Case

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  Diaphyseal wedge fracture of the clavicula

Introduction

Fractures of the clavicle are common injuries usually caused by a fall on an outstretched arm. Most clavicular fractures are treated nonoperatively, but many good indications for surgery exist. These include open fractures, fractures of the lateral third, fractures in association injuries to the scapula and nonunion. Although intramedullary nailing can be used for simple fractures of the shaft of the clavicle, plate fixation is the method of choice for most clavicular shaft fractures and both absolute and relative stability techniques can be used.

Müller AO/OTA Classification—diaphyseal clavicular fractures

15-B clavicle, diaphysis

3.2.1 Clavicular fracture (15—B1): stabilization with reconstruction plate 3.5

Surgical management

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  Stabilization with a reconstruction plate 3.5

Alternative implants

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  Reconstruction locking compression plate 3.5 with locking or conventional screws

  
  
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  LCP superior anterior clavical plate 3.5

1 Introduction

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  Clavicular fractures are not included in the Müller AO Classification, but the Orthopaedic Trauma Association lists the clavicle as bone 15 and middle-third diaphyseal fractures as type B. These are subdivided as simple (15-B1), wedge (15-B2), or complex (15-B3).

  
  
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  The usual mechanism of injury is a direct blow to the shoulder, forcing the lateral clavicle posteriorly and creating a fracture of the middle-third over the fulcrum of the first rib.

  
  
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  The subclavian artery and vein, together with the brachial plexus run immediately behind the clavicle and are at risk—both at the time of fracture and during internal fixation.

  
  
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  In all age groups, middle-third clavicular fractures will in most cases unite with simple conservative treatment. Treatment with a broad-arm sling or figure-of-eight bandage is equally effective in relieving discomfort and allowing early motion.

  
  
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  Reported nonunion rates vary but are generally accepted to be less than 5%. Not all nonunions are symptomatic.

  
  
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  Indications for primary surgical fixation of middle-third clavicular fractures include open fracture or impending skin perforation by a fracture fragment, associated injury to subclavian vessels, or brachial plexus and ipsilateral scapula neck fracture (floating shoulder).

  
  
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  More relative indications would include clavicular fractures in patients with multiple injuries or bilateral clavicular fractures. Recent studies suggest that accurate reduction and fixation may have a better functional outcome than conservative treatment, but this remains controversial.

2 Preoperative preparation

Operating room personnel (ORP) need to know and confirm:

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  Site and side of fracture

  
  
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  Type of operation planned

  
  
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  Ensure that operative site has been marked by the surgeon

  
  
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  Condition of the soft tissues

  
  
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  Implant to be used

  
  
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  Patient positioning

  
  
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  Details of the patient (including a signed consent form and appropriate antibiotic and thromboprophylaxis)

  
  
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  Comorbidities, including allergies

Instrumentation required:

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  Small fragment instruments

  
  
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  Reconstruction plates and 3.5 mm cortex screws

  
  
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  Corresponding bending pliers, irons, and templates

  
  
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  General orthopaedic instruments

  
  
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  Compatible air or battery drill with attachments

Equipment:

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  Operating table with extension for head support

  
  
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  Radiolucent operating table

  
  
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  Positioning accessories to assist with supine position of the patient

  
  
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  Image intensifier

  
  
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  X-ray protection devices for personnel and patient

3 Anesthesia

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  This procedure is performed with the patient under general anesthesia.