Arcuate osteoplasty for brachial plexus paralysis after plate fixation of mid-clavicle fracture: a case report and literature review

Abstract

Brachial plexus paralysis is a rare but serious complication following clavicle fractures that is often linked to neurovascular compression, with an incidence of 0.5% to 9.0%. This report presents a case of brachial plexus paralysis in a 61-year-old woman after surgical fixation of a deformed mid-clavicle fracture with a metal plate. Revision surgery was performed to address the paralysis, involving removal of the metal plate, arcuate osteoplasty to create a smooth arch beneath the clavicle, and re-fixation of the plate with adjusted superior angularity. We used this approach to relieve neurovascular compression and restore thoracic outlet space. Over a period of 1 year, significant recovery and successful fracture union were achieved. This case demonstrates that managing brachial plexus paralysis with revision surgery and osteoplasty can effectively restore both neurological function and bone healing.

Brachial plexus paralysis associated with clavicle fractures is a rare but serious complication that is often linked to neurovascular compression. This can manifest as thoracic outlet syndrome, with an incidence of 0.5% to 9.0% following clavicle fractures [1]. Paralysis typically arises either from direct trauma to the brachial plexus or is secondary to the compression exerted by callus formation during the fracture healing process [2]. Although less common, brachial plexus paralysis can also occur following surgical treatment involving internal fixation with metal plates [1-11]. Various approaches have been reported for managing brachial plexus paralysis after metal plate fixation to alleviate symptoms, including neurolysis and refixation of the metal plate, or plate removal with the risk of non-union [1-11]. In this report, we present a case of brachial plexus paralysis following internal fixation of a deformed mid-clavicle fracture with a metal plate. We performed arcuate osteoplasty beneath the clavicle, re-fixed the metal plate with increased superior angularity to restore the thoracic outlet space, and observed recovery of symptoms and bone union over a 1-year follow-up. We discuss this case in the context of the existing literature.

As this is a case report of a single patient, institutional review board approval was waived (No. 2025-03-001). The patient provided informed consent for the study.

CASE REPORT

As this is a case report of a single patient, institutional review board approval was not required. The patient provided informed consent for the study.

A 61-year-old woman, who was a motorcyclist, presented with discomfort in her right shoulder after colliding with a vehicle. Initial examinations in the emergency department revealed a mid-shaft clavicle fracture on the right side, along with intracranial injuries, including subdural and subarachnoid hemorrhages. She was admitted to the neurosurgery department for conservative management of her head injuries. The patient had a history of a similar fracture at the same site approximately 16 years earlier, also due to a motorcycle accident, which had been treated conservatively, resulting in union. Radiographs taken during the current admission revealed a deformed mid-clavicle fracture, likely due to the previous injury (Fig. 1).

Fig. 1.

Plain radiograph (A) and three-dimensional computed tomography scan (B) of a 61-year-old female motorcyclist's right clavicle are shown. She had a history of conservative treatment for a fracture in the same area 16 years ago, and deformities from the previous injury are evident along with the current clavicle fracture.

Two weeks after injury, the patient continued to experience discomfort in her right shoulder and expressed a desire for pain relief and early return to daily activities. Thus, surgical intervention was planned, including open reduction and internal fixation of the fracture with a plate, along with bone grafting using autogenous iliac cancellous bone, following the excision of deformed bone at the previous fracture site (Fig. 2).

Fig. 2.

The radiographic findings show open reduction and internal fixation with a metal implant, along with autogenous iliac cancellous bone graft and osteoplasty for the previous deformity.

The patient was evaluated 2 hours postoperatively and had a good radial pulse as well as a warm, well-perfused extremity, but decreased sensation in the ulnar and median nerve distributions distally. Motor function was graded as 3 of 5 in elbow flexion, wrist extension, thumbs up, finger abduction, metacarpophalangeal joint flexion and extension, and interphalangeal joint extension. Wrist flexion and interphalangeal joint flexion were graded as 2 of 5, and thumb flexion motor was 1 of 5. The patient had severe pain at the surgical site as well as in the shoulder, upper arm, and forearm. There was no evidence of hematoma at the surgical site.

To rule out the recurrence of intracranial injuries, brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed, which showed no evidence of worsening lesions. However, MRI and CT of the brachial plexus suggested possible localized compression by clavicle fragments (Fig. 3). Given the clinical diagnosis of secondary thoracic outlet syndrome due to indirect nerve compression by the reduced clavicle fragments, a revision surgery was performed on the same day.

Fig. 3.

