|Year : 2017 | Volume
| Issue : 2 | Page : 127-130
Crush neck with bilateral clavicle fractures managed with negative-pressure wound therapy and supracutaneous locked plating
Department of Orthopaedics, Kamineni Hospitals, Hyderabad, Telangana, India
|Date of Web Publication||14-Dec-2017|
Dr. Anuj Agrawal
Department of Orthopaedics, Kamineni Hospitals, King Koti Road, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Bilateral and open fractures of the clavicle are rare injuries, with Gustilo-Anderson Type III open clavicle fractures rarely seen. We have reported a case of bilateral clavicle fractures in a young male with crush injury of the neck on the right side, multiple associated rib fractures, and brachial plexus injury. The crush neck was managed with extensive debridement and clavicle fractures were managed with external fixation with a supracutaneous locking compression plate on the right side, and internal fixation with a reconstruction plate on the left side. The wound healed with serial negative-pressure dressings without any secondary procedure. Both the fractures united well with a good outcome. This case demonstrates the effective use of negative-pressure wound therapy and supracutaneous locked plating for a Gustilo-Anderson Type IIIB open fracture of the clavicle.
Keywords: Bilateral clavicle fractures, crush injury of neck, Gustilo-Anderson Type IIIB open clavicle fracture, negative-pressure wound therapy, open clavicle fractures, supracutaneous locked plating
|How to cite this article:|
Agrawal A. Crush neck with bilateral clavicle fractures managed with negative-pressure wound therapy and supracutaneous locked plating. J Orthop Traumatol Rehabil 2017;9:127-30
|How to cite this URL:|
Agrawal A. Crush neck with bilateral clavicle fractures managed with negative-pressure wound therapy and supracutaneous locked plating. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2021 Mar 2];9:127-30. Available from: https://www.jotr.in/text.asp?2017/9/2/127/220768
| Introduction|| |
Operative fixation of the clavicle is usually indicated for severe displacement, open fractures, and fractures associated with neurovascular injury. The presence of severe open wounds (Gustilo-Anderson Type III) contraindicates the use of internal fixation with plates, and external fixation of the clavicle is required in such cases. Use of conventional external fixators is cumbersome to the patients in the clavicle region, with functional and cosmetic problems due to prominent implants. Locking plates can be used as low-profile external fixators when placed in a supracutaneous fashion. Role of negative-pressure wound therapy (NPWT) in the management of large traumatic wounds is well established.
We have reported a case of bilateral clavicle fractures in a young male with crush injury of the neck on the right side, associated with brachial plexus injury, hemopneumothorax, and multiple, open fractures of the ribs and clavicle on the right side, presenting a challenge for both wound and fracture management. A good result was obtained with negative-pressure dressings and supracutaneous locked plating on the right side and internal fixation with a compression plate on the left side.
| Case Report|| |
A 39-year-old male patient presented after a road traffic accident, wherein he sustained a penetrating trauma in the right side of the neck by a metal strut of a truck. Radiologic examination [Figure 1] showed displaced fractures of both clavicles, fractures of the first five posterior ribs with costovertebral dislocations of the first three ribs on the right [Figure 1]. Primary management was done elsewhere with a thoracostomy for hemopneumothorax, ligation of bleeders in the neck, and insertion of a surgical drain in the neck wound. Multiple blood transfusions were given (12 transfusions over 3 days).
|Figure 1: Preoperative imaging of the patient (a) anteroposterior X-ray of the chest (b) anterior three-dimensional computed tomography reconstruction view (c) posterior three-dimensional computed tomography reconstruction view|
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The patient presented to our hospital for further management, 3 days after the initial trauma. He had complete brachial plexus palsy with Horner syndrome on the right side. There was an irregular 10 cm × 8 cm wound with a necrotic base in the Zone I of the neck [Figure 2]a. The wound was draining more than 200 ml of serosanguineous fluid per day. After 2 days of observation, a decision was taken to explore the neck wound for neurovascular injury, planning wound debridement, and fixation of right clavicle. Computed tomography angiography and other invasive investigations were not done. The left clavicle too was planned to be fixed internally in the second stage.
|Figure 2: Clinical pictures of the neck wound (a) at presentation (b) after debridement (c) negative-pressure dressing with hardware foam (d) 1 week after surgery (e) 3 weeks after surgery (f) 6 weeks after surgery, following plate and wound revision (g) final healing at 10 weeks|
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The wound was extended for exploration, similar to a supraclavicular approach used for first rib resection in thoracic outlet syndrome. The soft tissues of the neck were found badly crushed and devitalized. The scalenus medius/omohyoid muscles and scalene fat pad were completely debrided, with a partial debridement of scalenus posterior muscle. The transverse cervical artery was found torn and was ligated. The external jugular vein was found ligated by the previous team. All the three trunks of the brachial plexus were found intact, though contused. A huge soft tissue defect (10 cm × 8 cm, 6 cm deep) was left after debridement, precluding internal plate fixation of the right clavicle [Figure 2]b. The clavicle fracture was provisionally reduced with a K-wire and fixed with a supracutaneous locked plate as external fixator [Figure 2]b. NPWT was planned, and hence, the plate was applied close (3–4 mm away) to the skin to allow proper sealing of wound including the plate [Figure 2]c. The postoperative X-rays [Figure 3]a showed a satisfactory reduction of the fracture. The plate was mistakenly placed with the curved lateral end toward the medial side, causing difficulty in placement of lateral locking screws. The lateral most screw could not be locked into the plate but had good bicortical purchase.
