1 Introduction

Clavicle fractures are common, accounting for 5 %–10 % of all fractures.¹ Currently most of the displaced clavicle fractures are treated by reduction and internal fixation.² The surgical treatment options are open reduction and internal fixation with plates and screws being the gold standard for surgical fixation or intra-medullary fixation methods in which the titanium elastic nail being the most commonly used option.^3,4 The drawbacks of unlocked intra-medullary clavicle nail include implant migration and the requirement for routine removal.⁶

The spread of deep neck space infection from pharyngeal spaces to the mediastinal spaces occur by the investing layer of deep cervical fascia. From the deep cervical fascia, it can spread to superficial tissues and can lead to a progressive inflammation of the surrounding tissue and abscess formation. Neck space infections also spread through the carotid sheath and hence thrombosis of the internal jugular vein can occur.^7,8 Implants are always a source of infection in orthopaedic surgeries-both early and late. Intra-medullary implants when infected are always a hidden source of danger when unnoticed or neglected and serve as a focus of infection.¹²

We report the case of forty-one-year-old man with a deep neck space infection and para-tonsillar abscess which was later diagnosed to be an extension of an infected intra-medullary clavicle implant.

2 Case report

Forty one years old male presented to our out patient department with mild neck pain and discomfort over the right clavicle. The patient presented with mild pain and discomfort over his right clavicle. The patient had Chronic liver disesase (Non alcoholic steatohepatitis) and undergoing treatment for the same. He had no other comorbidities. He had mild tenderness over the medial end of right clavicle at the time of presentation. Patient had a right clavicle mid shaft fracture due to road traffic accident 4 years back (skid and fall from 2 wheeler) and was treated by closed reduction internal fixation with titanium elastic nail done elsewhere. Radiographs showed united fracture right clavicle with intra-medullary titanium elastic nail in situ. The nail had been inserted from the medial end of clavicle. The medial end of the nail was outside the clavicle. (Fig. 1).

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Fig. 1 Presenting X-ray showing the clavicle implant and the medial end outside the clavicle.

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Due to discomfort and pain at the insertion site, the patient was advised to have the right clavicle implant removed. The patient desired to return at a later time to have the implant removed.

3 Clinical findings

Three days later he presented to the Emergency Department with increasing pain and swelling at the site of pain. He had difficulty in breathing for the past one day.

On examination there was a soft tender swelling in middle of neck over the sternocleidomastoid muscle (Fig. 2) measuring approximately 3 × 3 cm in size.

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Fig. 2 Clinical photograph showing a swelling over the neck indicated in the arrow.

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The tonsils were enlarged and pushed medially, raising the suspicion of a para-pharyngeal abscess. Ultrasound neck showed multiple pockets of ill-defined collection on the right sternocleidomastoid muscle and collections extending into right sterno clavicular region.

4 Diagnostic assessment

Contrast enhanced computed tomography of neck was done and it showed a bulky right sternocleidomastoid and decreased attenuation with surrounding fat stranding along the entire muscle suggestive of infective myositis (Fig. 3). The medial end of nail was outside and anterosuperior to medial end of clavicle (Fig. 4).

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Fig. 3 CECT of neck showing a bulky sternocleidomastoid.

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Fig. 4 Sagittal CT cuts showing the clavicle implant indicated in the arrow.

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The blood paramaters and hemodynamic parameters is shown in (Table 1) and (Table 2). Patient developed septicemia. The source of infection was initially thought to be the para-pharyngeal abscess. But there was a doubt as to whether the infection may have spread from the implant as patient had initially presented with pain over the region of implant - medial end of the clavicle where the medial end of the implant was prominent. He was taken up for emergency neck abscess incision and drainage by a combined team of Ear, Nose and Throat Surgeons and Orthopaedic Surgeons.

5 Differential diagnosis

Tonsillar abscess, Deep neck space infection, Retropharengeal absceess, Bezold abscess. (Echographic studies were done to rule out the possible differentials).

6 Therapeutic Intervention

Under general anaesthesia patient was put in supine position and a longitudinal, 3 cm long skin incision was made over the middle third of sternocleidomastoid and total of 10 ml of frank pus was drained and unhealthy sternocleidomastoid muscle was noted. The drained pus was sent for microbiological and histopathological examination.

Patient was taken over by the orthopaedic team for clavicle implant removal.

Incision was made over previous surgical scar in medial aspect of the clavicle near the stereo clavicular joint. The soft tissue was cleared and the medial end of the titanium elastic nail was identified. 30 ml of pus was drained from the medial entry site of the implant in the clavicle. The tens nail was tightly adherent to the clavicle, making it very difficult to delaminate the implant from the bone. After some difficulty the TENS nail was removed (Fig. 5). Following the nail exit intra-operatively we noted by gentle probing that this region was connecting to the neck abscess region. Post operatively the patient initially showed signs of improvement but the patients general condition worsened and he developed cardiorespiratory arrest on second post operative day. In spite all resuscitative measures patient could not be revived.

