IATROGENIC PNEUMOTHORAX FOLLOWING PLATE FIXATION OF THE CLAVICLE.

Editor,

A 37-year-old right hand dominant male sustained a comminuted, displaced midshaft fracture of his left clavicle as the result of a motorcycle accident. He did not incur any other injuries. After discussing the treatment options, a decision was taken to proceed with open reduction and plate fixation of his left clavicular fracture. The procedure was performed under general anaesthesia in the beach chair position. A direct incision was made over the left clavicle and the fracture was exposed and reduced. The fracture was stabilised using a pre-contoured titanium plate with a combination of nonlocking and locking screws. No concerns were reported in the peri-operative period by the anaesthetic team. A routine check x-ray of the left clavicle was obtained the following day which demonstrated an excessively long medial screw (Figure 1a) with a left apical pneumothorax confirmed on a chest radiograph (Figure 1b). The patient returned to theatre for insertion of a left-sided chest drain and screw exchange. The pneumothorax resolved and the patient’s left clavicular fracture proceeded to complete union.

Figure 1

Figure 1a (top): left clavicle check x-ray demonstrating an apical pneumothorax and an excessively long medial screw (white arrow); Figure 1b (bottom) demonstrating a leftsided pneumothorax (white arrow pointing to edge of lung).

Fractures of the clavicle are common representing 2.6 to 5% of all fractures and approximately 80% of fractures affect the middle third of the clavicle.1 The incidence of high-energy fractures with displacement, comminution and shortening is increasing and as a result operative fixation for such injuries is being performed more commonly.1 Infection, implant failure, non-union, scar-related pain, prominent hardware and refracture are the most commonly reported operative complications.2

Plate fixation is the most common method of operative management.3 The plate is most commonly placed on the superior surface of the clavicle with screws inserted in a cranial-caudal direction potentially placing the lung apex and the neurovascular structures at risk during drilling and screw insertion. The risk however of either an iatrogenic pneumothorax or neurovascular injury is regarded in the literature as a rare occurrence.3,4 Some centres have recommended obtaining a chest x-ray routinely to exclude pneumothorax following clavicle fixation. Shubert et al.3 concluded from their study that due to the rarity of iatrogenic pneumothorax, radiation exposure and cost, in combination with the poor sensitivity of chest radiographs to detect pneumothoraces, obtaining a routine chest x-ray without clinical indication may be unnecessary.

Pneumothorax in relation to clavicular fractures is a well-described preoperative complication existing in the literature.3,5 In our case, the patient had a preoperative chest x-ray which did not demonstrate pulmonary trauma and given the excessive difference in length between the most medial screw and the adjacent screw we conclude that the patient incurred an iatrogenic pneumothorax due to surgical error. We acknowledge that intra-operative screening would have identified the long medial screw but the pneumothorax maynot have been appreciated.

We emphasise the importance of careful surgical technique when performing plate fixation of a midshaft clavicular fracture, in particular, ensuring a guard is placed under the clavicle when drilling and close attention to screw length. Furthermore, we recommend careful scrutiny of postoperative clavicle radiographs due to the rare but potential risk of iatrogenic pneumothorax.