Posttraumatic Nonunion of the Clavicle in a 13-Year-Old Boy Causing an Arteriovenous Fistula
A 13-year-old boy was referred to clinic with a prominent dilatation on the right side of his neck that had been gradually enlarging since he sustained a displaced fracture of the middle third of his right clavicle 6 months previously. This was treated conservatively by the referring hospital []. The patient was uninhibited in daily activities, but complained of ongoing pain at the fracture site and was concerned about his cosmetic appearance. His past medical history consisted of a congenital atrial septal defect with partial anomalous pulmonary venous drainage, which was surgically corrected at the age of 18 months. On examination, there was a nonpulsatile dilation in the right anterior triangle of his neck overlying the clavicle which was tender on palpation. There was no other visible deformity and he had full range of motion of the ipsilateral shoulder.\nAn ultrasound and computed tomography (CT) scan were arranged, which revealed a hypertrophic angulated nonunion of the clavicle fracture. The surrounding callus formation was shown to be compressing the EJV, impeding its drainage, and causing the striking distension measuring 2 cm in diameter. The anatomy of the carotid and subclavian arteries appeared normal.\nFollowing multidisciplinary discussion, a decision was made to operatively reduce and fix the clavicle nonunion. Intraoperatively, gross callus formation was found at the fracture site. However, an arteriovenous fistula was also discovered in a vascular cavity in the callus between a branch of the subclavian artery and the EJV. The fistula was excised and adjacent veins ligated and closed by vascular surgeon before the clavicle fracture was reduced and fixed with a six-hole contoured plate without the use of bone graft.\nRadiographs taken 1 week postoperatively confirmed satisfactory position of the clavicle fixation. At 1-month follow-up, the EJV was less prominent and there was no residual pain around the shoulder. At 6-months follow-up, the patient was asymptomatic with full range of movement of the ipsilateral shoulder. Radiographs and CT scans showed union of the fracture site with good alignment of the clavicle []. A CT venogram revealed an enlarged right EJV with a stenosed lower end and tortuous collaterals to the right internal jugular vein and subclavian vein, but no residual arteriovenous fistula [].