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Fig. 5 Removed clavicle implant.

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7 Follow-up and outcomes

The outcome of the surgery was considered successful, with drainage and removal of the osteosynthesis medium. Nevertheless, due to severe septic shock, the patient deceased the day after surgery".

8 Discussion-

Infections of the deep neck tissues are often difficult and complicated -in diagnosis, localisation, access and management. The anatomy of the neck is extremely complex, with critical airway, intestinal, and major vascular structures and nerves. The affected tissues may be deep and almost impossible to palpate or visualize externally. The structures which are nearby can become involved in the inflammatory reaction and lead to neuro-vascular, bony or airway issues.

Neck abscess includes peritonsillar infections, retropharyngeal infections, submandibular infections, buccal infections and parapharyngeal space infections. The available of antibiotics have made deep neck space infection relatively rare. However, diabetes mellitus has been a major risk factor and had made these neck space infections appear more frequently.^7,8

The common sources of neck space infections are dental infections, tonsillitis, salivary gland infections and oral malignancies. The neck space infections are relatively serious group of infections which can rapidly progress to sepsis, airway related complications and life-threatening complications. These infections remain an important health problem with significant morbidity and potential mortality.⁷

It is very important in evaluating the blood parameters (Total count, ESR and CRP) along with echographic studies to exclude the differential diagnosis like parapharyngeal abscess, Retropharyngeal abscess and lemierre syndrome. Even thouh MRI was not done in our case, it is critical to discern osteomyelitis from other potential diagnoses, especially in cases where systemic infection symptoms are observed.

Intramedullary clavicle fixation methods includes Rockwood Pin, Hagie Pin and Titanium elastic nail (TEN). A novel intramedullary clavicle implant the Sonoma CRx is an alternative for minimally displaced clavicle fractures.^9–11 The benefits of using titanium elastic nail is that the incision is smaller, which results in less tissue damage and better cosmetic results. TEN has a stress distribution similar to the intact clavicle.⁵ The TEN's drawbacks include implant migration, shortening and routine removal of the implant.¹⁰

To the best of our knowledge the deep neck space infection due to intramedullary clavicle implant has not been reported. There are only a few published articles about clavicle TEN’S related infection. Since this kind of case is extremely rare treatment recommendations could not be standardized due lack of multiple case experience.

The implication of interprofessional team collaboration in providing optimal care to patients with deep neck infections should be prioritized.

Routine removal of clavicle tens is one of the disadvantages of clavicular pinning is given in may studies. The implant related deep infections in clavicle tens fixation is very less.⁶ The spread of deep neck space infection from medial end of clavicle through the sternocleidomastoid is shown in (Fig. 6).

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Fig. 6 Diagramatic illustration of spread of deep neck space infection from medial end of clavicle through the sternocleidomastoid.

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The deep seated neck infections which presents with a neck swelling or paratonsillar abscess can always be deceiving and shifts the surgeons attention to the oral cavity and the regional lymph nodes, In such cases with a previous surgery near the shoulder region or any fractures near the shoulder region, the possibility of implant related infection or any infection related to previous surgery should always be kept in mind as an important differential diagnosis.

9 Conclusion-

Infection of implants used for internal fixation of clavicle can spread to the neck rapidly and present as a deep neck space infection and abscess. This case report should alert Orthopaedic Surgeons to this possibility and ensure that implant removal is done at the earliest once such infection is suspected.

Clinical message

Many cases will give difficulty in diagnosing and proposing a treatment plan among young orthopaedic surgeons in their practice. This is one of the cases that had such difficulty.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Ethics approval –

Approved from university.

Consent to participate -

Informed consent was obtained.

Consent to publish -

The authors affirm that human research participants provided informed consent for publication of the images.

Informed consent-

Obtained.

Authors contribution

All authors read and approved the manuscript.

Ethics

All procedures were performed in compliance with relevant laws and institutional guidelines. The institutional ethics committee(IEC) approved the project.

CRediT authorship contribution statement

Sivabalaganesh Amirthalingam: Material preparation, data collection and analysis were performed, The first draft of the manuscript was written by the corresponding author. Karthikeyan Manickam: Material preparation, data collection and analysis were performed, guided in writing the manuscript, The draft was critically reviced. Sundar Suriyakumar: Material preparation, data collection and analysis were performed, guided in writing the manuscript, for important intellectual content. J.K. Giriraj Harshavardhan: Material preparation, data collection and analysis were performed, guided in writing the manuscript, The final draft was approved, All authors commented on previous versions of the manuscript, All authors read, Commented and approved the manuscript, All authors contributed to the study conception and design.