The Journal of Bone and Joint Surgery 81:256-258 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.
Posttraumatic Cleidoscapular Synostosis Following a Fracture of the Clavicle. A Case Report*
ABID A. QURESHI, M.D. and
KEN N. KUO, M.D., CHICAGO, ILLINOIS
Investigation performed at Rush-Presbyterian-St. Luke's Medical Center, Chicago
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Introduction
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Fractures of the clavicle are common in both children and adults; such fractures accounted for 43 percent of 1603 injuries of the shoulder girdle as reported by Rowe11 in 1958. Most fractures of this type heal uneventfully as noted by Hippocrates1 in 400 B.C. Several late complications have been identified, including nonunion, malunion, neurovascular compromise, and posttraumatic arthritis3. We report the case of a child in whom a cleidoscapular synostosis developed following a segmental fracture of the clavicle; this complication has not been reported previously, to our knowledge.
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Case Report
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An eight-year-old girl was seen in January 1995 for the evaluation of a deformity of the left shoulder, which was occasionally painful at night and during cold weather. Two years earlier, she had been injured while riding as a passenger in the backseat of an automobile that was broadsided by another vehicle; she was not wearing a seat belt at the time of the accident. She sustained an injury of the left shoulder and a minor injury of the head; medical evaluation revealed a fracture of the left clavicle and a small extradural hematoma without a fracture of the skull. She was observed as an inpatient for three days and was discharged with the left arm in a sling. During the following year she was evaluated by two orthopaedic surgeons, who recommended physical therapy.
Our examination revealed a fixed winging deformity of the left scapula, with a palpable mass along the anterosuperior aspect of that bone. The entire clavicle was palpable from the sternoclavicular joint to the acromion, without tenderness. Abduction of the shoulder was limited to 150 degrees on the left compared with 180 degrees on the right. The ranges of flexion, internal rotation, and external rotation were symmetrical. The fixed winging of the left scapula, as viewed from behind the patient, did not change throughout the range of motion of the shoulder. Motor, sensory, and spinal examinations revealed normal findings.
A review of the radiographs that had been made at the time of the original injury revealed a segmental fracture of the clavicle, consisting of a greenstick fracture of the middle third of the clavicle and a physeal separation at the distal portion of the clavicle. The distal fragment was angulated posteriorly, and a large gap was evident between the proximal fragment and the acromion (Fig. 1). Serial follow-up radiographs demonstrated that the distal portion of the clavicle had reconstituted secondary to new-bone formation and that the segmental fragment had fused to the anterosuperior margin of the scapula (Figs. 2, 3-A, and 3-B). This finding was confirmed on a three-dimensional computed tomographic scan (Fig. 4). A diagnosis of cleidoscapular synostosis was made.
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FIG1: Fig. 1 Radiograph made at the time of the injury, showing a segmental fracture of the left clavicle. The distal fragment is angulated posteriorly, and a gap is evident between the proximal fragment and the acromion.
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FIG2: Fig. 2 Radiograph made one month after the injury, showing new-bone formation between the midclavicular fracture and the acromion. This new bone probably formed within the intact periosteal sleeve of the distal portion of the clavicle.
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FIG3-A: Fig. 3-A Anteroposterior and oblique radiographs of the clavicle, made at the time of the two-year follow-up examination, showing the fusion of the original distal clavicular fragment (arrow) and the scapula, creating a cleidoscapular synostosis.
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FIG3-B: Fig. 3-B Anteroposterior and oblique radiographs of the clavicle, made at the time of the two-year follow-up examination, showing the fusion of the original distal clavicular fragment (arrow) and the scapula, creating a cleidoscapular synostosis.
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FIG4: Fig. 4 Three-dimensional computed tomographic scan of the shoulder, demonstrating the cleidoscapular synostosis. The distal clavicular fragment (arrow) spans the area from the middle of the shaft of the clavicle to the spine of the scapula.
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Operative excision of the synostosis was performed to relieve the intermittent pain and to correct the fixed deformity. At the time of operative treatment, a superior incision was made in line with the proximal part of the clavicle and was then curved posteriorly along the osseous mass toward the scapula. Extraperiosteal dissection was then performed. There was a solid bridge of bone between the middle of the shaft of the clavicle and the anterosuperior surface of the scapular spine, with complete osseous union at both ends of the synostosis. The synostosis was removed after an osteotomy was performed at the anterior surface of the scapular spine and at the posterior margin of the clavicle. The fragment measured four centimeters in length and 0.9 centimeter in diameter. The surrounding soft tissue filled the space created by the excision; no interpositional material was used. At the two-year follow-up examination, the patient was asymptomatic and had a full and symmetrical range of motion of both shoulders. The scapular winging on the left side had completely resolved, and radiographs demonstrated no evidence of recurrence of the synostosis (Fig. 5).
