65-year-old woman with missed open clavicle fracture and subsequent infection
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A 65-year-old right-hand dominant woman with no reported past medical history presented with left clavicular pain and wound drainage 8 days after she was struck by a motor vehicle in her home country of Guyana.
She initially had pain and abrasions about the left shoulder, as well as rib pain. However, she denied any bleeding, oozing or a puncture wound at the time of injury. At the hospital in Guyana, she was diagnosed with a left distal-third clavicle fracture and multiple rib fractures and was discharged home with a sling. She denied receiving any antibiotics at the hospital or upon discharge. At home, she developed a wound over the posterosuperior trapezial region during the subsequent week and the wound began to drain purulent fluid. She was brought to the United States by her family who live in the Queens borough of New York to receive medical care.
At the time of presentation to the emergency room, she was noted to have 5-cm x 2-cm ulceration and draining sinus and obvious purulence to the posterolateral shoulder near the trapezius with associated surrounding erythema and exquisite tenderness (Figure 1). Radiographs demonstrated a Neer 2A distal clavicle fracture with significant superior displacement of the medial fragment (Figures 2a and 2b). She was also found to have fractures to the third through fifth ribs, a temperature of 100.2°, tachycardia to 99 and blood pressure of 115/74. Blood cultures were obtained in the ED and were negative.
Source: Kevin M. Lehane, DO
What are the next best steps in management of this patient?
See answer below.
Antibiotics, irrigation and debridement, and distal clavicle excision
Given the delayed presentation and extensive infection with associated sepsis, the patient was indicated for immediate fluid resuscitation and IV antibiotic therapy with vancomycin and Zosyn (piperacillin and tazobactam, Pfizer), as well as urgent irrigation and debridement with excision of the distal clavicle.
Distal clavicle excision technique
The patient was brought to the OR and placed supine on radiolucent flat table. She was placed under general anesthesia, and the left upper extremity was prepped and draped in usual sterile fashion. Intraoperatively, the patient was observed to have a 5-cm x 2-cm area of necrotic skin with an area of a draining sinus track in the middle of this overlying the clavicle. A surgical time-out was performed.
Sharp excision of necrotic skin with a 10 blade was performed with 5-mm margins proximally and distally with a depth of 10 mm. Deep soft tissue biopsy of the underlying trapezial muscle and subcutaneous tissue was obtained and sent for both tissue culture and pathology analysis. Multiple fluid swabs were sent for aerobic, anaerobic, fungal and acid-fast bacilli testing. Deep, open bone, biopsy samples of the distal clavicle were obtained as well. Dissection was carried through the trapezial muscle, the pectoralis major muscle medially and deltoid laterally to expose the clavicle fracture site. The infection was found to have eroded through the trapezoidal fascia and subcutaneous tissue with obvious gross purulence and necrosis of the surrounding soft tissue. The lateral end of the medial clavicle fragment was found to be necrotic and moth-eaten secondary to acute osteomyelitis.
All devitalized soft tissue was sharply excised with cautery, including subcutaneous tissue, trapezial myofascial tissue, proximal aspect of the clavicular head of pectoralis major and the proximal aspect of the anterior head of deltoid. Approximately 5 cm of the main clavicle fragment was excised using a combination of rongeurs, curettes and microsagittal saw. The lateral/distal clavicle fragment was completely removed up until the acromioclavicular joint as it was also found to be nonviable, and the coracoclavicular ligament attachments to the distal clavicle were excised. Of note, a communicating abscess was found anterior to the clavicle in the subcutaneous tissue and within the proximal biceps muscle and pectoralis muscle that was incised and decompressed. The muscle fibers of each were viable and were not debrided. The wound was irrigated with several liters of saline and betadine solution, and vancomycin powder was placed.
