The patient is placed in the beach-chair position with a small pad behind
the shoulder blade and the involved upper extremity tucked into the side with
a bed sheet (Fig. 2). It is not
routinely necessary to drape the arm free. The head of the patient is
supported with a headrest and is slightly tilted to the opposite side to
provide easy access to the clavicle with operative instruments. The operative
site is prepared in standard sterile fashion and is draped from the lateral
border of the acromion to the sternum (Fig.
3).
A horizontal skin incision is made along the superior surface of the
clavicle and centered over the fracture site. The skin, platysma, and
subcutaneous tissue are raised as a single flap
(Fig. 4). Care is taken to
avoid injury to any identifiable supraclavicular nerves. Some denervation is
inevitable; however, this is usually not a long-term clinical problem because
of gradual reinnervation of the skin from the medial and lateral sides of the
incision. The underlying myofascial layer is identified and is sharply
dissected down to bone so that a single continuous thick flap is raised for
later closure over the plate. Thereby, a two-layer soft-tissue closure will be
achieved at the conclusion of the procedure.
Next, the fracture is exposed and carefully assessed
(Fig. 5). Typically, the
proximal fragment is displaced superiorly, while the distal fragment is
displaced inferiorly, translated medially, and rotated anteriorly; the flat
superior surface of the distal fragment thereby faces more anteriorly rather
than directly superiorly as a result of the action of the deforming muscles.
After removal of the interposing soft tissue and clearing of the fragment
ends, the fracture is anatomically reduced and is held in place with a
reduction clamp (Figs. 6-A and
6-B). A 3.5-mm dynamic compression plate is centered accurately
over the fracture site so that at least three screws can be placed in each of
the proximal and distal
fragments9. We
usually position the plate over the superior surface of the clavicle (Figs.
7 and
8). The plate is then clamped
to the proximal and distal fragments with two bone-holding forceps. It is not
routinely necessary to use a blunt retractor under the clavicle, but care must
be taken to avoid overdrilling deep to the clavicle. If inadvertent plunging
does occur, then a chest radiograph is necessary postoperatively to rule out
pneumothorax. Bleeding from injury to the subclavian vessels will typically
stop with manual pressure. If the fracture is oblique, a 3.5-mm lag screw is
placed across the fracture site. Butterfly fragments, if present, are reduced
and fixed to a major fragment with an interfragmentary compression screw if
possible. It is important not to strip these fragments of their soft tissues.
In approximately 20% of cases, the fracture is very comminuted, and in such
situations the plate is applied in the neutral mode without compression.
However, in the majority of cases, compression is applied through the
plate.
It is important to correctly restore length and rotation. Preoperatively,
the distance between the acromioclavicular joint and the sternoclavicular
joint on the contralateral side is measured both clinically and
radiographically in order to estimate the amount of clavicular length to
restore.
Following wound irrigation, meticulous closure is performed in two layers.
The myofascial layer is closed with number-1 absorbable sutures in an
interrupted fashion (Fig. 9).
Then the subcutaneous tissues are closed with number-2.0 absorbable sutures,
and the skin is closed with a subcuticular stitch or staples. The incision is
infiltrated with 0.5% bupivacaine (Fig.
10), and the arm is placed in a standard sling. An anteroposterior
radiograph of the clavicle is made in the recovery room
(Fig. 11). A chest radiograph
is not routinely made unless a specific injury to the pleura is suspected.
The arm is maintained in a sling on a full-time basis for two weeks, after
which use of the sling is discontinued and active assisted range-of-motion
exercises of the shoulder in the scapular plane are begun. Full active motion
is initiated at four weeks. When clinical and radiographic signs of union are
present, strengthening and resistive exercises of the rotator cuff, deltoid,
and trapezius are begun, usually at six to eight weeks. By three to four
months, most patients are allowed to participate in all sports activities.
