Recurrent Midshaft Clavicle Nonunion with a Large Segmental Bone Defect Treated with Autologous Iliac Crest Bone Graft and Dual Plating: A Case Report.

INTRODUCTION: Clavicle fractures are common, and although most midshaft fractures heal successfully, large segmental defects are associated with an increased risk of nonunion. Clavicle nonunion is often severely disabling, with patients experiencing chronic pain, progressive deformity, reduced shoulder strength, and impaired upper-extremity function. The standard approach reserves non-vascularized iliac crest bone graft (ICBG) for defects up to about 3 cm, whereas larger defects are conventionally reconstructed with vascularized grafts. Reports of successful non-vascularized iliac crest grafting for very large segmental defects, particularly in the revision setting after prior failed fixation and grafting, are uncommon. We present this case to expand the documentation of non-vascularized reconstruction and to offer technical guidance for this challenging clinical scenario. CASE REPORT: A 40-year-old woman of Hispanic (Puerto Rican) background presented with right shoulder pain and functional limitation after two prior operations for a displaced midshaft clavicle fracture, which left a 4.5-cm segmental defect. She had a longstanding heavy smoking history. After confirmed smoking cessation and nutritional optimization, she underwent open reconstruction with a tricortical autologous iliac crest graft harvested using an ultrasonic bone scalpel, combined with orthogonal dual plating. At 2-year follow-up, she had full active range of motion, normal strength, restored clavicular length, and stable fixation, with no donor-site complications. CONCLUSION: A large segmental midshaft clavicle defect exceeding the size usually considered suitable for non-vascularized grafting was reconstructed successfully with autologous ICBG and dual plating, with durable clinical and radiographic results. The case supports non-vascularized grafting as a reasonable option in selected patients, particularly where vascularized grafting is not readily available, and underscores the importance of addressing modifiable risk factors such as smoking before reconstruction. It adds to a small body of evidence and may broaden reconstructive options in orthopedic and trauma practice.