Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls
A 58-year-old right-hand dominant male presented with painful nonunion of a Neer type II left lateral clavicle fracture in February 2010. His main complaint was of pain and clicking, particularly on heavy lifting. He had no significant past medical history but he was a heavy smoker. (Radiographs in Figure and show the left clavicle after the initial injury sustained in July 2009 and symptomatic non-union in February 2010 respectively).\nThe patient underwent surgical intervention with open reduction and internal fixation (ORIF) using a lateral clavicle locking plate (Periloc, Smith and Nephew) and iliac crest bone grafting of the left lateral clavicle in March 2010. The procedure was performed through a transverse incision. The nonunion site was debrided. Bone graft from the iliac crest was inserted and the fixation was performed using the locking plate; five of the eight lateral 2.7 millimeter (mm) screws allowed by the plate were inserted, though the lateral fragment of the clavicle was only large enough to allow insertion of two screws. The patient was discharged with the arm immobilized in a sling. Outpatient physiotherapy was arranged and instructions were given to perform pendular exercises within a pain free range. Flexion and abduction were restricted for the first 6 weeks.\nFollow-up radiographs 6 weeks later showed that the plate had failed and pulled out of the lateral fragment []. The plate caused significant tenting of the skin and therefore removal of metalwork was done. The nonunion was managed by stabilizing the medial fragment with a coracoclavicular sling, fixed with a 3.5 mm screw and washer.\nWhen reviewed 8 weeks postoperatively, the patient had an Oxford Shoulder Score (OSS) of 28. There was no pain or instability at the site of the fracture. At the last review in December 2011, the patient had an asymptomatic nonunion with no shoulder pain, a full range of movement, and an OSS of 48 [].