The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 10

Scientific Articles | October 01, 2007

Clavicular Anatomy and the Applicability of Precontoured Plates

Jerry I. Huang, MD¹; Paul Toogood, BS¹; Michael R. Chen, MD¹; John H. Wilber, MD¹; Daniel R. Cooperman, MD¹

¹ Department of Orthopaedics, University Hospitals Case Medical Center, Case Western Reserve University, 645 Hannah House, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail address for J.I. Huang: orthojerr@yahoo.com

View Disclosures and Other Information

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the AO North America Resident Trauma Research Grant. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Orthopaedics, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio

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J Bone Joint Surg Am, 2007 Oct 01;89(10):2260-2265. doi: 10.2106/JBJS.G.00111

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Abstract

Background: Plate fixation of clavicular fractures is technically difficult because of the complex anatomy of the bone, with an S-shaped curvature and a cephalad-to-caudad bow. The purpose of the present study was to characterize variations in clavicular anatomy and to determine the clinical applicability of an anatomic precontoured clavicular plate designed for fracture fixation.

Methods: One hundred pairs of clavicles were analyzed. The location and magnitude of the superior clavicular bow were determined with use of a digitizer and modeling software. Axial radiographs were made of each clavicle and the precontoured Acumed Locking Clavicle Plate, which is designed to be applied superiorly. With use of Adobe Photoshop technology, the plates were freely translated and rotated along each clavicle to determine the quality of fit and the location of the "best fit."

Results: The location of the maximum superior bow was lateral, with a mean distance of 37.2 ± 18.4 mm from the acromial articulation and with a mean magnitude of 5.1 ± 5.9 mm. There was no significant difference in the location or magnitude of the apex of the bow between specimens from male and female donors. The anatomic precontoured clavicular plate had the best fit in specimens from black male donors and the worst fit in specimens from white female donors, with a poor fit being seen in 38% (nineteen) of the fifty specimensfrom white female donors. The best location for superior plate application was along the medial aspect of the clavicle.

Conclusions: The apex of the superior bow of the clavicle is typically located along the lateral aspect of the bone, whereas the medial aspect of the superior surface of the clavicle remains relatively flat, making it an ideal plating surface. The precontoured anatomic clavicular plate appears to fit the S-shaped curvature on the superior surface of the majority of clavicles in male patients but may not be as conforming in white female patients. While this plate fits in the medial three-fifths of the clavicle, it does not fit as well laterally.

Clinical Relevance: Recent studies have shown that displaced midshaft clavicular fractures that are treated with plate fixation have better functional outcomes than those that are treated nonoperatively. An understanding of clavicular anatomy is paramount for optimal plate design and fracture fixation. Our data provide potentially important information for future clavicular plate designs and applications.

Figures in this Article

Clavicular fractures account for 2% to 5% of all adult fractures and occur more commonly in younger individuals^1-3. Eighty percent of clavicular fractures in adults occur in the middle one-third of the bone^1,2. Surgical treatment is seldom necessary as most midshaft clavicular fractures do well with nonoperative treatment^4,5. Although infrequent, malunions and nonunions can lead to substantial long-term sequelae, including persistent pain, weakness, and loss of range of motion^6-9. Moreover, recent studies have demonstrated nonunion rates of =15% for displaced midshaft clavicular fractures^10,11. The indications for open reduction and internal fixation include open fractures, skin tenting, symptomatic nonunions, and initial shortening exceeding 20 mm.

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Fig. 1: Photograph illustrating the technique used to determine the location and magnitude of the maximum superior clavicular bow. Measurements were made with use of a MicroScribe Digitizer G2 3D and Rhinoceros modeling software.

Surgical options for the treatment of clavicular fractures include intramedullary or plate fixation. Although intramedullary fixation is minimally invasive, there is a serious risk of pin migration^12-15. Plate fixation can be technically difficult because of the complex anatomy of the clavicle with its S-shaped curvature and cephalad-to-caudad bow. Pelvic reconstruction plates are often used as they are easier to contour. However, 3.5-mm limited-contact dynamic compression plates offer better biomechanical stability than 3.5-mm reconstruction plates do with respect to torsional and compressive loads¹⁶. Unfortunately, they can be difficult to contour to the normal anatomy. In response to this problem, precontoured anatomic plates have been developed. The precontoured Locking Clavicle Plate (Acumed, Hillsboro, Oregon) is a low-profile plate that is designed to fit the superior surface of the clavicle with minimal soft-tissue irritation. The purpose of the present study was to characterize variations in clavicular anatomy with respect to its S-shaped curvature and superior bow and to determine the clinical applicability of this anatomic precontoured clavicular plate for fracture fixation.

