Purpose: Injury to the clavicle is a rare cause of outlet syndrome. We report eight cases to determine the diagnostic and therapeutic features and report outcomes.

Material and methods: This series of eight patients (five women and three men), mean age 48 years (11)70) sufferred from pain irradiating to the upper limb with paraesthesia in the ulnar teritorry of the hand together with diminished muscle force. The diagnosis was established 23.1 months (mean, range 1–10 years) after the initial comminutive mid-third fracture. The displaced bone which was treated orthopaedically. Standard x-rays revealed: four deformed calluses, two atrophic nonunions, one fracture with a vertical fragment (rapid osteosynthesis performed to avoid acute plexus compression) and finally one resection of the mid third (secondary to osteitis). The electromyogram confirmed the diagnosis, generally with compression of a secondary anteromedial trunk. 3D reconstruction scans (measurement of the costo-cleidal space) were obtained.

Results: Pain disappeared the day after surgery as did the paraesthesia in seven out of eight patients. The clavicle healed in 13 to 18 months.

Discussion: Different mechanisms can cause compression of the brachial plexus after displaced comminutive fracture of the clavicle. Different therapeutic modalities have been proposed. The outlet syndrome should be considered following displaced fractures of the mid third of the clavicle in patients presenting pain irradiating to the upper limb. The diagnosis is confirmed by electromyography. Proper analysis of the clavicle is obtained with 3D CT scan allowing adapted surgical treatment.

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery.

Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing.

Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4.

Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A.

Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid.

Most obstetric brachial plexus palsies are due to rupture of the upper roots in babies whose delivery was complicated by shoulder dystocia. If treated by early exploration and grafting, they have a favourable prognosis.

We reviewed 36 babies who had had an obstetric brachial plexus palsy after a breech delivery and found that they had a different pattern of injury; 81% had avulsion of the upper roots. This injury cannot be treated satisfactorily by exploration and microsurgical grafting and carries a considerably worse prognosis for shoulder function.