Midshaft Clavicle Fractures: Operative Indications

Benton Heyworth, MD

Open fracture
Tented skin at risk of necrosis and open fracture (Figure 2-1)
Neurovascular injury
Floating shoulder girdle
Polytrauma (relative)
Completely displaced fracture with comminution and significantly “droopy” appearance of the shoulder (relative)
Comminuted fracture with vertical butterfly (relative)
Completely displaced fracture with significant (>2 cm) shortening in overhead athlete (relative)

Positioning

The patient can be positioned supine on the solid radiolucent table with a bump behind the scapula. However, the standard table in a “sloppy” beach chair (40°-50°) position with patient centered enables fluoroscopy of clavicle (more lateral placement can place clavicle over a radiopaque bar on the side of the standard OR table). We prefer this 45° beach-chair position as it (1) has less anesthetic risk for cerebral flow hypotension or air embolus than full beach-chair sitting position; (2) still diminishes venous congestion in neck; (3) allows for excellent surgical exposure and fluoroscopy views; and, (4) allows protection of brachial plexus and artery while exposing fracture (Figure 2-2).

Surgical Approach

Skin incision 1 to 2 cm below clavicle in Langer’s lines with proximal soft tissue dissection (critical for avoidance of scar lying over plate, which is a risk factor for post-operative, symptomatic hardware) (Figure 2-3)
Expose and protect supraclavicular cutaneous nerves as they descend across clavicle (generally 1-3 branches will be encountered)
Incise and later repair platysma

Figure 2-1 ▪ A and B, Two clinical views of displaced diaphyseal clavicle fracture butterfly fragment tenting the anterior skin.
Subperiosteal exposure of proximal and distal fracture fragments
- Essential to maintain soft tissue attachments to butterfly free fragment(s)
During drilling, utilize malleable retractors, Homan/Bennett retractors, or Cobb elevators behind/under fragments to protect underlying essential neurovascular structures

Figure 2-2 ▪ A and B, 90° fluoroscopic views of the standard OR setup in modified beach-chair position for ORIF clavicle.

Figure 2-3 ▪ Incision marked below the clavicle and fracture site.

Technique

Reduce fracture
- This may include carefully untwisting butterfly fragment(s) while maintaining soft tissue attachment to enhance biologic healing, lessen nonunion risk, and restore longitudinal anatomy of the clavicle
Apply reduction clamps to align fracture anatomically (Figure 2-4)
For comminuted fractures, utilize an extra implant with either a temporary smooth small diameter wire or a permanent lag screw (2.0, 2.7, or 3.5 mm) to fix free fragment(s), thereby reducing 3-or 4-part fracture to a 2-part fracture (Figure 2-5)
Place appropriate-sized plate with at least four cortices screw fixation planned on each side of the fracture (Figure 2-6). Bend as necessary to fit bone (Figure 2-7).
- Usually plate is placed superiorly, with screws oriented superior to inferior
- At times, specialty “anterior” plates can be placed anteroinferior to clavicle
- Given high rates of union with clavicle fractures, particularly in adolescents, extended, more rigid fixation is rarely needed, and increases chances of symptomatic hardware or eccentric plate placement. Therefore, shorter plates (6-hole, 7-hole, or, rarely with comminuted fractures, 8-hole plates) are preferred.
Careful drilling, depth measurement, and compressive screw fixation
- Use malleable retractors or Cobb elevators inferior and posterior to clavicle inside the periosteal layer to help prevent over-penetration drilling or screw(s) fixation that puts neurovascular structures at risk and/or results in screw irritation postoperatively (Figure 2-8)
- Eccentric compressive drilling and screw placement will compress fracture fragment(s) and lessen risk of delayed healing or nonunion

Fluoroscopy views (AP, 40 cephalad) or standard portable X-ray views (AP, 40′ cephalad) to confirm desired fracture fixation and hardware placement (Figure 2-9)

Figure 2-4 ▪ A, Open reduction with manipulation of fracture reduction with bone clamps. B, Temporary smooth wire passed to maintain reduction while preparing plate for fixation.

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