Materials and Methods

Materials and Methods | Results | Discussion | References

One hundred pairs of clavicles (200 clavicles) from skeletally mature individuals who had ranged from twenty-one to thirty-five years of age at the time of death were obtained from the Hamann-Todd Collection at the Cleveland Museum of Natural History. Specimens from twenty-five white male donors, twenty-five white female donors, twenty-five black male donors, and twenty-five black female donors were selected at random.

Clavicular Anatomy

The most medial and lateral edges of the clavicle were marked with use of the digitizer, and then the point of the maximum superior bow was identified (Fig. 1). The superior clavicular bow was defined as the apex of the cephalad bowing as seen on the frontal view. The location and magnitude of the apex of the superior clavicular bow were determined with use of a MicroScribe G2 3D Digitizer (Immersion; San Jose, California) and Rhinoceros modeling software (McNeel, Seattle, Washington). The S-shaped curvature was defined as the curve as seen on the axial/superior view. In order to characterize the Sshaped curvature, medial and lateral angulations at the apices of the S curve were measured for each specimen with use of a goniometer. An unpaired Student t test was used to determine differences between specimens from male and female donors as well as between specimens from black and white donors, with the level of significance set at p < 0.05. Measurements of the location and magnitude of the superior bow apex were performed in triplicate at separate time-points by the same observer (P.T.). Duplicate measurements were made by a second observer (J.I.H.) independently at a different time-point. Pearson coefficients were calculated to determine intraobserver and interobserver reliabilities.

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Figs. 2-A through 2-D: Digital enhancement of radiographs of individual clavicles and plates. Clavicular radiographs (Fig. 2-A) were digitally manipulated for image analysis (Fig. 2-B). Similarly, radiographs of the plates were digitally manipulated for image analysis (Fig. 2-C). The plate was then freely translated to position it at a location of "best fit" on the clavicular shaft (Fig. 2-D).

Anatomic Plate Fit

The precontoured Acumed Locking Clavicle Plate is the only anatomic clavicular plating system that is currently available for clinical use in the United States. There are three designs for the eight-hole plates: Design A (straight), Design B (standard), and Design C (curved). The standard design is also available in six-hole and ten-hole options. Axial radiographs of each clavicle and plate were made on the same cassette to standardize for magnification. With use of Adobe Photoshop (Adobe Systems, San Jose, California), the plates and clavicles were then manipulated digitally and edge-enhanced for image analysis (Figs. 2-A, 2-B, 2-C, 2-D). Digitized representations of the plates were freely translated and rotated along each clavicle to determine the quality of fit and the location of "best fit." "Best fit" was defined as placement of the plate in a location that best matched the S-shaped curvature of the clavicle with minimum anterior or posterior plate overhang. The location of "best fit" along the clavicular shaft was characterized with respect to the most medial edge of the plate relative to the sternal articulation as well as the location of fractures that would be amenable to plate fixation with at least three proximal and three distal bicortical screws. Fit was defined as good (no overhang), fair (mild anterior or posterior overhang of the plate over the clavicle), or poor (both anterior and posterior plate overhang or screw-hole overhang) (Figs. 3-A, 3-B, and 3-C).

Travel Distance

In addition to determining the location of best fit along the clavicular shaft, the potential for medial and lateral plate travel was also estimated. Travel was defined as the shift in the location of the plate on the clavicle medially and laterally before screw-hole overhang occurred. With a specimen that had a good fit, the amount of medial and lateral travel of the plate along the clavicular shaft was determined. Medial travel distance was defined as the distance between the medial edge of the plate in the "best fit" location and the sternal articulation. Total travel distance was defined as the distance between the medial edge of the plate in the lateral fit location and the sternal articulation.