Computed tomography (A) and magnetic resonance imaging (B) of the brachial plexus suggested possible localized compression by the clavicle fragments.

During the revision surgery the plate was removed, the fracture site was exposed, and a butterfly fragment beneath the clavicle was excised. Each side was held with reduction forceps and the lower half of the fracture surface was excised with a micro-saw and osteotome, creating space for the clavicle to form a smooth arch (arcuate form) when the fracture was reduced. Cancellous bone from the initial surgery was placed beneath the clavicle to act as a cushion between the clavicle and the brachial plexus, while also promoting bone union. The removed metal plate was re-fixed after bending it to create a superior angularity at the fracture site (Fig. 4). Immediately after the surgery, the severe pain at the surgical site showed much improvement, but recovery of strength was not prominent. Subsequently, gradual improvement was noted. Electromyography (EMG) performed 16 days postoperatively confirmed the presence of brachial plexopathy (Table 1).

Fig. 4.

To maintain the stability of the fracture along with brachial plexus decompression, the lower part of the clavicle was excised to form a smooth arch (arcuate form), and the metal plate was bent to create a superior angularity and then fixed in place. Cancellous bone from the initial surgery was placed beneath the clavicle to act as a cushion between the clavicle and the brachial plexus, while also promoting bone union.

Table 1.

Electromyography performed on the 16th day post-surgery showing right brachial plexopathy (whole arm type, primarily affecting the lower trunk)

Muscle	Psw	Fib	Rec	Amp	Dur	Pol	Interf
Rt APB	–	–	Reduced	Decreased	Increased	–	Incomplete
Rt ADM	–	–	Zero	Zero	Zero	–	–
Rt FCR	+	+	Zero	Zero	Zero	–	–
Rt FCU	+	+	Zero	Zero	Zero	–	–
Rt ECRL	–	–	N	N	N	–	Complete
Rt biceps brachii	+	+	Reduced	Decreased	Increased	–	Incomplete
Rt triceps	–	–	N	N	N	–	Complete
Rt deltoid	+	+	N	N	N	–	Complete
Rt cervical paraspinals	–	–				–	-
Rt supraspinatus	–	–	Reduced	Decreased	Increased	–	Incomplete
Rt infraspinatus	–	–	Reduced	Decreased	Increased	–	Incomplete

Psw: positive sharp waves, Fib: fibrillation potentials, Rec: recruitment, Amp: amplitude, Dur: duration, Pol: polyphasia, Interf: interference pattern, Rt: right, APB: adductor pollicis brevis, ADM: adductor digiti minimi, FCR: flexor carpi radialis, FCU: flexor carpi ulnaris, ECRL: extensor carpi longus, N: non-specific.

Continuous rehabilitation led to significant improvement in the hand and upper extremity by 6 months postoperatively, as confirmed by follow-up x-rays showing fracture union (Fig. 5) and near-normal flexion and extension of the fingers (Fig. 6). EMG and nerve conduction studies performed 1 year after complication onset demonstrated significant recovery of motor and sensory functions, with only partial subjective sensory deficits remaining.

Fig. 5.

An x-ray taken 6 months after surgery shows union of the clavicle fracture.

Fig. 6.

At 6 months after surgery, there is evidence of near-complete recovery of finger movement.

DISCUSSION

The increasing preference for surgical management of clavicle fractures has led to a rise in associated complications. The most common complications include non-union, malunion, delayed union, and neurovascular injuries. Although less frequent, brachial plexus injury can occur either due to direct trauma to the clavicle or secondary to pressure from callus formation. Recent studies have reported cases of brachial plexus injury following surgical treatment of acute or delayed/non-union clavicle fractures. We compiled 11 studies on this topic (Table 2). Except for two studies, all cases involved delayed union or nonunion that occurred more than 3 months after the injury.

Table 2.

Studies reporting brachial plexus injury following surgical treatment of clavicle fractures

