Working Diagnosis:
The final diagnosis was a healed mid-clavicle fracture with bony changes and poor biomechanics causing scarring and entrapment of the supraclavicular brachial plexus trunks at the level of the 1st rib and scarring and entrapment of the clavicular branches of the lateral and medial pectoral nerves.

Treatment:
The treatment used was an ultrasound-guided hydro-dissection of the right supraclavicular brachial plexus off of the first rib and between the upper/superior, middle, and lower/inferior trunks via an in-plane approach. The infusate was solution of 10mg Kenalog, 0.25 mL 1 percent Lidocaine without Epinephrine, and 0.75 mL 0.5 percent Ropivacaine in 24 mL D5W.

Outcome:
The supraclavicular brachial plexus nerve hydro-dissection achieved 100 percent relief of pain immediately after the procedure. In combination with radiofrequency nerve ablation of the lateral pectoral nerve, he experienced significant pain relief allowing him to return to his baseline level of exercise and discontinued all pain medications. He was also able to return to active duty, and on follow-up, he reported 0/10 pain at rest. He endorsed periodic pain with activity associated with spasm of the right deltoid, which had been responsive to stretching and at home physical therapy. He declined a need for any additional procedures.

Author's Comments:
Clavicle fractures account for 2.6 percent of all fractures and are a common injury suffered during a motor vehicle accident.1,2,3 Fractures of the middle 1/3, as in this case, are the most common and are often managed conservatively.3,4 Neurovascular complications are rare, but several case reports have described thoracic outlet syndrome and compression of the brachial plexus after a fracture. Many of these reports focus on severe cases treated surgically.5,6,7 There are few reports describing hydro-dissection as a management tool for thoracic outlet syndrome. One case report described successful treatment with hydro-dissection for vascular thoracic outlet syndrome, not neurogenic.8 This case represents a novel treatment for patients with chronic shoulder pain due to entrapment of multiple nerves in the region.

Editor's Comments:
Neurogenic thoracic outlet syndrome following conservative treatment of a clavicle fracture is rare. In the absence of a defined anatomic abnormality, the costoclavicular distance (space between the clavicle and first rib) is independently associated with thoracic outlet syndrome. Causes of thoracic outlet syndrome following clavicular fracture include: impingement due to a displaced fracture fragment, significant fracture angulation, hypertrophic callus formation, and malunion. For patients who are conservatively managed, consider incorporating a neurologic exam during follow-up evaluations. While surgical management is appropriate for acute thoracic outlet syndrome or patients with neurologic deficits, this case demonstrates hydrodissection as a helpful modality for chronic neurogenic thoracic outlet syndrome without neurologic deficits.

References:
1) Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002; 11:452.
2) Eiff, MP, Hatch, et al. Clavicle and scapula fractures. In: Fracture Management for Primary Care, 2nd ed, WB Saunders, Philadelphia 2002. p.198.
3) Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br 1998; 80:476.
4) Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma 1998; 12:572.
5) Alzahrani MM. Late brachial plexopathy after a mid-shaft clavicle fracture: A case report. World J Orthop. 2023 Oct 18;14(10):776-783. doi: 10.5312/wjo.v14.i10.776. PMID: 37970622; PMCID: PMC10642401.
6) Saito T, Matusmura T, Takeshita K. Brachial plexus palsy after clavicle fracture: 3 cases. J Shoulder Elbow Surg. 2020 Feb;29(2):e60-e65. doi: 10.1016/j.jse.2019.09.027. Epub 2019 Nov 26. PMID: 31784383.
7) Thavarajah D, Scadden J. Iatrogenic postoperative brachial plexus compression secondary to hypertrophic non-union of a clavicle fracture. Ann R Coll Surg Engl. 2013 Apr;95(3):e55-7. doi: 10.1308/003588413X13511609956174. PMID: 23827280; PMCID: PMC4165262.
8) Ver Hoef JM, Clearfield D. Hydrodissection for the Treatment of Vascular Thoracic Outlet Syndrome. Cureus. 2022 Sep 16;14(9):e29229. doi: 10.7759/cureus.29229. PMID: 36277577; PMCID: PMC9578509.

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