IORG Case Snippet

Case Presentation and Concise Review of Literature

This is a new Section Created for Compilation of cases presented in the IORG Facebook Case Discussion Forum.

These cases will be selected by the IORG Team and will be presented in following format along with a current review of literature on the topic

The contributor will be acknowledged and all members comenting on the case will also be acknowledged.


Post Traumatic Costo-Clavicular Compression Syndrome Secondary to Clavicle Non union

Contributed by Dr Rahul Satpute in IORG Facebook Case Discussion Forum

‎45/M/Rt handed/# Rt clavicle on 8/7/11-immediately c/o hypoasthesia in Rt thumb & index finger-this complaint was neglected by ortho collegue as per patient.Figure of 8 bandage was applied for25 days. Now Patient c/o pain & pricking at fracture site,tingling in hand,weakness in Right upper limb.
O/E-click palpable on shoulder abduction and adduction,tend++at fracture site,no abnormal mobility,
As compared to power of opposite side,Rt triceps/grip/shoulder abd-weak,decreased sensations-thumb/index/middle fing.
Radial,ulnar pulse=N

.X-Ray on 19/9/11
MRI was done which showed -# with moderate callus,surrounding soft tissue edema compressing on lat & post cords of brachial plexus with post traumatic injury at level distal to interscalene triangle,plexus cords appear intact.

Cerv.spine-mild annular disc bulge-central & Rt paracentral disc protrusion& annular tear atC4-5/C5-6 ,without any compression at C5,mild compression of C6 Rt per patient weakness has gradually increased.

Comments on the Case In IORG Forum

      • Dinesh Agrawal- kindly post more mri images.  what was mode of injury. whether patient was having any neck pain or radiculopathy before injury.

      • Rajasekhar Rao P - It is non union plate it and bone graft it. Dont try to remove the callus over the plexus you might damage it. just stabilise it and fix it you will give more room for the plexus, this is costo-clavicular syndrome post traumatic.
        Rajasekhar Rao P - post traumatic costo-clavicular compression syndrome.

 Review of Literature by IORG Team

On review of literature we found following articles on the topic with presentation similiar to the presented case. We are providing the details of the papers with abstracts

1.Brachial plexus palsy secondary to clavicular nonunion. Case report and literature survey.

Kay SPEckardt JJ.Clin Orthop Relat Res. 1986 May;(206):219-22


Compression neurapraxias of the brachial plexus secondary to nonunion of the clavicle are extremely rare. These palsies routinely affect the medial cord, producing primarily ulnar nerve symptoms. The nonunions that cause them are almost exclusively hypertrophic and are usually in the middle third of the clavicle. These palsies result from the entrapment of the medial cord of the brachial plexus within the costoclavicular space of Berkheiser. Onset of symptoms is highly variable. Treatment recommendations are divided between partial clavicular excision and open reduction with internal fixation. Because this lesion requires operative intervention, it must be carefully distinguished from traction palsy of the plexus for which it is easily mistaken. This distinction requires a meticulous neurologic examination during the initial evaluation of the patient with an acute calvicular fracture.

Pubmed Link

2.Late lesions of the brachial plexus after fracture of the clavicle.
Della Santa D, Narakas A, Bonnard C.Ann Chir Main Memb Super1991;10(6):531-40.


Unité de Chirurgie de la Main, HCU, Geneva, Switzerland.


Fractures of the clavicle, particularly those which are markedly displaced, may, in rare instances cause injury to the subclavian vessels and the brachial plexus which manifest progressively days or weeks after the initial trauma. More often than not, however, a costo-clavicular compression syndrome appears months or years after the clavicular fracture as a result of constriction by scar which invests the neuro-vascular bundle, by a secondary aneurysm or by hypertrophic callus. The authors report 16 such cases, one of which was treated conservatively, thirteen treated by surgical intervention while two cases are awaiting operation. These patients represent just over 1% of brachial plexus lesions seen over a period of twenty years in two surgical centres. Operative treatment consists of reduction of the clavicular deformity, possibly first rib resection, liberation of the plexus and correction of a vascular lesion as required. The outcome is usually good.

Pubmed Link


3.Damage to the arm plexus caused by atypical callus formation following clavicular fracture].

[Article in German]
Jahn R, Friedrich B.Unfallchirurg. 1989 May;92(5):227-8.


Secondary brachial plexus paralysis do not occur very often as a consequence of collar bone fractures. It is difficult to detect the cause, especially as there can be quite a long interval between the trauma and occurrence of the first symptoms. The problem is discussed with reference to a case observed by the authors: atypical callus formation 7 weeks after a clavicular fracture that was conservatively treated and had healed had led to brachial plexus damage. The patient was treated 11 months later by a trauma surgeon. Once the callus had been removed she was finally free of symptoms.

Pubmed Link


4.  Brachial-plexus injury after clavicular fracture: case report and literature review.

Rumball KM, Da Silva VF, Preston DN, Carruthers CC.Can J Surg. 1991 Jun;34(3):264-6.


Faculty of Medicine, University of Ottawa, Ottawa Civic Hospital, Ont.


Brachial plexus injury is a rare complication of the fractured clavicle. The authors describe the second reported case of brachial plexus injury due to secondary fracture displacement. This case emphasizes the following points: the neurologic status of the arm after a fracture of the clavicle must be documented; fractures of the middle one-third of the clavicle are prone to displacement; patients should be advised to report immediately any new symptoms in the arm; when fracture displacement is the cause of brachial-plexus compression then a trial of conservative therapy is indicated; the prognosis for neurologic recovery after this injury is good.

