Discussion :

In neonates and children, these fractures are very common and generally heal well. In adults, the force required to fracture the clavicle is greater, healing occurs at a slower rate, and risk of potential complications is higher. The clavicle is the sole articulation of the shoulder girdle to the trunk. It protects major underlying vessels, lung, and brachial plexus. Displaced clavicle fractures can injure these structures because of their proximity and sharp edges.  

Extensive clinical studies reported in the literature have indicated that non-operative treatment is the treatment of choice for clavicular fractures. It has also been suggested by some that open reduction may contribute to the development of non-union. From 1970 to 1978, twenty-five of approximately 800 patients with a fracture of the clavicle were treated by open reduction and internal fixation with a threaded intramedullary wire or pin or with cerclage suture (one case). The patients' ages ranged from thirteen to fifty-nine years. All fractures healed without infection or migration of the pin. Based on this experience and a review of the English-language literature, they concluded that the indications for open reduction and internal fixation should be: (1) neurovascular compromise due to posterior displacement and impingement of the bone fragments on the brachial plexus, subclavian vessels, and even the common carotid artery; (2) fracture of the distal third of the clavicle with disruption of the coracoclavicular ligament; (3) severe angulation or comminution of a fracture in the middle third of the clavicle; (4) the patient's inability to tolerate prolonged immobilization (required by closed treatment) because of Parkinson's disease, a seizure disorder, or other neuromuscular disease; and (5) symptomatic non-union following treatment by closed methods. 2 

Internal fixation of the clavicle is rarely necessary. When it is warranted, the clavicle's complex three-dimensional morphology and functional anatomy, proximity to vital structures, and the multidirectional biomechanical forces acting upon it place considerable demands on any implant used for skeletal fixation. Mullaji AB et al treated nine clavicles with the recently-introduced 3.5 mm low contact-dynamic compression plate (LC-DCP). Surgery was performed for symptomatic non-union in six patients, shoulder dysfunction following a malunited fracture in one, for an open fracture in one, and for an acute fracture associated with brachial plexus injury in one. After an average follow-up period of 17 months union was secured in each case. The advantages afforded by the 3.5 mm LC-DCP in internal fixation of the clavicle with its uniquely demanding anatomical and biomechanical characteristics are discussed. 3 

In a multicenter, prospective clinical trial, conducted by Canadian Orthopaedic Trauma Society, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disability of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). They concluded that operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients. 4

In another series of study done by Poigenfürst J et al, there was no bony infection or infected pseudarthrosis. Four clavicles refractured after removal of the plate and five operations led to pseudarthroses which were successfully treated by reoperation. Radiological and clinical results in the majority of the re-examined patients were excellent. Among total of 131 fractures of the clavicle treated with plate and screws, such a devastating complication as we found in our case, was not mentioned. 5

Ali Khan MA etc al. reported treatment of twenty mid-clavicular fractures by plate fixation. They mentioned that the technique they used gave relief from pain within 12 hours and resulted in bony union all cases. There were no such complications as they reported. 6

23 fresh type II (Neer 1963) lateral clavicular fractures were treated operatively. In 19 cases fixation was done with two Kirschner wires, in four cases plating was performed. The coracoclavicular ligament was left unsutured. The average follow-up period was 4.5 (1-12) years. In 22 cases out of 23 the subjective outcome was good or satisfactory. 22 fractures united and there were few complications, but above mentioned complications were not found. 7

From the different large and small studies from case series to multi-centric controlled trials, we reviewed, did not mention such a devastating complication. Till date there are controversies and debates on the treatment of fracture clavicle, though we mostly observe its acceptable alignment and union without specific interventions. We, therefore, recommend conservative treatment of fracture clavicle in our setup with geo-socio-economic conditions.