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FIG5: Fig. 5 Radiograph made two years postoperatively, showing no evidence of recurrence of the synostosis.
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Discussion
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The immature bone of children is susceptible to different patterns of failure than is the mature bone of adults. In children, ligaments are more resistant to stress than are bone and cartilage. Physeal fractures frequently occur when major ligaments attach directly to an epiphysis. The deforming forces that would separate an acromioclavicular joint in an adult are more likely to result in a fracture of the distal part of the clavicle at the physis in a child5,8. This physeal separation has been defined as a pseudodislocation or a Rockwood10 type-IV fracture of the clavicle.
In children, the periosteum is thicker and more loosely attached to the bone and exhibits greater osteogenic potential than that in adults7. Avulsion of the periosteum can lead to periosteal bone formation6. Complete loss or displacement of a bone segment and preservation of an intact periosteal sleeve may result in complete reformation of the missing bone2. We believe that this process led to the nearly full reconstitution of the distal portion of the clavicle in our patient.
Golthamer4 initially described duplication of the clavicle, or so-called os subclaviculare, in 1957. He attempted to relate his findings to embryological development and did not address the possibility of a traumatic etiology. Twigg and Rosenbaum12 also described a case of bifid clavicle in which both branches of the distal end of the bone articulated with the acromion. No history of trauma was noted by their patient. Ogden9, in a series involving fourteen distal clavicular fractures, described one instance of duplication of the distal portion of the clavicle. In that patient, a traumatic episode had produced a tear in the periosteal sleeve as well as physeal separation at the distal portion of the clavicle. Ogden concluded that an embryological etiology of bifid clavicle has not been proved.
The case of our patient is unique in that it involved a greenstick fracture of the middle third of the clavicle and a Rockwood10 type-IV physeal separation at the distal portion of the clavicle, or a pseudodislocation of the acromioclavicular joint10. This segment of the distal part of the clavicle united with the scapula and produced a painful winging deformity.
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Footnotes
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*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Department of Orthopaedic Surgery, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Suite 1063, Chicago, Illinois 60612. E-mail address for Dr. Kuo: kennank@aol.com.
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References
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Adams, F.: The Genuine Works of Hippocrates. Baltimore, Williams and Wilkins, 1939.
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Borgi, R.; Butel, J.; and and Finidori, G.: La regenerescence diaphysaire d'un os long chez l'enfant. Rev. chir. orthop., 65: 413-414, 1979.
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Craig, E. V.: Fractures of the clavicle. In The Shoulder, pp. 387-397. Edited by C. A. Rockwood, Jr., and F. A. Matsen, III. Philadelphia, W. B. Saunders, 1990.
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Golthamer, C. R.: Duplication of the clavicle ("os subclaviculare"). Radiology, 68: 576-578, 1957.
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Katznelson, A.; Nerubay, J.; and and Oliver, S.: Dynamic fixation of the avulsed clavicle. J. Trauma, 16: 841-844, 1976.[Medline]
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Ogden, J. A.; Pais, M. J.; Murphy, M. J.; and and Bronson, M. L.: Ectopic bone secondary to avulsion of the periosteum. Skel. Radiol., 4: 124-128, 1979.
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Ogden, J. A.: Chondro-osseous development and growth. In Fundamental and Clinical Bone Physiology, pp. 108-171. Edited by M. R. Urist. Philadelphia, J. B. Lippincott, 1980.
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Ogden, J. A. [editor]: Chest and pectoral girdle. In Skeletal Injury in the Child, p. 214. Philadelphia, Lea and Febiger, 1982.
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Ogden, J. A.: Distal clavicular physeal injury. Clin. Orthop., 188: 68-73, 1984.
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Rockwood, C. A., Jr.: Fracture of the outer clavicle in children and adults. Orthop. Trans., 6: 472, 1982.
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Rowe, C. R.: Fractures of the clavicle. In Fractures and Other Injuries, pp. 259-263. Edited by E. F. Cave. Chicago, Year Book Medical, 1958.
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Twigg, H. L., and and Rosenbaum, R. C.: Duplication of the clavicle. Skel. Radiol., 6: 281, 1981.[Medline]
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Introduction
Case Report