1: Open Reduction and Plate Fixation of Displaced Clavicle Fractures

PROCEDURE 1 Open Reduction and Plate Fixation of Displaced Clavicle Fractures



Jeremy A. Hall, Michael D. McKee



image


Indications




PITFALLS



• Operative treatment of clavicle fractures must consider both patient and fracture factors.

• Relative contraindications:
image Noncompliance

image Advanced age (>60 years)

image Medical comorbidities, especially diabetes

image Alcoholism

image Prior radiation to area

image Poor skin/soft tissue condition



Controversies



• Controversy still exists regarding operative versus nonoperative treatment of clavicle fractures as nonoperative treatment has been the standard of care since the 1960s.

• Debate continues regarding intramedullary versus plate fixation.

• Questions remain regarding less than 2 cm of shortening as an indication.



Treatment Options



• Options for treatment of displaced clavicle fractures include open reduction and internal fixation or use of a sling for comfort.

• For operative treatment, open reduction and internal plate fixation is preferred as intramedullary fixation controls length and rotation poorly.

• For nonoperative treatment, a simple sling is preferred.

• A figure-of-8 bandage can lead to brachial plexopathy if not applied appropriately, and has little influence on fracture outcome.


image Open fracture

image Fracture with associated upper extremity neurovascular compromise

image Clavicle fracture with associated scapulothoracic dissociation

image Completely displaced midshaft clavicle fracture in young active individuals, especially with shortening

image Displaced lateral third clavicle fracture

image Lateral third intra-articular clavicle fracture

image Associated displaced glenoid fracture (floating shoulder)


Examination/Imaging



image The overlying skin and soft tissues are examined for deficits, old scars, or previous incisions.

image The length of the injured clavicle is measured from the sternoclavicular joint to the acromioclavicular joint, and compared to the opposite uninjured side both clinically and radiographically.

image A carefully documented neurovascular examination of the upper extremity is done to exclude preoperative injury.

image Anteroposterior and 20° cephalad upshot views of the clavicle are obtained to assess fracture configuration.
• Figure 1 shows an anteroposterior radiograph of a completely displaced midshaft clavicle fracture with significant displacement and rotation at the fracture site.

image

FIGURE 1



Surgical Anatomy



image The clavicle forms an anterior strut to maintain the position of the shoulder on the thoracic cage (Fig. 2).
• It is an S-shaped bone with a cephalad-to-caudad bow.

• The subclavian vessels and brachial plexus pass posterior/posteroinferior to the clavicle before passing inferior to the coracoid and into the arm.

• The apex of the lung lies posterior/posteroinferior to the clavicle.

• Superficially, cutaneous braches of the intermediate supraclavicular nerve fan out over the anterior-superior region of the middle third of the clavicle.

image The sternoclavicular joint is a diarthrodial joint allowing movement in both the horizontal and vertical planes, as well as 20–40° of rotation relative to the manubrium, and is stabilized by the joint capsule.

image The acromioclavicular joint is a planar joint allowing approximately 20° of rotation relative to the acromion. This joint is stabilized by the capsule and intracapsular ligaments, as well as the conoid and trapezoid coracoclavicular ligaments.

image Together, these joints allow movement of the clavicle of up to 60° in the vertical plane and 20° in the horizontal plane, and up to 40° of rotation.

image

FIGURE 2



Positioning




PEARLS



• A bump under the shoulder girdle will aid in fracture reduction, as it allows the shoulder and lateral fragment to lateralize or “fall away” from the fracture site.

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 1: Open Reduction and Plate Fixation of Displaced Clavicle Fractures

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