Congenital Pseudoarthrosis of Clavicle Treatment & Management

Updated: May 07, 2018
  • Author: L Andrew Koman, MD; Chief Editor: Jeffrey D Thomson, MD  more...
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Treatment

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 (eg, iliac crest), and rigid fixation with a plate and screws has yielded reliable results. [18, 19, 20] Poor results with the use of bovine cancellous xenograft (Tutobone) have been reported [21] ; this should be avoided because of reaction, nonunion, and difficulty achieving union. A case report details salvage with a vascularized bone graft.

Operative 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 should be 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 [22] ; if not, use a bone graft; do not use bovine xenograft (Tutobone)
  • Apply an appropriate-sized compression plate [23]
  • 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. [24] 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. [25] However, in contradistinction to congenital pseudoarthrosis secondary to neurofibromatosis, union is common. Fixation with a plate and screws is superior to the use of threaded pins. [26]

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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