Management of Midshaft Clavicle Non-union with Autologous Iliac Crest

Bone Grafting and Locking Plate Fixation: A Case Report

Abstract
Clavicle fractures are common injuries that typically heal with conservative management.
However, midshaft clavicle fractures can occasionally progress to non-union, particularly
when significantly displaced or inadequately immobilized. We present a case of a 38-year-
old male with an atrophic midshaft clavicle non-union successfully treated using open
reduction, internal fixation with a pre-contoured locking compression plate (LCP), and
autologous iliac crest bone grafting. Postoperative outcome was excellent with radiographic
union and restoration of function.

Keywords: Clavicle non-union, midshaft clavicle fracture, bone grafting, plating, LCP,
internal fixation

Introduction
Fractures of the clavicle constitute approximately 5% of all adult fractures, with the
midshaft being the most commonly involved site [1]. Most clavicle fractures unite with
conservative treatment; however, non-union can occur in up to 15% of cases, particularly
those that are completely displaced or comminuted [2,3]. Atrophic non-unions are
challenging to treat and usually require surgical intervention with mechanical stability and
biological augmentation using bone graft [4].

We present a case of symptomatic atrophic non-union of the midshaft clavicle in a young

Case Presentation
A 38-year-old right-handed male manual laborer presented with persistent left shoulder
pain and deformity 10 months after sustaining a midshaft clavicle fracture in a road traffic
accident. The initial injury was managed conservatively with an arm sling. Over time, the
patient reported persistent pain, difficulty lifting objects, and limited range of motion.

Clinical examination revealed visible deformity and tenderness over the midshaft clavicle.
Palpable mobility was noted at the fracture site during shoulder movement. Neurological
examination was normal.

Radiographic evaluation showed a clear midshaft clavicle non-union with sclerotic and
tapered fracture ends without bridging callus, consistent with an atrophic non-union [5].
Surgical Technique
Under general anesthesia, the clavicle was approached superiorly. Fibrous tissue at the non-
union site was excised, and bone ends were freshened until punctate bleeding was
observed. Autologous corticocancellous bone graft was harvested from the ipsilateral
anterior iliac crest. The fracture was anatomically reduced and stabilized with a 3.5 mm
pre-contoured LCP. Bone graft was packed into the fracture site circumferentially.

The wound was closed in layers, and the arm was supported in a sling postoperatively.

Postoperative Management
The patient was given intravenous antibiotics for 48 hours. Passive range of motion
exercises were started at 10 days postoperatively. Active-assisted and active range of
motion exercises were initiated at 4 weeks. Strengthening began at 8 weeks, and full return
to work was allowed at 12 weeks.

Outcome
At 3-month follow-up, the patient reported significant reduction in pain and improved
shoulder mobility. At 6 months, radiographs confirmed complete union of the fracture site.
The patient returned to his pre-injury occupation without restrictions. The Disabilities of
the Arm, Shoulder and Hand (DASH) score improved from 65 preoperatively to 12
postoperatively.

Discussion
Non-union of midshaft clavicle fractures can lead to persistent pain, deformity, and
functional impairment. Displacement, initial conservative treatment, and patient-related
factors such as smoking are known risk factors for non-union [6,7].

Surgical fixation using pre-contoured locking plates offers mechanical stability and allows
for early mobilization [8]. Autologous iliac crest bone graft remains the gold standard for
treating atrophic non-unions due to its osteoconductive, osteoinductive, and osteogenic
properties [9,10].

Our case highlights the importance of timely surgical intervention in cases of symptomatic
non-union, particularly in manual laborers who require full functional recovery. The
combination of stable fixation and biological enhancement through autologous bone
grafting can result in predictable and successful outcomes [11].

Conclusion
Midshaft clavicle non-union is a disabling condition that can be effectively managed with
internal fixation and autologous bone grafting. Early diagnosis and appropriate surgical
technique are crucial to restore function and prevent long-term complications.
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