Study	Year	Case	Diagnosis (time of surgery after injury)	Symptom onset	Neurogenic condition	Treatment	Union
Namdari et al. [2]	2012	1	Atrophic nonunion (7 mo)	Operation day	Diffuse brachial plexopathy-mainly lower trunk	Fragment excision	Union
Jeyaseelan et al. [3]	2013	21	Acute fractures	NA	NA	Neurolysis in 17 cases	NA
Rosati et al. [1]	2013	1	Atrophic delayed union (4 mo)	5 Days after operation	Complete denervation on extensor digitorum, flexors of fingers	Implant removal and mobilization of fragment	Nonunion
Thavarajah et al. [4]	2013	1	Hypertrophic nonunion (8 mo)	Operation day	Brachial plexus injury mainly C5-T1	Plate removal, partial clavicle ostectomy and neurolysis	Nonunion
Matthews et al. [5]	2015	1	Atrophic delayed union (3 mo)	3 Days after operation	BPI+diabetic peripheral poly neuropathy	Weakness only Conservative treatment	Union
						BMP?
Jin et al. [6]	2019	1	Atrophic nonunion (20 mo): lengthening	2 Days after operation	Progressive whole arm type complete	Plate removal and mobilization	Nonunion
Kim et al. [7]	2020	1	Fixation loss and postoperative nonunion (5 mo)	3 Days after operation	Progressive	Plate removal and superior angulation	Healing but not confirmed on radiographs
Johnson et al. [8]	2020	1	Atrophic nonunion (5 mo)	2 Days after operation	Subjective numbness	Getting better: conservative treatment	Union
					No EMG
Cao et al. [9]	2021	1	Acute fracture	Operation day	No EMG	Conservative treatment	NA
McGillivray et al. [10]	2022	2	Postoperativenonunion	Operation day	NA	Staged operation: (1) implant removal (2) elective operation: neurovascular exploration, callus excision, implant revision and bone graft	Union
			Postoperativeinfection nonunion	Operation day and progression	NA	Delayed elective operation: neurovascular exploration, callus excision, implant revision and bone graft	Union
Larrota et al. [11]	2024	1	Atrophic nonunion (5 mo)	3 Days after operation	Posterior cord (musculocutaneous and axillary nerve)	Conservative treatment	Union

NA: not available, BPI: brachial plexus injury, BMP: bone morphogenetic protein, EMG: electromyography.

Cao et al. [9] reported a case involving a 34-year-old woman who experienced significant reduction in the range of motion of the right elbow, wrist, and fingers following surgery. Conservative treatment with oral methylcobalamin and nerve stimulation led to complete symptom resolution within 60 days, but additional diagnostic tests such as EMG or MRI were not conducted, leaving the exact nature of the injury unclear.

Jeyaseelan et al. [3] analyzed 21 cases of surgically treated acute clavicle fractures and found that midshaft fractures fixed between 2 and 4 weeks after injury carry significant risk of brachial plexus injury. Increased comminution of the fracture and clavicle shortening during fixation are additional risk factors. Among the cases they described, four underwent nerve transfer or nerve graft procedures following nerve exploration, while the remaining cases had good outcomes with neurolysis alone without bone procedures.

Matthew et al. [5], Johnson et al. [8], and Larrota et al. [11] reported good outcomes with conservative treatment. Commonly, these cases involved atrophic forms of delayed or nonunion, with the initial symptoms appearing 2–3 days after surgery. Larrota et al. [11] hypothesized that hypertrophic non-union can lead to plexus involvement due to compressive phenomena (due to insufficiently resected bony callus), and these cases typically present immediately in the recovery room. Their management involves surgical removal of the plate, complete callus resection, and neurolysis. On the other hand, atrophic non-union may cause plexopathy due to traction or elongation of the plexus during clavicle length restoration. They noted that these cases typically present in a subacute fashion between the second and third postoperative day, and that conservative management through clinical observation and rehabilitation appears to be a reasonable approach. In our case, the acute onset of symptoms immediately after surgery, along with the deformity from the previous fracture, suggest that secondary thoracic outlet syndrome likely developed due to compression by bony fragments during the reduction process. In light of existing studies, this scenario indicates that surgical intervention, including osteoplasty, is more appropriate than conservative management.

Rosati et al. [1], Jin et al. [6], and Kim et al. [7] reported cases in which, after surgical treatment of atrophic non-unions, initial symptoms appeared 2 to 5 days later. However, these cases showed progressive patterns, and while removal of internal fixation and debridement or resection of the fracture site led to nerve recovery, fracture union was not achieved. McGillivray et al. [10] suggested that if brachial plexus symptoms occur immediately after clavicle fixation and if combined plastic/vascular surgical procedures are feasible, emergent nerve/vascular exploration and internal fixation should be performed simultaneously. If simultaneous surgery is not possible, they recommend initially emergent removal of metal fixation followed by MRI to identify the compression site and then performing staged internal fixation in conjunction with plastic/vascular surgical consultation.

In our case, both decompression and fracture union could be achieved without direct nerve and vascular exploration by resecting a portion of the lower clavicle in an arch-shaped manner. The metal plate was contoured with superior angularity to restore the thoracic outlet space while preserving fracture contact.