MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 3.5 LCP CLAV HK PL 6H 18 HK DPTH/73/RT-S; PLATE,FIXATION,BONE

Model Number	241.096S
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Nonunion/Delayed-union Bone Fracture (2369); Skin Inflammation/ Irritation (4545)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint # (b)(4).Additional narrative: complainant part is not expected to be returned for manufacturer review/ investigation.Without a lot number, the device history records review could not be completed as no product was received.The investigation could not be completed, no product was received; no conclusion could be drawn at the time of filing this report.The product was not returned.Based on the information available, it has been determined that no corrective and preventative action is proposed.This complaint will be accounted for and monitored via post market surveillance activities.If additional information is made available, the investigation will be updated as applicable.Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported that on an unknown date, the patient had a nonunion, lateral fracture.Lcp clavicular hook plate 3.5 was used with grafton paste, 5cc.There was a reoperation due to dps implants and hardware removal, patient could feel implant.Union was not achieved.Patient outcome is unknown.No further information is available.This complaint involves 1 (one) device.This report is for (1) 3.5 lcp clav hk pl 6h 18 hk dpth/73/rt-s.This report is 1 of 2 for (b)(4).

• Brand Name: 3.5 LCP CLAV HK PL 6H 18 HK DPTH/73/RT-S
• Common Device Name: PLATE,FIXATION,BONE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12484704
• Report Number: 2939274-2021-05474
• Device Sequence Number: 14675521
• Product Code: HRS
• UDI-Device Identifier: 10886982165855
• UDI-Public: (01)10886982165855
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K061753
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: health professional,study
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 08/20/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: 241.096S
• Device Catalogue Number: 241.096S
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/20/2021
• Initial Report FDA Received Date: 09/16/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 28 YR