International Journal of Research in Orthopaedics

Panchal L et al. Int J Res Orthop. 2026 Mar;12(2):537-539

http://www.ijoro.org

Case Report

DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20260531

Refracture of a malunited clavicle: angular deformity as an under-recognized biomechanical risk factor

Lalit Panchal, Sagar Bagwe*, Bhushan Rathod, Akash Ambhore

Department of Orthopaedics, Fortis SL Raheja hospital, Mumbai, Maharashtra, India

Received: 24 January 2026

Accepted: 20 February 2026

*Correspondence:

Dr. Sagar Bagwe,

E-mail: Bagwesv@Gmail.Com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Angular deformity in clavicle fractures is often considered acceptable in adults when displacement and significant shortening are absent. However, altered biomechanics resulting from angular malunion may predispose to refracture. We report a 40-year-old male with a previously malunited clavicle fracture treated non-operatively who sustained a refracture following minor trauma. After failure of conservative management, open reduction and internal fixation with a clavicular reconstruction plate was performed. This case highlights angular malunion as an under-recognized biomechanical risk factor for clavicle refracture in adults and suggests that angular deformity should be considered during initial fracture assessment.

Keywords: Clavicle fracture, Malunion, Refracture, Angulation, Biomechanics

INTRODUCTION

Management of midshaft clavicle fractures has evolved over the past two decades, with increasing evidence supporting operative fixation in selected adult patients.1-3 Established surgical indications include complete displacement, shortening greater than 2 cm, comminution, and skin compromise. Isolated angular deformity without displacement is frequently managed conservatively.

Pediatric studies have demonstrated higher refracture rates in angulated clavicle fractures compared to completely displaced fractures.4 Angular deformity alters clavicular length and load transmission across the sternoclavicular and acromioclavicular joints, leading to altered biomechanics and reduced shoulder strength.5-7 Adult data addressing refracture following angular malunion remain limited, making this case clinically relevant.

CASE REPORT

A 40-year-old healthy male presented with right shoulder and clavicular pain following a fall with direct lateral impact. He reported a previous right clavicle fracture at the age of 28 years that had been treated non-operatively. Although he returned to daily activities, he experienced intermittent pain and reduced shoulder strength. Radiographs revealed a refracture of the right clavicle adjacent to a previous angular malunion, with shortening compared to the contralateral side (Figure 1). Initial treatment consisted of immobilization using an arm sling for five weeks. Due to persistent pain and absence of radiological signs of union, surgical intervention was planned. Through a standard anterior approach, thick periosteal flaps were elevated. A spiral oblique midshaft fracture was identified approximately 4 cm medial to a malunited distal clavicle segment, which demonstrated nearly 100 degrees of anterior angulation (Figure 2). Fracture was freshened and reduced using bone-holding forceps. Temporary fixation was achieved with a Kirschner wire, followed by lag screw fixation using a 3.5-mm cortical screw (Figure 2). An eight-holed clavicular reconstruction plate was applied in neutralization mode. Post-operative period was uneventful. Shoulder mobilization started immediately postoperatively. Weight lifting on right upper limb was allowed at 6 weeks, after radiological signs of union.

At 2-month follow-up, the patient achieved a painless full range of shoulder motion with significant improvement in strength. Radiographs demonstrated satisfactory alignment and progression toward union (Figure 3).

Figure 1: Pre-operative X-ray.
Figure 1: Pre-operative X-ray.
Figure 2: Intraoperative image showing malunited old fracture distal to reduced fresh fracture line.
Figure 2: Intraoperative image showing malunited old fracture distal to reduced fresh fracture line.
Figure 3: Postoperative X-ray.
Figure 3: Postoperative X-ray.

DISCUSSION

Clavicular angulation alters load transmission and creates stress concentration at the site of malunion. Axial loading results in compressive forces on the concave side and tensile forces on the convex side of the callus, predisposing it to failure under relatively low-energy trauma.4,8 Even modest shortening or angular deformity has been associated with reduced shoulder strength and patient dissatisfaction.6,7,9

Masnovi et al demonstrated higher refracture rates in angulated clavicle fractures compared to completely displaced fractures, suggesting that angular deformity may represent a greater biomechanical risk than displacement alone.4 Although these findings are well established in pediatric populations, adult cases of refracture following angular malunion are rarely reported. Plate fixation allows restoration of clavicular length and alignment, thereby correcting altered biomechanics and reducing refracture risk.1,2,10-12

CONCLUSION

Angular malunion of the clavicle is an under-recognized risk factor for refracture in adults. Refracture occurring adjacent to a malunited segment should be managed surgically to restore alignment and prevent further biomechanical compromise. Consideration of angular deformity during initial fracture management may help prevent refracture and improve long-term outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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