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Complications of clavicle fracture and acromioclavicular. What the general surgeon should know
G. Mouzopoulos, M. Stamatakos, Helen Arabatzi, Mathaios Tzurbakis (Chirurgia, 103 (5): 509-512)
Introduction
It is believed that the fractures of the clavicle account for 2.5 to 5% of the total fractures of human skeleton (1). Such fractures are usually subjected to conservative treatment, by merely suspending the upper limb; in this way, we accomplish the union of the fracture in the majority of cases with satisfactory functional results (2). Similarly, the ruptures of the acromio-clavicular joint are mild injuries which are conservatively treated with excellent prognosis (3).
However, on account of the contiguity of the clavicle and the acromio-clavicular joint with significant vital structures, such as the lungs, the infraclavicular vessels and the brachial plexus, one cannot rule out a coexisting lesion of these structures after a fracture of the clavicle or a rupture of the acromio-clavicular joint.
Given that the clinical examination of the patients with a fracture of the clavicle or a rupture of the acromio-clavicular joint is, quite often, carried out in a superficial in the emergencies department, the usual complications cannot be disclosed but after such injuries occur.
The complications which take place following a fracture of the clavicle or rupture of the acromio-clavicular joint, is the damage of the subclavian vessels, the pneumothorax or haemothorax, the damage of the brachial plexus and the scapulothoracic dissociation.
Injury of the subclavian vessels
The injury of the subclavian vessels scarsely occurs, because such are protected from muscular and osseous structures, such as: the subclavius muscle, the clavicle, the 1st rib and the deep-inside fascia of the cervix (4).
Vascular damage usually arise from a fracture of the clavicle; they pertain to the near and the middle segment of the subclavian artery, at the points of excrescence of the vertebral and thoracic arteries (4). Next, in terms of frequency, is the lesion of the subclavius muscle on account of its solid connection with the clavicle, by way of the cervical fascia, while it is not unlikely to also suffer a damage of the internal jugular vein, the suprascapular artery, the axillary artery or the carotid artery (5).
Around half of cases with injury of the subclavius artery occur after fractures of the clavicle (6). As the near downward part moves, by way of displacement, towards the top due to the powerful pull of the sternocleidomastoid muscle, it comes across with the vessel in its course and causes it to be injured (7). If no lesion of the vessel occurs with the initial displacement of the fracture, then it is improbable that it will occur at a later date, because the peripheral segment is displaced towards the bottom and towards the front, on account of the shoulder's weight, while the near part is displaced towards the top and rear part of the the sternocleidomastoid muscle, without these pieces getting in contact with the subclavius vessels (6).
Nevertheless, a damage of the subclavius vessels has been reported even after the non-displaced fractures in the nature of green-stick or fractures with a slight angulation (8).
The injuries of the vessels include ulceration, occlusion, convulsion or strain. Usually, the injury of the subclavius artery develops in a sever manner as soon as the initial bruise breaks out. The late lesion from the pressure on account of the oversized callus or nonunion is out of the ordinary (9).
The rupture of the vessel causes a life-threatening bleeding, while the arterial thrombosis or coagulation leads to ischemia of the limb. Finding points of profuse bleeding or ischemia of the hand must arouse our suspicions. The colour and the temperature of the upper limb may be normal, while the absence of pulsation, the development of an extensive haematoma in the subclavius area, the presence of a systolic murmur, and the pulsating mass must lead us to the diagnosis of a severe injury (6).
The criteria which dictate if an angiography will be carried out to rule out an injury of the suprarclavius artery according to Sturm and Cicero include: a fracture of the 1st rib, absence or weakening of radial artery's pulses, pulsating haemetoma at the supraclavius area, widening of the medias-tinum in the simple thorax x-ray and paresis of the brachial plexus (10). However, notwithstanding that the angiography is the preferred examination for the diagnosis of the lesion in the subclavius artery, this is not always helpful in the diagnosis of the post-trauma aneurysm when the canal is narrow and no adequate quantity of skiagraphic material comes in (11). Also, the ultrasonography Doppler cannot be applied, because the imaging of the vessels is difficult on account of the interference of the osseous masses of the clavicle and the ribs (12).
The contusion or convulsion spasm of the vessels may later be complicated with thrombosis. The differential diagnosis of the arterial convulsion from the rupture of the artery is difficult and their discussion may be assisted by blocking out the area of the sympathetic system (13).
An additional injury of the vascular wall may lead to an aneurysm formation and the development of thrombo-embolic phenomena or pressure of the brachial plexus (14).
Compression of the subclavius vein between the clavicle and the 1st rib, with an accompanying thrombus formation is the most common vascular complication which develops late following the fracture of the clavicle (15). It is frequently accompanied with a lesion of the brachial plexus and the subclavius artery. The point of obstruction corresponds to the point where the subclavius vein crosses the 1st rib and passes under the subclavius muscle and the pleuro-clavicular joint and, because of that, it is pressed by its thoracic-clavicular fascia (16).
