68 Open Reduction and Internal Fixation of Midshaft Clavicle Fracture

10.1055/b-0039-167717

68 Open Reduction and Internal Fixation of Midshaft Clavicle Fracture

Camden Tissue and David L. Helfet

Abstract

Historically, midshaft clavicle fractures have been treated conservatively. Recent clinical trials have demonstrated improved clinical outcomes with operative fixation of these displaced fractures and functional deficits in those treated conservatively. With operative care, open reduction and internal fixation with plates and screws is most commonly used. Multiple plate locations are possible. We believe that dual, orthogonal, mini-fragment plate fixation combines the advantages biomechanically of the different plate locations as well as allows use of low-profile plates that minimize the risk of hardware irritation. This technique reliably leads to anatomic union and decreases the number of secondary operations.

68.1 Goals of Procedure

Fractures of the clavicle are common with an incidence of 30 to 60 per 100,000 population per year. ¹ ^, ² Clavicle fractures comprise 35 to 44% of fractures about the shoulder and 2.6 to 4% of all fractures in the adult population. ² ^, ³ Among those, fractures of the middle one-third of the clavicle account for the majority (69–81%). ¹ ^– ³ The clavicle functions as a strut for the upper extremity. It is the only osseous attachment for the upper extremity to the axial skeleton and an important site for muscle insertion. Forces applied to the upper extremity are transmitted to the trunk via the clavicle and its articulation with the acromion process of the scapula and the manubrium of the sternum. The goal of surgery on the clavicle is to anatomically reconstruct the clavicular length, alignment, and rotation with stable, balanced internal fixation while preserving blood supply and allowing for early range of motion of the shoulder and rehabilitation. Further goals of the operation include recovery of muscle strength and endurance, patient satisfaction with shoulder function and appearance, and avoidance of nonunion or symptomatic malunion.

68.2 Advantages

Historically, fractures of the midshaft clavicle were treated conservatively in either a sling or a figure-of-8 brace. This treatment was driven by early studies reporting that the nonunion rate with conservative treatment of clavicle fractures is exceedingly rare (<1%). ⁴ ^, ⁵ Outcomes in these studies were often surgeon reported or radiographic. Any residual shoulder deformity was thought to be a cosmetic concern and shoulder function was unaffected. However, over the past 15 to 20 years, multiple prospective studies have shown less favorable outcomes. Conservatively treated displaced midshaft clavicle fractures have significantly decreased strength and endurance compared to the uninjured side. ⁶ Nonunion rates from 7 to 24% have been reported. ⁷ ^– ¹⁰ It is common (42%) to have pain or paresthesias 6 months after injury with conservative management. ⁷ Patients are dissatisfied with the cosmetic result of their shoulder and function overall. ⁶ ^– ⁸ Changes in the bony morphology can lead to altered scapular kinematics and changes in maximal muscle moments about the shoulder. ¹¹ ^– ¹³ A recent study of cadavers found that the presence of an ipsilateral clavicle fracture was correlated with development of glenohumeral arthritis. ¹⁴

Because of these numerous undesirable consequences uncovered in the literature, operative treatment has gained traction. High-level evidence comparing operative versus conservative treatment for displaced midshaft clavicle fractures found that operative treatment leads to faster time to union, better patient-reported outcomes, less nonunions, no symptomatic malunions, faster return to function, and better patient satisfaction with the shoulder. ¹⁵ ^, ¹⁶ Operative treatment has shown to be financially beneficial as well, with faster return to work, less pain medication requirement, and less need for physical therapy. ¹⁷

68.3 Indications

The indications for surgical treatment of acute, midshaft clavicle fractures are shortening, displacement, or translation. The degree needed to indicate a patient for surgical treatment remains a topic of debate. Complete displacement, presence of comminution, advancing age, female gender, and initial shortening of 2 cm have all been associated with risk of nonunion and the risk of long-term sequelae. ⁶ ^, ⁸ ^, ⁹ ^, ¹⁸ Symptomatic malunions with shortening of the clavicle will have worse clinical outcomes. In our practice, we i ndicate patients with complete displacement or shortening of the clavicle for surgical management. Other indications for surgical treatment of midshaft clavicle fractures include open or impending open fracture with skin at risk, multiply traumatized patients in need of mobilization, concomitant neurovascular injuries, and fracture of glenoid neck of the scapula resulting in a “floating shoulder.” Relative indications for surgery include patients in whom rapid return to work is desirable such as professional athletes or surgeons and patients in whom the cosmetic appearance of the shoulder is important such as professional models.

68.4 Contraindications

True contraindications to this procedure are rare. Relative contraindications include pediatric patients because of their inherent healing and remodeling abilities, nondisplaced and minimally displaced fractures, and patients with medical comorbidities that preclude surgery.

68.5 Preoperative Preparation/Positioning

68.5.1 Physical Examination

As with any patient, a thorough history and physical examination is the important first step in management. Examination of the skin over the fracture site is mandatory as skin tenting and impending open fracture will alter the timing of treatment. The neurovascular examination is important to rule out injuries to the subclavian artery or vein or the brachial plexus as these may alter the surgical management. It is also prudent to examine the breath sounds and radiographs to rule out hemothorax or pneumothorax as these injuries have been reported in conjuncture with clavicle fractures. ¹⁹ ^, ²⁰

68.5.2 Imaging

Standard radiographs of the clavicle include anteroposterior view and a 45-degree cephalad view, also known as a “serendipity” view ( Fig. 68.1 ). The “serendipity” view is useful in that the underlying thoracic structures no longer obscure the view of the clavicle. These two views will commonly provide adequate information about fracture pattern, displacement, and shortening to make surgical plans. If there is a borderline case, one can obtain upright views to allow gravity to gently stress the fracture site and show the true amount of displacement and shortening. Forty-one percent of patients who do not have complete displacement on supine films will have complete displacement on upright films. ²¹ If on physical examination, there is evidence of a neurovascular injury, one must rule out scapulothoracic dissociation. This can be done on chest radiographs by comparing the distance of the scapula from midline bilaterally. CT scans, though not usually necessary for treatment, can show evidence of scapulothoracic dissociation, intrathoracic injury, and details of the clavicle fracture fragments.

**Fig. 68.1** Plain radiographs of a displaced midshaft clavicle fracture with multiple butterfly fragments including anteroposterior and “serendipity” views.

68.5.3 Positioning

The patient is placed supine on a standard radiolucent table ( Fig. 68.2 ). A rolled towel is placed beneath the scapula to elevate the clavicle and allow for draping of the posterior shoulder. The patient’s head is tilted away from the surgical field and secured. If the procedure is to be done under general endotracheal anesthesia, the endotracheal tube is secured on the opposite corner of the mouth to keep the tube out of the surgical field. Most commonly, we perform this procedure under regional (interscalene) block and sedation. The surgical field is isolated with adhesive drapes and surgical sterilization is performed. Stockinette is used to cover the hand and forearm and Ioban (3M, St. Paul, MN) is used to seal the surgical field from the surrounding areas including the axilla.