Unusual Presentation of a Clavicle Fracture Locked Under the First Rib with Global Brachial Plexus Injury: A Case Report.

CASE: Thoracic penetration of the medial half of clavicle fracture is rare and can be life-threatening and limb-threatening because of its proximity to the pleura and neurovascular structures. We report an unusual presentation of the medial portion of clavicle fracture locked under the first rib associated with the pneumothorax and global brachial plexus palsy successfully reduced by gentle manipulation. Partial injury to the subclavian vein was repaired. Nerve transfer was performed for brachial plexus palsy. The patient showed good functional recovery. CONCLUSION: Reduction of locked intrathoracic clavicle fracture was performed safely by gentle manipulation. Subsequent appropriate interventions for the brachial plexus palsy led to a good outcome.

Modified bone tie: a new method to achieve interfragmentary compression in unstable oblique metacarpal and phalangeal fractures.

Oblique fractures of the metacarpal and phalanx are inherently unstable especially when there is comminution at the fracture site. Nonoperative management of these fractures requires prolonged immobilization and results in poor outcome. Internal fixation is the preferred method of treatment for these fractures. The various methods used for internal fixation are the Kirschner wires, intraosseous wiring, tension band wiring, minifragment screws and plates. Kirschner wires are the most commonly used fixation device because of their versatility and easy availability. The main disadvantage is lack of rigid fixation as it does not provide interfragmentary compression and pin track infection, if left outside the skin. To overcome these problems intraosseous wiring and tension band wiring were used. The main disadvantage of these procedures is the need for multiple drilling and extensive soft tissue dissection which is detrimental for a comminuted oblique fracture. Minifragment screws and plates provide rigid fixation but the screw can split the small bone fragment and also does not allow any adjustment once it is inserted. Plates tend to be bulky. Bone tie was described as a method of interfragmentary compression with some advantages over the interosseous wiring techniques and tension band wiring. We have modified the original bone tie to make it easier to use and to provide more stable fixation. We present our experience with its use in unstable oblique fractures of the metacarpal and phalanges, which are challenging to treat.