MAUDE Adverse Event Report: I.T.S. GMBH CLAVICLE PLATE, MEDIAL, 3.5MM, 10-HOLE

Model Number	21122-10
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Information (3190)
Date of Event	08/02/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device history record (dhr) of clavicle plate (21122-10) was inspected and showed no deviations.The quality forms met all dimensional and visual criteria at the time of release with no issues documented during the manufacturing that would contribute to this complaint condition.A review of the raw material device history record revealed no deviation.The material was determined to be conforming and was used as is per product development approval.As stated in the surgery report, the patient had additional rip and pelvic fractures and walked with crutches 1, 5 weeks after surgery.When using crutches at a clavicle fracture, the entire load runs over the clavicle and leads to a high bearing, which caused the plate breakage.
Event or Problem Description
It was reported that a clavicle plate, medial, 3.5mm, 10-hole was determined to be broken postoperatively.Original implant date (b)(6) 2017.A revision surgery was performed on (b)(6) 2017.

• Brand Name: CLAVICLE PLATE, MEDIAL, 3.5MM, 10-HOLE
• Common Device Name: CLAVICLE PLATE, MEDIAL, 3.5MM, 10-HOLE
• Manufacturer (Section D): I.T.S. GMBH; autal 28; lassnitzh?he, styria 8301 ; AU 8301
• MDR Report Key: 8572271
• Report Number: 3004369035-2017-00061
• Device Sequence Number: 11359631
• Product Code: HRS
• UDI-Device Identifier: 09120034305214
• UDI-Public: 09120034305214
• Combination Product (Y/N): N
• Initial Reporter Country: AU
• PMA/510(K) Number: K050852
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 05/02/2019

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: 21122-10
• Device Catalogue Number: 21122-10
• Device Lot Number: 679/031702
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/02/2017
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/07/2017
• Initial Report FDA Received Date: 05/02/2019
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 73 YR
• Patient Weight: 90