Clavicle, shaft: spiral wedge fracture—15-B1

10.1055/b-0034-87609

Clavicle, shaft: spiral wedge fracture—15-B1

Vajara Phiphobmongkol

Case description

A 21-year-old man was transferred from another hospital 1 day after being injured in a road traffic accident. He sustained a fracture of the midshaft of the right clavicle associated with a fracture of the right proximal humerus.

Indication for MIPO

Ipsilateral fractures of the clavicle and humeral neck (“floating shoulder”) are indications for surgical stabilization. This clavicle fracture had a spiral wedge fragment. MIPO was indicated to bridge the main fragments of the clavicle with a plate to preserve the vascular supply to the wedge fragment.

a Fracture of the middle third of the shaft of the right clavicle (15-B1). b Fracture of the right proximal humerus (11-A3).

Preoperative planning

Both clavicle and proximal humeral fractures were planned for fixation during the same operation. The fracture of the proximal humerus is treated with a locking proximal humeral plate (LPHP). This can be done before or after fixation of the clavicle. The fixation method of the proximal humerus is not described here.

The fracture of the right clavicle is fixed with a contoured LCP reconstruction plate 3.5 using MIPO technique. Templating can be performed preoperatively to determine the length and position of the LCP ( Fig 11.3-2 ), or intraoperatively. A plastic clavicle bone model is used as a template and bending pliers are used to contour the selected plate to the superior surface of the clavicle. The plate is then sent for sterilization.

For unstable fractures, as in this case, reduction and maintaining reduction can be difficult, so a set of small external fixators was then chosen and prepared. Refer to the reduction technique described and images provided in chapter 11.1, 6.3 Step-by-step operative procedure for the planning.

a LCP reconstruction plate 3.5 placed against the plastic bone model before contouring. b S-shape of contoured plate.

a–b Bending pliers are used to contour the plate for the superior surface of the clavicle. Drill sleeves are inserted into the threaded holes of the plate during contouring to prevent deformation and damage of the threaded holes. c Plate shape after contouring.

Operating room setup

Anesthesia

General anesthesia with positive pressure ventilation is the preferred technique for operative fixation of clavicular fractures.

Patient and image intensifier positioning

The patient is positioned supine on a radiolucent operating table. The C-arm is positioned to approach from the opposite side to the injury, allowing space for the surgeon to stand with clear access to the injured side.

All C-arm images, AP, cephalad, and caudad tilt are checked and when sufficient, the operation can proceed. (Images were also checked for the proximal humerus which was fixed here.) The whole upper extremity of the injured side is prepared and draped so that it can be mobilized freely during the operation.