A medium Hemovac (Zimmer Biomet) drain was placed deep to the trapezial fascia. The pectoralis muscle medial, deltoid muscle lateral and trapezium muscles proximal were mobilized by dissection anterior and posterior to the muscles to allow for mobilization over the large 10-cm x 3-cm defect which remained after debridement. A #1 polydioxanone suture was used to advance the muscle flaps over the defect and suture the muscles together in the space where the clavicle was previously. There was complete closure of the defect with the muscle flaps. A second medium Hemovac drain was placed superficially. A 2-0 polydioxanone suture was used to close the deep subcutaneous layer over the superficial drain and 2-0 nylon retention sutures were used to close the skin layer of the 10-cm x 3-cm open wound. An incisional wound vacuum-assisted closure (VAC) was placed over the wound. The patient was awoken and returned to the recovery room in stable condition, with plans for possible repeat debridements depending on drainage, clinical stability and wound appearance. Postoperative radiographs are demonstrated in figures 3a and 3b.
Postoperative rehabilitation
Postoperatively, the patient was maintained in a regular sling with range of motion as tolerated, without lifting restrictions for 4 weeks. Infectious disease was consulted, and the patient was placed on empiric antibiotics of vancomycin and Zosyn until cultures were finalized. Hemovac drains were removed after 5 days when output was zero. Cultures subsequently grew MRSA. IV vancomycin was administered for 2 weeks, while the patient remained in the hospital and participated in daily occupational therapy. The incisional wound VAC was removed after 7 days with excellent appearance of the surgical site, and the decision was made at that time to continue with IV antibiotic therapy. After 2 weeks, the patient was transitioned to oral linezolid for 4 weeks based on infectious disease recommendations. Postoperative course was complicated medically by patient developing influenza and pneumonia, which was treated with Zoysn during the hospital stay. The Nylon sutures were removed postoperative day 18 with excellent wound healing, no erythema or drainage, and the patient was discharged home on day 19 after being medically stable.
At 4 weeks postoperatively, the patient followed up in the outpatient office. Her wound was noted to have healed well without any signs of infection, her pain was well-controlled and her shoulder range of motion was noted to be 175° of forward flexion, 75° of external rotation, internal rotation to L1 vertebrae and abduction to 100° (Figures 4a to 4d). Radiographs obtained at the time demonstrated maintained osseous alignment of the remaining medial clavicle without interval displacement from postoperative radiographs (Figures 5a and 5b), and she was able to perform most of her activities of daily living.
Discussion
Clavicle fractures are common injuries, representing 44% of all shoulder girdle-related fractures and 2.6% to 3.3% of all orthopedic fractures. However, open clavicle fractures are rare, with a reported incidence of 1.8% of all clavicle fractures; are more common in the younger population; and a result of high-energy trauma. Fractures of the distal third clavicle are less common than midshaft fractures and account for only 10% to 30% of all clavicle fractures. Distal clavicle fractures may be treated conservatively or surgically; however, there is a lack of consensus on the gold standard of treatment. Although rare, when open clavicle fractures occur, they are more often associated with serious concomitant injury. The general standard of care treatment of open fractures throughout the body is early antibiotics within 1 hour, followed by irrigation and debridement within 6 to 12 hours and internal fixation. However, there is a paucity of information in the orthopedic literature regarding appropriate management techniques of open clavicle fractures and treatment outcomes, especially in the delayed presentation with associated infection.
The most common complications of clavicle fractures vary by treatment, with hardware prominence most common for operative complications and malunion/nonunion as most common for nonoperative complications. Infection after clavicle fractures is reported at approximately 0.4% to 3.5%, and almost always associated with operative treatment. In a study by Jonathan Sliepen and colleagues reviewing all clavicle fractures treated at their institution, of 630 clavicle fractures, only three patients had an open fracture and no patients developed a fracture-related infection. Delay in debridement of open fractures has been cited in numerous studies as a risk factor for deep infection, including the study by Peter D. Hull, FRCS(Tr&Orth), and colleagues, which demonstrated a 3% increased risk of infection for every hour of delay.