Results

Materials and Methods | Results | Discussion | References

Clavicle Anatomy

The mean length of the clavicle (and standard deviation) was 145.0 ± 12.7 mm. Male donors, in general, were larger than female donors and had longer clavicles (mean, 152.6 ± 10.2 mm compared with 137.3 ± 10.2 mm). There was a wide spectrum of S-shaped curvatures. The location of the maximum superior bow was lateral, with a mean distance of 37.2 ± 18.4 mm from the acromial articulation and with a mean magnitude of 5.1 ± 5.9 mm (Figs. 4 and 5). There was no significant difference in the location or magnitude of the apex of the bow between specimens from male and female donors. Specimens from white donors had a bow apex that was significantly more medial compared with those from black donors (41.3 compared with 33.1 mm; p < 0.01) and a trend toward a larger bow magnitude that was not significant (5.49 compared with 4.72 mm; p = 0.07). There was good reproducibility in the measurements with respect to location and magnitude of the bow, with high Pearson coefficients for both interobserver and intraobserver reliabilities (R² > 0.75).

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Figs. 3-A, 3-B, and 3-C: Digital images of clavicles with good fit (Fig. 3-A), fair fit (Fig. 3-B), and poor fit (Fig. 3-C). The presence of anterior and posterior plate overhang was more easily detected with the digital conversions. A specimen with a good fit had no overhang. A specimen with a fair fit had mild anterior or posterior overhang. A specimen with a poor fit had both anterior and posterior overhang or screw-hole overhang.

The S-shaped curvature as seen on the axial view was described with respect to the angulation of the curve apices medially and laterally. The medial angulation was more consistent, with less variation than the lateral angulation. The mean medial angulation was 36.6° ± 7.4°, whereas the mean lateral angulation was 51.8° ± 12.7°. There was no significant difference in medial or lateral angulation between specimens from male and female donors (36.3° ± 7.6° compared with 36.9° ± 7.3° and 52.6° ± 12.6° compared with 51.1° ± 12.9°, respectively) or between specimens from white and black donors (37.2° ± 7.8° compared with 36.0° ± 7.1° and 51.4° ± 13.0° compared with 52.3° ± 12.4°, respectively).

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Fig. 4: Graph illustrating the distribution of the location of the maximum clavicular bow (the apex of the superior bow) relative to the acromial articulation (in millimeters). Most of the clavicles had maximum bowing over the lateral aspect of the clavicular shaft.

Anatomic Plate Fit

In each specimen, plate fit was determined as good (no overhang), fair (mild anterior or posterior overhang of the plate over the clavicle), or poor (both anterior and posterior plate overhang or screw-hole overhang). The anatomic precontoured clavicle Design B plate (standard design) had the best fit in specimens from black male donors and the worst fit in specimens from white female donors. Overall, this design had a good or fair fit (no or mild plate overhang over the clavicle) in 87% (174) of all 200 specimens, with a good or fair fit in 96% of specimens from male donors; however, a good or fair fit was noted in only 62% (thirty-one) of the fifty specimens from white female donors (Table I).

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TABLE I Quality of Fit of the Anatomic Precontoured Plates on the Superior Surface of the Clavicle^*

	Quality of Fit (no. of specimens)
Donor Type	Good	Fair	Poor
Black male	40	9	1
White male	25	22	3
Black female	20	27	3
White female	6	25	19

Overall, good or fair fit was seen in 87% of the specimens analyzed.

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TABLE I Quality of Fit of the Anatomic Precontoured Plates on the Superior Surface of the Clavicle^*

	Quality of Fit (no. of specimens)
Donor Type	Good	Fair	Poor
Black male	40	9	1
White male	25	22	3
Black female	20	27	3
White female	6	25	19

Overall, good or fair fit was seen in 87% of the specimens analyzed.

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Fig. 5: Graph illustrating the distribution of the magnitude of maximum clavicular bow (in millimeters). Substantial variation in the magnitude of the clavicular bow apex can be seen.

The best location for plate application was superiorly along the medial aspect of the clavicular shaft. On the average, the plate fit best when its medial edge was 12.3 ± 6.1 mm away from the sternal articulation, or 8.5% ± 3.8% of the length from medial to lateral. On the basis of this location, the plate would be most effective for the fixation of fractures located 44.5 to 72.7 mm from the sternal edge, or in the medial 30.7% to 50.3% portion of the clavicle.