Pubmed Link

5.Brachial plexus palsy caused by secondary fracture displacement in a patient with closed clavicle fracture.

Lin CCLin J.Orthopedics. 2009 Oct;32(10).


Department of Orthopedic Surgery, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan.


In adults, brachial plexus injury due to clavicle fractures is rare, and is most commonly caused by nonunion, malunited fragments, hypertrophic callus, or pseudoaneurysm of the subclavicular artery or vein. Brachial plexus palsy in acute fractures caused by direct fragment compression is exceptional. Conservative treatment of nondisplaced and displaced midclavicle fractures in adults usually produces satisfactory outcomes. This article presents a case of a 74-year-old man who sustained a closed, midshaft right clavicle fracture complicated by secondary displacement and brachial plexus injury. Initially, the fracture was nondisplaced, and he was treated conservatively. However, he returned 2 weeks later with shoulder pain and coldness, progressive numbness, and weakness of the right extremity. Physical examination revealed weakness of the flexion and extension of his elbow, wrist, and finger joints with slightly diminished right side radial pulsation. Radiographs demonstrated a displaced clavicle fracture with a vertically angulated intermediate fragment and narrowed costoclavicular space. Magnetic resonance imaging revealed bony fragments with a perifocal soft tissue mass encroaching on the brachial plexus and axillary artery. During surgery, the brachial plexus was found to be markedly stretched due to compression by the bony fragments and an organized blood clot. After meticulous neurolysis, the blood clot and intermediate bony fragments were removed and the distal fragments were reduced and fixed with a metal plate and interfragmentary screws. Secondary fracture displacement is possible after a nondisplaced clavicle fracture if the arm is not well protected, even if the original fracture appears stable and no neurological or circulatory symptoms are present.

 Pubmed Link


6. Brachial plexus compression caused by recurrent clavicular nonunion and space-occupying pseudoarthrosis: definitive reconstruction using free vascularized bone flap-a series of eight cases.

Krishnan KG, Mucha D, Gupta R, Schackert G.Neurosurgery. 2008 May;62(5 Suppl 2):ONS461-9; discussion 469-70.


Department of Neuroradiology, Carl Gustav Carus University Hospital, Dresden, Germany.



In rare cases, space-occupying pseudoarthrotic clavicular nonunion causes symptomatic brachial plexus compression. The surgical treatment of clavicular pseudoarthrosis has been extensively reported in the literature. This article reports our experience of a definitive treatment strategy using free vascularized fibula flaps in cases of persistent compression of the brachial plexus by relapsing bony nonunion mass lesions.


Six men (age range, 46-59 yr) and two women (ages 48 and 52 yr) with nonunions of clavicular midshaft fractures were referred between August 2001 and March 2005 because of progressive compression of the subclavicular neurovascular bundle. All of them had displaced traumatic clavicle fractures that had been treated previously at other institutions. At least two surgical reconstructive procedures had been performed beforehand. Four patients had motor deficits owing to compressive brachial plexus lesions; all showed symptoms of combined thoracic outlet syndrome. Our surgery consisted of resection of the space-occupying clavicular pseudoarthrosis (all eight patients), external neurolysis of the brachial plexus (four patients) and reconstruction of the resulting bone defect with free vascularized fibula flap secured with plates (all eight patients). Vascularity of the bone flap was studied using three-phase bone scintigraphy.


All patients became free of pain symptoms after surgery. Muscle strength in two of the four patients with preoperative motor deficits improved to normal within 3 months; the other two patients required 6 and 8 months, respectively. Three-phase bone scintigraphy showed adequate perfusion of the bone flaps in all patients. Postoperative bleeding at the recipient site occurred in three patients; these required revision. One patient showed an osseosubcutaneous fistula 6 months after surgery, which was treated conservatively. There was no recurrence of pseudoarthrosis or neurovascular compression at a mean follow-up period of 38.5 months.


Recurrent space-occupying pseudoarthrosis of the clavicle complicated with neurovascular compression might warrant definitive reconstruction using a free vascularized bone flap.

Pubmed Link


7.Delayed brachial plexus neurapraxia complicating malunion of the clavicle.


Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Kaohsiung, Taiwan, ROC.


Delayed brachial plexus neurapraxia is a rare complication of midshaft clavicular fracture. The symptoms are variable and occur insidiously. Surgical decompression to release the compression of brachial plexus is the treatment of choice and usually has a good result. We report a patient whose brachial plexus was compressed by malunion of the clavicle. This patient had a good outcome after treatment with intramedullary nailing and Knowles pin fixation after corrective osteotomy without bone grafting.

Pubmed Link

8.Brachial plexus palsy secondary to clavicular nonunion.

Derham CVarghese MDeacon PSpencer NCurley P.J Trauma. 2007 Oct;63(4):E105-7.


Department of Vascular Surgery, Pinderfields General Hospital, Wakefield, West Yorkshire, United Kingdom.

 Pubmed Link 


How to Cite: Satpute R. Post Traumatic Costo-Clavicular Compression Syndrome Secondary to Clavicle Non union. IORG Case Sinppet.; 2011: 1