|Figure 3: Postoperative X-rays of the patient (a) after supracutaneous plating of the right clavicle (b) after internal fixation of the left clavicle (c) after revision of the right plate (d) 1 year postoperative, after implant removal on the right|
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Serial vacuum dressings were done, changed every 4–5 days. We employ hardware foam and central suction for negative-pressure dressings, greatly reducing the costs of therapy. The closed left clavicle fracture was fixed internally with a lag screw and neutralization reconstruction plate [Figure 3]b. There was rapid healing of the cavitary neck wound [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, but the surgical incision under the plate gaped open [Figure 2]e, due to the adjacent negative pressure and closely applied plate. Once there was no need of further vacuum dressings (4 weeks after the index surgery), the plate was revised to a proper location 2 cm away from the skin [Figure 3]c, with removal of the K-wire and the wound under the plate was closed with excision of granulation tissue. There was only 4 cm × 4 cm superficial skin defect left by that time [Figure 2]f, which was left to heal with secondary intention. Good healing of the wound and fractures was seen at 10 weeks [Figure 2]g and the external fixator was removed. Final radiographs at 1 year showed good bony consolidation of both clavicle fractures [Figure 3]d.
Progressive neurological recovery was seen in the right upper limb, with complete recovery of the lower roots of the brachial plexus (hand function), but only partial recovery of the upper roots (shoulder function). At the latest follow-up at 2 years, the patient had achieved normal range of motion of the left shoulder [Figure 4]a, with restricted movements on the right side [Figure 4]b. He had no significant pain or other symptoms and had joined back his previous occupation, being satisfied with the outcome of the surgery.
|Figure 4: (a and b) Range of motion of both shoulders 2 years after surgery. Abductor weakness persists on the right side|
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| Discussion|| |
Although fractures of clavicle are quite common, with an incidence of 2%–5% of all fractures, open fractures of the clavicle are infrequently seen., In a series of 1000 clavicle fractures described by Robinson, only two Gustilo-Anderson Type I open fractures were seen, with no Type II/III fractures. We are not aware of any Gustilo-Anderson Type IIIB fracture of the clavicle reported in literature. Bilateral clavicle fractures are too uncommon, accounting for <0.5% of all clavicle fractures. Both these conditions are a result of a high energy trauma with severe associated injuries, such as head and pulmonary injury. The mechanism of injury in bilateral fractures is a compressive force across both shoulders.
Most open fractures of the clavicle occur due to inside-out penetration by a bony spike. These can be fixed internally with a plate after wound debridement with primary closure of the wound. Rarely, there may be extensive soft tissue damage, as in crush neck due to penetrating trauma. In such cases, external fixation of the clavicle is required for temporary or definitive stabilization, facilitating multiple dressings or debridements. Conventional pin fixators when used in the clavicle cause inconvenience to the patient due to the bulky apparatus with multiple pins. Besides appearing cosmetically displeasing, these also cause difficulty in neck movements and can catch clothes, requiring alteration in patient clothing. Furthermore, there are frequent reports of pin loosening and pin-tract infections with these. Severe open fractures of the clavicle are rarely seen, and the use of fixators is mostly described for management of infections and nonunions.,
Locking plates have been used as external fixators due to their angular stable property. Kloen  first reported a case series of locked plates applied externally calling it as “supercutaneous” plating, though we find the term “supracutaneous” plating more appropriate to describe the plate location. Supracutaneous locked plates provide practical advantages to the patients due to the low profile of the construct with a smooth surface, allowing a trouser or a shirt to be worn over it. Moreover, pin-tract infection has been seen less frequently with locking plates. We could find only two studies in the literature reporting the use of supracutaneous locking plates in clavicle.,
Use of supracutaneous locking plates is particularly suited for the clavicle region. Apart from avoiding the cosmetic and functional problems mentioned above, these provide a better safeguard against pin/screw migration which can be disastrous in the chest region. Furthermore, when NPWT is required for an adjacent wound, application of a locking plate greatly facilitates sealing of the wound, incorporating the plate under the occlusive dressing [Figure 2]c. We placed the plate too close to the skin the first time with resultant wound gaping and would recommend a distance of at least 6–8 mm between the plate and the skin even if NPWT is required.
Application of a supracutaneous locking plate is technically more challenging than a conventional external fixator, and previous authors have employed locking reconstruction plates for the ease of contourability. However, an anatomically precontoured locking compression plate has been shown to be more stable than a reconstruction plate  and should be preferred over the latter. With correct plate orientation during the plate revision, we did not face any difficulty in its application. The fracture should be reduced well before plate application, and the screws away from the fracture should be inserted first to ensure central bicortical placement.
NPWT has recently emerged as an effective tool in the management of severe open fractures. It works by increasing vascularity, clearance of excessive fluids, decreasing bacterial growth and mechanical stress. The need of plastic surgery procedures such as myocutaneous flaps and split skin grafts is greatly decreased by it. In our case, the extensive neck wound left after debridement would otherwise require a free or pedicled latissimus dorsi flap for soft tissue coverage, but it healed successfully by NPWT in a few weeks.
| Conclusion|| |
We have shown good results with bilateral plating of the clavicle, supracutaneous on one side, with NPWT, in a complex case of crush neck with bilateral clavicle and rib fractures, hemopneumothorax, and brachial plexus palsy. A supracutaneous locked plate is a suitable alternative to a conventional external fixator for Gustilo-Anderson Type III fractures in the clavicle region.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]