarthrosis secondary to neurofibromatosis, union is common. Fixation with a plate and screws is superior to threaded pins.[23]

Hardware is removed if painful or unduly prominent. Neurovascular injury is rare but may occur. Infection may occur in the postoperative period.

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Contributor Information and Disclosures
Author

L Andrew Koman, MD Professor and Chair, Department of Orthopedic Surgery, Associate Director, Surgical Sciences, Wake Forest University School of Medicine

L Andrew Koman, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy for Cerebral Palsy and Developmental Medicine, American Society for Reconstructive Microsurgery, North Carolina Medical Society, North Carolina Medical Society, Sigma Xi, Orthopaedic Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, Clinical Orthopaedic Society, Eastern Orthopaedic Association, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George H Thompson, MD Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Jeffrey D Thomson, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Department of Pediatric Orthopedic Surgery, Associate Director of Clinical Affairs for the Department of Surgical Subspecialties, Connecticut Children’s Medical Center; President, Connecticut Children's Specialty Group

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Mininder S Kocher, MD, MPH Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston

Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.

References
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  18. Elliot RR, Richards RH. Failed operative treatment in two cases of pseudarthrosis of the clavicle using internal fixation and bovine cancellous xenograft (Tutobone). J Pediatr Orthop B. 2011 Sep. 20(5):349-53. [Medline].

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  20. Renger RJ, Roukema GR, Reurings JC, Raams PM, Font J, Verleisdonk EJ. The clavicle hook plate for Neer type II lateral clavicle fractures. J Orthop Trauma. 2009 Sep. 23(8):570-4. [Medline].

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  22. Glotzbecker MP, Shin EK, Chen NC, Labow BI, Waters PM. Salvage reconstruction of congenital pseudarthrosis of the clavicle with vascularized fibular graft after failed operative treatment: a case report. J Pediatr Orthop. 2009 Jun. 29(4):411-5. [Medline].

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