69 Open Reduction and Internal Fixation of Distal Clavicle Fractures
Abstract
Clavicle fractures account for approximately 4% of all fractures, with distal clavicle fractures comprising 15 to 20% of all clavicle fractures. Treatment of distal clavicle fractures is more complex than midshaft clavicle fractures due to the potential involvement of the coracoclavicular ligaments, the acromioclavicular ligament, and the close proximity to the acromioclavicular joint. Although most distal clavicle fractures can be treated nonoperatively, surgical management is indicated for widely displaced fracture fragments, as these are associated with increased risk of nonunion. During surgical treatment, hardware purchase in the distal fracture segment may prove challenging due to a limited area for fixation. This chapter reviews two preferred operative techniques for open reduction and internal fixation of distal clavicle fractures: anatomic distal plate fixation (with or without coracoid augmentation) and hook plate fixation. We review indications for operative intervention, technique for fixation, postoperative care, and pearls/potential pitfalls in practice.
69.1 Goals of Procedure
The goals of distal clavicle surgical fixation are to provide anatomic reduction and stable fixation, resulting in fracture union and return to function for the patient.
69.2 Advantages
69.2.1 Advantages: Anatomic Distal Clavicle Plate
Advantages of fixation of distal clavicle fractures using a distal clavicle plate include the anatomic contour of the plate and the ability to augment the construct with coracoclavicular fixation. No scheduled hardware removal is required with this technique, potentially limiting the number of surgical interventions required.
69.2.2 Advantages: Hook Plate
Advantages of using a hook plate include the ability to address fracture patterns in which the distal fragment is too small to provide adequate screw purchase. The stout fixation provided by the hook plate also allows for earlier initiation of shoulder motion.
69.3 Indications
Absolute indications for distal clavicle fracture fixation include open fractures, traumatic acromioclavicular (AC) joint arthrotomy, neurovascular injury, and impending skin compromise. Relative indications for surgical management include displaced distal clavicle fractures.
69.4 Contraindications
Contraindications for distal clavicle fracture fixation include fractures in patients not healthy enough to undergo operative intervention and minimally displaced fractures. Hardware implantation is also contraindicated in the presence of active infection.
69.5 Preoperative Preparation/Positioning
Open reduction and internal fixation (ORIF) of distal clavicle fractures is accomplished in either the supine or the beach-chair position and is based on surgeon preference. Supine positioning is a simple setup with easier fluoroscopic imaging, while the beach-chair position is more familiar to many surgeons. For supine positioning, the patient is placed on a reversed cantilever radiolucent table ( Fig. 69.1a, b). “Flat-top” radiolucent tables with support at the head and the feet make it difficult to obtain inlet and outlet images of the clavicle. If a flat-top table is used, the patient should be positioned as far distal on the table as possible, permitting maximum c-arm tilt. In the supine position, the patient’s operative shoulder is positioned on the edge of the bed and the patient’s nonoperative arm is tucked to the side of the body. The c arm is placed on the opposite side, perpendicular to the table. A radiolucent arm board can be attached to the table on the operative side and positioned against the side of the bed for operative extremity support. A small towel bump is positioned beneath the patient’s ipsilateral scapula and the patient’s head and neck are gently rotated away from the operative clavicle, improving access. The endotracheal tube should be secured on the opposite side of the involved clavicle and the sternal notch should be included in the prep and drape. The entire operative arm is prepped and draped free, permitting easy manipulation of the extremity during reduction and fixation. In the beach-chair position, the bed is elevated 30 to 45 degrees and the patient’s hips and knees are positioned in a gently flexed position and supported by a foam wedge or pillows ( Fig. 69.2 ). The bed is rotated 90 degrees so the c arm can be brought in either parallel to the table from above the patient or perpendicular from the side of the table to obtain adequate fluoroscopic views. With either position, the surgeon should confirm that adequate fluoroscopic views can be obtained before proceeding with sterile preparation and draping.
69.6 Operative Technique
69.6.1 Surgical Approach
The clavicle and AC joint are marked and an incision is made along the inferior border of the clavicle. The incision should extend laterally past the AC joint for adequate exposure. Before making the incision, preinjecting the incision line with a local anesthetic with epinephrine solution aids hemostasis. As the dissection proceeds through the subcutaneous tissues, sensory branches of the supraclavicular nerve are encountered crossing perpendicular to the surgical field. When possible, these branches are identified and preserved. In most cases, however, one or more of these branches must be sacrificed to obtain exposure, and patients must be counseled on the risk of postoperative anterior chest wall numbness. The fracture site is exposed by sharply elevating muscle fibers of the trapezius posteriorly and the deltoid anteriorly. Care should be taken to preserve soft-tissue attachments, when possible, to preserve osseous blood supply. The fracture hematoma is evacuated and the fracture edges are meticulously cleaned to obtain adequate visualization for reduction.
69.6.2 Fixation with Anatomic Distal Clavicle Plate
We recommend the beach-chair position when using this implant due to the ease of placing supplemental coracoid fixation if needed, and the ability to use a commercially available arm holder. Reduction of distal clavicle fractures can be challenging due to the firm coracoclavicular ligaments that are often attached to the distal fragment. This makes manipulation of lateral fragments difficult because they are less mobile than the fragments in a middle third pattern. Trying to reduce the lateral fragment, with the attached conoid and trapezoid ligaments, to the more superior medial fragment can result in comminution of the lateral fragment. The majority of the reduction force is therefore concentrated on reducing the more mobile medial fragment to the less mobile lateral fragment. Once the fragments are reduced and held with reduction forceps, lag screw fixation is performed if possible. The size of the fragments often requires smaller screw sizes, generally 2.4 or 2.7 mm in diameter. After provisional fixation, an anatomically contoured distal clavicle plate (Arthrex, Naples, FL) is placed superiorly in neutralization mode. These precontoured plates have a wide distal flare, permitting a cluster of smaller diameter screws to be placed into the distal fragment. Bicortical screw fixation is performed medially with nonlocking cortical screws, with at least six cortices (three screws) utilized. Distally in the smaller fragment locking screws are typically employed and a locking screw guide is used to drill before screw placement. If there is considerable comminution at the fracture site, but the distal fragment is large enough to accommodate appropriate screw fixation, the comminuted fragments are bypassed and the distal clavicle plate is used in a bridging fashion ( Figs. 69.3, 69.4 ).
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