CRITICAL CONCEPTSINDICATIONS:The majority of clavicular fractures can be treated effectively with
nonoperative means. Operative fixation is indicated in healthy, physically
active individuals between the ages of sixteen and sixty years with any of the
following:A completely displaced midshaft fracture with shortening of >2 cmSuperior displacement with skin tenting and/or an impending open
fractureAn associated neurovascular injuryAn open clavicular fractureA floating shoulder with a completely displaced clavicular fractureAn obvious clinical deformity with shoulder asymmetry (a combination of
shortening, rotation, and displacement)Multiple injuries with any of the above indicationsCONTRAINDICATIONS:Active infection in the operative areaPrior soft-tissue irradiation in the operative areaBurns over the clavicular areaDebilitating medical conditionsA high risk of poor patient compliance, especially due to substance abuse
(drugs and/or alcohol)An elderly patient with a sedentary lifestylePITFALLS:Preoperative planning and patient selection are crucial. Patients at high
risk for multiple falls, alcohol abuse, or noncompliance may have early
mechanical failure of the fixation and are not candidates for this
procedure.Failure to carefully contour the plate to accommodate the s-shape of the
clavicle can lead to implant prominence and soft-tissue irritation at the ends
of the plate. The use of a precontoured anatomic plate helps to decrease
soft-tissue irritation.A minimum of three 3.5-mm screws should be placed in each of the proximal
and distal fragments, and ideally the plate should be applied in compression
mode to reduce the risk of delayed union or nonunion.Cautious drilling, especially when sharp drills and taps are used, is of
paramount importance in this procedure. A blunt retractor placed under the
clavicle, which adds undesired soft-tissue dissection, can be used if
necessary. We have found that this step is not required as experience
increases.The intervening fragments should not be stripped. They should be teased
into position, with preservation of soft-tissue attachments and ensuring that
the length and rotation of the clavicle are correct.A postoperative chest radiograph is required only in rare circumstances
where a pleural injury is suspected.AUTHOR UPDATE:Currently, we are using a precontoured "anatomic" plate
designed for the clavicle to decrease soft-tissue irritation and the
intraoperative time required for plate contouring
(Fig. 12).We have found that it is not necessary to have the arm draped free to
obtain or maintain fracture reduction; rather, the arm is tucked into the side
and the operative site is simply draped off.At present, the procedure is performed with use of a regional anesthetic
with supplemented infiltration of local anesthesia. This method improves
postoperative pain control and allows the procedure to be performed on an
outpatient basis.A "minimally invasive" technique can be used as expertise
increases. This includes shorter incisions, extensive mobilization of
subcutaneous tissues, sliding of the plate under the myofascial layer, and the
use of small stab incisions through the myofascial layer for placement of the
screws.
CRITICAL CONCEPTS
INDICATIONS:
The majority of clavicular fractures can be treated effectively with
nonoperative means. Operative fixation is indicated in healthy, physically
active individuals between the ages of sixteen and sixty years with any of the
following:
A completely displaced midshaft fracture with shortening of >2 cmSuperior displacement with skin tenting and/or an impending open
fractureAn associated neurovascular injuryAn open clavicular fractureA floating shoulder with a completely displaced clavicular fractureAn obvious clinical deformity with shoulder asymmetry (a combination of
shortening, rotation, and displacement)Multiple injuries with any of the above indications
A completely displaced midshaft fracture with shortening of >2 cm
Superior displacement with skin tenting and/or an impending open
fracture
An associated neurovascular injury
An open clavicular fracture
A floating shoulder with a completely displaced clavicular fracture
An obvious clinical deformity with shoulder asymmetry (a combination of
shortening, rotation, and displacement)
Multiple injuries with any of the above indications
CONTRAINDICATIONS:
Active infection in the operative areaPrior soft-tissue irradiation in the operative areaBurns over the clavicular areaDebilitating medical conditionsA high risk of poor patient compliance, especially due to substance abuse
(drugs and/or alcohol)An elderly patient with a sedentary lifestyle
Active infection in the operative area