The only case of clavicle fracture-related infection prior to surgical intervention in the literature we were able to find is a case report by Eric J. Strauss, MD, and colleagues, who described a closed distal clavicle fracture that was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. The patient was treated with irrigation and debridement and external fixation. To the best of our knowledge, this is the first described case of fracture-related infection of the distal clavicle treated with distal clavicle resection. Given the delayed presentation and resultant necrotic bone, operative repair of the clavicle was deemed futile, due to the resultant bone loss and morbidity of subsequent procedures needed to address such. Short-term follow-up has been excellent, with eradication of the infection and satisfactory clinical outcomes and range of motion. The outcomes of distal clavicle resection in the literature have been positive but are generally indicated for acromioclavicular pathology rather than infection or tumor. In a study looking at open distal clavicle resections, Peter J. Novak, MD, and colleagues noted no significant differences in the strength of the affected shoulder compared with the opposite shoulder, as well as no cephalad migration of the lateral clavicle. Despite the resection of a large portion of the distal clavicle and coracoclavicular ligaments in this case, the short-term outcomes of both range of motion and function have been positive in our patient. Our procedure could prove beneficial in cases of infection, trauma or oncologic lesions in which the distal clavicle is deemed unsalvageable.
Key points
- Open fractures of the clavicle are rare, and little is reported on appropriate management, especially in the delayed setting with associated infection.
- Resection of the distal clavicle may be an appropriate procedure if there is a large amount of associated necrotic bone.
- Short-term range of motion and clinical outcomes after the procedure are good.
- References:
- Amer KM, et al. J Clin Orthop Trauma. 2020;doi:10.1016/j.jcot.2020.08.020.
- Court-Brown CM, et al. Injury. 2006;doi:10.1016/j.injury.2006.04.130.
- Gottschalk HP, et al. J Orthop Trauma. 2012;doi:10.1097/BOT.0b013e31821c0b7f.
- Hull PD, et al. Bone Joint J. 2014;doi:10.1302/0301-620X.96B3.32380.
- Mouzopoulos G, et al. Orthop Nurs. 2009;doi:10.1097/NOR.0b013e3181b579d3.
- Neer CS 2nd. Clin Orthop Relat Res. 1968;58:43-50.
- Nordqvist A, et al. Clin Orthop Relat Res. 1994;300:127-132.
- Novak PJ, et al. J Shoulder Elbow Surg. 1995;doi:10.1016/s1058-2746(10)80006-0.
- Postacchini F, et al. J Shoulder Elbow Surg. 2002;doi:10.1067/mse.2002.126613.
- Sagi HC, et al. J Orthop Trauma. 2021;doi:10.1097/BOT.0000000000002094.
- Sagi HC, et al. J Orthop Trauma. 2021;doi:10.1097/BOT.0000000000002095.
- Shen WJ, et al. Injury. 1999;doi:10.1016/s0020-1383(99)00140-0.
- Sliepen J, et al. Injury. 2023;doi:10.1016/j.injury.2023.110910.
- Strauss EJ, et al. Bull NYU Hosp Jt Dis. 2008;66:129-133.
- Wolf S, et al. BMC Musculoskeletal Disord. 2022;doi:10.1186/s12891-022-05075-5.
- For more information:
- Matthew V. Abola, MD; Andrew S. Bi, MD; Abhishek Ganta, MD; Sanjit R. Konda, MD; and Kevin M. Lehane, DO, can be reached at the department of orthopedic surgery at NYU Langone Orthopedic Hospital and Jamaica Hospital Medical Center. Bi’s email: andrew.bi@nyulangone.org. Konda’s email: sanjit.konda@nyulangone.org. Lehane’s email: kevin.lehane@nyulangone.org.
- Edited by Andrew Bi, MD, and Pooja Prabhakar, MD. Bi is a chief resident in the department of orthopedic surgery at NYU Langone. He will pursue a fellowship in sports medicine at Rush University Medical center following residency completion. Prabhakar is a chief resident in the department of orthopaedic surgery at the University of Washington. She will pursue a fellowship in foot and ankle surgery at Baylor University Medical Center following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
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