MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC 2.7MM/3.5MM VA-LCP LAT ANT CLAVICLE PLATE/11H/113MM

Model Number	02.112.048
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Nerve Damage (1979); Pain (1994); Skin Inflammation/ Irritation (4545)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product complaint #: (b)(4).Additional product code: hwc.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 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 underwent a fracture fixation for a shaft fracture utilizing va-lcp anterior plate.Decreased internal rotation, pain/impingement laterally reported post-operative.Reoperation was performed due to hardware removal 1 year postoperatively, patient could feel implant.Union was achieved after 6 weeks.Patient is due for dps implants.Patient outcome is unknown.No further information is available.Concomitant device reported: unknown cortex screws (part# unknown, lot# unknown, quantity 9).This complaint involves one (1) device.This report is for (1) 2.7mm/3.5mm va-lcp lat ant clavicle plate/11h/113mm.This report is 1 of 1 for (b)(4).

• Brand Name: 2.7MM/3.5MM VA-LCP LAT ANT CLAVICLE PLATE/11H/113MM
• Common Device Name: 2.7MM/3.5MM VA-LCP LAT ANT CLAVICLE PLATE/11H/113MM
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 12491754
• Report Number: 2939274-2021-05552
• Device Sequence Number: 14386649
• Product Code: HRS
• UDI-Device Identifier: 10886982033055
• UDI-Public: (01)10886982033055
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K101536
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: study
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 08/23/2021

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: 02.112.048
• Device Catalogue Number: 02.112.048
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/23/2021
• Initial Report FDA Received Date: 09/17/2021
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 47 YR