Prior soft-tissue irradiation in the operative area
Burns over the clavicular area
Debilitating medical conditions
A high risk of poor patient compliance, especially due to substance abuse
(drugs and/or alcohol)
An elderly patient with a sedentary lifestyle
PITFALLS:
Preoperative planning and patient selection are crucial. Patients at high
risk for multiple falls, alcohol abuse, or noncompliance may have early
mechanical failure of the fixation and are not candidates for this
procedure.Failure to carefully contour the plate to accommodate the s-shape of the
clavicle can lead to implant prominence and soft-tissue irritation at the ends
of the plate. The use of a precontoured anatomic plate helps to decrease
soft-tissue irritation.A minimum of three 3.5-mm screws should be placed in each of the proximal
and distal fragments, and ideally the plate should be applied in compression
mode to reduce the risk of delayed union or nonunion.Cautious drilling, especially when sharp drills and taps are used, is of
paramount importance in this procedure. A blunt retractor placed under the
clavicle, which adds undesired soft-tissue dissection, can be used if
necessary. We have found that this step is not required as experience
increases.The intervening fragments should not be stripped. They should be teased
into position, with preservation of soft-tissue attachments and ensuring that
the length and rotation of the clavicle are correct.A postoperative chest radiograph is required only in rare circumstances
where a pleural injury is suspected.
Preoperative planning and patient selection are crucial. Patients at high
risk for multiple falls, alcohol abuse, or noncompliance may have early
mechanical failure of the fixation and are not candidates for this
procedure.
Failure to carefully contour the plate to accommodate the s-shape of the
clavicle can lead to implant prominence and soft-tissue irritation at the ends
of the plate. The use of a precontoured anatomic plate helps to decrease
soft-tissue irritation.
A minimum of three 3.5-mm screws should be placed in each of the proximal
and distal fragments, and ideally the plate should be applied in compression
mode to reduce the risk of delayed union or nonunion.
Cautious drilling, especially when sharp drills and taps are used, is of
paramount importance in this procedure. A blunt retractor placed under the
clavicle, which adds undesired soft-tissue dissection, can be used if
necessary. We have found that this step is not required as experience
increases.
The intervening fragments should not be stripped. They should be teased
into position, with preservation of soft-tissue attachments and ensuring that
the length and rotation of the clavicle are correct.
A postoperative chest radiograph is required only in rare circumstances
where a pleural injury is suspected.
AUTHOR UPDATE:
Currently, we are using a precontoured "anatomic" plate
designed for the clavicle to decrease soft-tissue irritation and the
intraoperative time required for plate contouring
(Fig. 12).We have found that it is not necessary to have the arm draped free to
obtain or maintain fracture reduction; rather, the arm is tucked into the side
and the operative site is simply draped off.At present, the procedure is performed with use of a regional anesthetic
with supplemented infiltration of local anesthesia. This method improves
postoperative pain control and allows the procedure to be performed on an
outpatient basis.A "minimally invasive" technique can be used as expertise
increases. This includes shorter incisions, extensive mobilization of
subcutaneous tissues, sliding of the plate under the myofascial layer, and the
use of small stab incisions through the myofascial layer for placement of the
screws.
Currently, we are using a precontoured "anatomic" plate
designed for the clavicle to decrease soft-tissue irritation and the
intraoperative time required for plate contouring
(Fig. 12).
We have found that it is not necessary to have the arm draped free to
obtain or maintain fracture reduction; rather, the arm is tucked into the side
and the operative site is simply draped off.
At present, the procedure is performed with use of a regional anesthetic
with supplemented infiltration of local anesthesia. This method improves
postoperative pain control and allows the procedure to be performed on an
outpatient basis.
A "minimally invasive" technique can be used as expertise
increases. This includes shorter incisions, extensive mobilization of
subcutaneous tissues, sliding of the plate under the myofascial layer, and the
use of small stab incisions through the myofascial layer for placement of the
screws.