The symptoms consists of the dilatation of veins of the upper limb and of the front thoracic wall, which is reduced with the movement of shoulders downwards (17). Notwith-standing that the presence of thrombus within the vein does not threaten the viability of the hand it runs the risk of pulmonary embolism.
In addition, the fractures of the proximal part of the clavicle may be accompanied with obstruction of carotid artery, either on account of pressure from the fracture fragments or on account of production of oversized callus, causing syncoptic attacks. (18)
In the beginning, the belying vascular lesion may seem as a mere trauma with no symptoms and it thus may elude diagnosis, this resulting later to a noisy outlook of arterial thrombosis and the risk to salvage the limb.
Artery pressure must be measured on both limbs for any differences and in case of doubt, the member in question must be further examined with an angiography.
The treatment of the arterial injury initially consists of treating the hypovolemia and the accompanying injuries (pneumothorax) and next end to end suturing of the lesion or placement of a venous graft. Finally, the fracture of the clavicle is remedied by way of surgery (19, 20, 21).
The treatment of the subclavius vein damage consists of the excision of the abutant callus which causes the pressure or, if the clavicle is normal, then the 1st rib is removed (6).
Pneumothorax - Haemothorax
Due to the contiguity of the middle part of the clavicle with the top of the lung and the pleura, it is possible that a pneumothorax or haemothorax develop from the bony fragment of the displaced fracture of clavicle (22).
The mechanism of the injury in the 60% of the cases consists of the immediate damage of the shoulder following a low energy violence (23).
It is observed in 3% of cases and the co-existence of scapula or upper ribs fractures contributes to the diagnosis (24).
The treatment requires drainage of the hemithorax and conservative or internal osteosynthesis of the clavicle's fracture.
Damage of the brachial plexus
Around 1% of the lesions of the brachial plexus occurs following a fracture of the clavicle and it develops either early or late (25).
More frequent though is the late development of a lesion of the brachial plexus, on account of the creation of an oversized callus, which usually traps the rear side and the middle part on adults, within the pleuro-clavicular area (26).
Notwithstanding that brachial plexus is protected by the periosteum of the rear part of clavicle, the subclavius muscle and the clavicle, it is possible that a trauma occurs immediately, especially in the case of displaced or cominuted fractures of the clavicle's middle part (27).
The severe injury of the brachial plexus usually involves the rear part and, more rarely, the entire brachial plexus. It develops on the form of nerve-apraxia, mainly from exulceration, rather than from a direct strain from the fractural extremities of the clavicle which are displaced rearwards (28).
The forces which cause the severe lesions of the brachial plexus have a direction from the top to the bottom or from the front to the rear, causing a stress on the brachial plexus, which is pressed on the transversal apophysis of the cervical part of spine. Also, it is possible that roots of the brachial plexus are detached above the clavicle, or that they are directly detached from the spine (29).
The symptoms may concern the entire brachial plexus or to originate from the injury of only one nerve. The patient frequently complains for paresthesias or pain of the upper limb following a fracture of clavicle. The symptoms are aggravated after an abduction or external rotation of the shoulder, after lifting a weight or when developing activities in which the upper limb is used above the head level, while they go down when the patient has a rest. (30)
The diagnosis is filed in the records of the personal history and the objective examination, while it is also substantiated with the MRI, which gives an image of the relationship between the brachial plexus and the fractural limbs, as well as with the electromyogram. (31)
In addition, in the simple x-rays, when ascertaining a gap of the fracture fragments which is bigger than 1cm, there is increased suspicion for a lesion of the brachial plexus (6).
The existence of a fracture of the clavicle with an accompanying damage of the brachial plexus gives a notion of an accompanying injury of the subclavius vessels.
The development of a severe neuropathy presents a better prognosis as compared with the late development of neuropathy (32).
The treatment of the severe neuropathy calls for the disassociation of the brachial plexus from the fracture fragments and the internal osteosynthesis of the fracture (33).
The injury of the brachial plexus after a rupture of the acromio-clavicular joint is rare and it usually develops on the form of neuro-apraxia. Sturm and Perry studied 59 cases of post-trauma lesion of the brachial plexus and found out that only in two cases there was also a rupture of the acromio-clavicular joint (34). The mechanism of the injury calls for stretching the brachial plexus due to the fall of the shoulder following the rupture of the acromio-clavicular joint or to direct trauma of the area of the shoulder.
Scapulothoracic dissociation
The scapulothoracic dissociation is characterized from the excessive upward dislocation of the acromioclavicular joint combined with nerve-vascular injuries (complete or partial injury of the brachial plexus as well as injury of the subclavius or axillary vessels), dislocation of the acromio-clavicular joint or displaced fracture of the clavicle, or rupture of the sterno-clavicular joint and partial or complete rupture of muscles attachements (such as deltoid, trapezoid, rhomboid, lesser thoracic, levator of scapula and latissimus dorsi muscle) with a highlighted haematoma of the shoulder's soft tissue (35).
The complete type is clinically evident, but as a rule the type which is accompanied with a rupture of the acromio-clavicular joint belies from a sub-clinical viewpoint and may escape the attention, this resulting in a risk of losing the upper limb, due to the significant vascular lesion (36).

References
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