With all of the specimens that had a good fit, medial travel was possible to the sternal articulation on all specimens without the creation of screw-hole overhang. Laterally, the average travel was 1.67 ± 0.76 cm (10.9% ± 4.4% of the length of the clavicle) without the creation of screw-hole overhang. The total travel distance of the plate from medial to lateral was a mean of 3.30 ± 0.84 cm. Allowing for plate travel, the precontoured anatomic clavicular plate is well contoured for the fixation of fractures in the medial 20.0% to 61.2% portion of the clavicle.

Discussion

Materials and Methods | Results | Discussion | References

Traditionally, most midshaft clavicular fractures have been treated nonoperatively on the basis of literature from the 1960s that demonstrated low nonunion rates in association with nonoperative treatment and suggested that surgical fixation of clavicular fractures may lead to higher complication rates and a higher probability of fracture nonunion^4,17. However, several recent studies have demonstrated nonunion rates of 15% to 20% in association with displaced, comminuted midshaft fractures that were treated nonoperatively^10,11,18. In a recent randomized, prospective study in which nonoperative treatment of displaced midshaft clavicular fractures was compared with plate fixation, patients in the operative fixation group had significantly better functional outcomes, a lower rate of nonunion, and a lower incidence of symptomatic malunion¹⁹. Most complications in the operative fixation group were hardware-related.

Currently, plate fixation is the procedure of choice for the treatment of open fractures, severely displaced fractures, and nonunions^20-22. Therefore, an understanding of the complex anatomy of the clavicle is paramount in order to achieve an optimal plate design and effective fracture fixation.

The options for plate location are anteroinferior and superior^16,20-30. Some of the theoretical advantages of anteroinferior plating include less hardware prominence and the ability of the surgeon to direct instrumentation away from infraclavicular neurovascular structures^20,23. However, Iannotti et al. demonstrated that applying the plate superiorly provides better stability at the fracture site¹⁶.

The present study illustrates that the apex of the superior bow of the clavicle is typi cally located along the lateral aspect of the bone, whereas the medial aspect of the superior surface of the clavicle remains relatively flat, making it ideal for plating. In contrast, the anterior surface of the clavicle is curved, with one apex located anteromedially and another apex located posterolaterally. While the precontoured Acumed Locking Clavicle Plates were found to fit the S-shaped contour on the superior surface of the majority of clavicles in specimens from male donors, this was frequently not the case in specimens from white female donors. The difference in fit was usually because the clavicles from female donors were narrower than the plates. It should be noted that, in the majority of specimens in which the standard Design B plate did not have a good or fair fit, the Design A (straight) and Design C (curved) plates also had a poor fit (data not shown).

The precontoured Acumed Locking Clavicle Plate is adequately shaped for the fixation of fractures in the medial three-fifths of the clavicular shaft. This is an important fact to keep in mind when performing preoperative planning for plate fixation of a midshaft clavicular fracture. Patients with a fracture that is located in the lateral two-fifths of the clavicular shaft may require the use of a different plate design such as a contoured pelvic reconstruction plate.

The main limitation of the present study was that it was a two-dimensional analysis of plate fit rather than a three-dimensional analysis. Digital representations of the plates and clavicles, rather than actual placement of the plates onto the clavicular specimens, were used to determine plate fit. We used this method because we believed that digitized images would provide better visualization of plate fit and plate overhang. Plate fit was analyzed with respect to the S-shaped curvature of the clavicle on the axial view but not the frontal view. Intra-operatively, bending these plates in an anterior-posterior direction (in the same plane as the plate) would be extremely difficult whereas bending them in a cephalad-caudad direction (perpendicular to the plane of the plate) would be relatively easy. Thus, from a clinical perspective, we thought that assessment of plate fit on the frontal view would not be as pertinent.

The present study provides a comprehensive analysis of the S-shaped curvature and cephalad-caudad bow of the clavicle, which can be used to facilitate the design of clavicle plates in the future. ?

References

Materials and Methods | Results | Discussion | References

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Topics

bone plates ; clavicle

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Jerry I. Huang, Paul Toogood, Michael R. Chen, John H. Wilber, Daniel R. Cooperman; Clavicular Anatomy and the Applicability of Precontoured Plates. The Journal of Bone & Joint Surgery. 2007 Oct;89(10):2260-2265.

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