Midshaft Clavicle Injuries: Operative Management



Fig. 7.1
Zanca view : beam directed with 10° of cephalic tilt providing excellent visualization of AC joint



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Fig. 7.2
Quesana view : beam pointed 45° superior and 45° inferiorly to assess amount of displacement


Two commonly accepted classifications for clavicle injuries are the AO/OTA, which divides clavicle fractures in three subtypes according to the location of the fracture line and the Robinson Classification which adds variables of proven diagnostic value such as comminution, displacement, or intraarticular extension (Fig. 7.3).

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Fig. 7.3
Robinson’s classification



Management



Mid-shaft Clavicle Fractures (AO/OTA 15-B)


This is by far the most common fracture type and where the bulk of literature focuses to find out whether the operative or non-operative treatment is most adequate.


Operative Versus Non-operative Management of Mid-shaft Clavicular Fractures


Traditionally, middle third clavicle fractures have been treated non-operatively with sling or Figure-of-Eight brace immobilization. Neer and Rowe reported acceptable results of conservatively treated mid-shaft clavicle fractures [1, 3]. Hill et al. were the first to report unsatisfactory functional results in patients who underwent non-operative treatment for displaced mid-shaft clavicle fractures [11]. The authors argued that open reduction and internal fixation (ORIF) would be the preferred treatment in these cases. In 2006, the first randomized control trial (RCT) performed on this topic by McKee [4] yielded better DASH scores and a lower nonunion rate in patients who underwent ORIF of their displaced mid-shaft clavicle fractures. The reoperation rate for the surgical group was 12%, with irritation of the implant the most common cause for reoperation. In 2007, a meta-analysis [12] by the Canadian Orthopedic Society showed that the majority of clavicle fractures managed non-operatively had normal motion and strength. In a meta-analysis of RCTs, Mckee [6] later found that operative treatment significantly reduces the incidence of nonunion and symptomatic malunion. Nevertheless, the study failed to demonstrate superior long-term outcomes of operative treatment versus non-operative care. Robinson [7] asserted that ORIF reduces the rate of nonunion. However, they reported that the improvement in functional outcomes associated with surgery appears to result from plate fixation as the mechanism of nonunion prevention (Figs. 7.4a, b and 7.5a–d).

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Fig. 7.4
(a) Injury film of acute displaced mid-shaft clavicle fracture . (b) Two months follow-up showing callus formation and satisfactory healing


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Fig. 7.5
(a) Injury film of displaced mid-shaft clavicle fracture . (b) Fixation with lag screws and neutralization plate. (c) Follow-up showing fracture healed. (d) Removal of painful hardware once fracture healed

The problem remains that 25% of patients develop a nonunion or a symptomatic malunion [12]. The goal of the surgeon is to identify these patients in the acute setting and treat them with ORIF.

The economics of treating these fractures is another variable that should influence our surgical decision making. In 2010, Pearson [5] published in a multicenter RCT that surgery for displaced mid-shaft clavicle fractures was not cost-effective. One major advantage of operative treatment in actively employed patients is a significantly earlier return to work, thus minimizing loss of income, and a decreased usage of pain medication [13, 14]. Conversely, Walton et al. [15] reported that in unemployed individuals, initial non-operative treatment followed by delayed operative treatment only as needed is less costly than initial operative fixation.

Fixation of clavicle fractures is an elective procedure that is technically easier to perform within 2 weeks of injury. Das et al. [16] showed that there is no difference in long-term clinical outcomes whether the fracture is fixed within 3 weeks of injury or between 3 and 12 weeks post-injury. While outcomes are no different, the procedure becomes technically more challenging due to scarring and early callus formation.


Indications for Operative Treatment


Absolute indications for surgical fixation include open or impending open fractures, and neurologic or vascular compromise. Relative indications for surgical treatment include displaced fractures, shortening of two or more centimeters, comminution, poly-trauma, high level athletes, and symptomatic nonunion or malunion [8] (Table 7.1).


Table 7.1
Surgical indications for displaced mid-shaft clavicle fractures































Absolute

Relative

Open injury/impending open

>2 cm displacement

Neurologic or vascular compromise

Comminution

Floating shoulder

Cosmesis/patient discontentment
 
Polytrauma
 
Athletes
 
Seizure disorder
 
Painful nonunion or malunion


Factors Linked to Failure of Conservative Treatment


Robinson [9] and Zlowodzki et al. [17] showed that there are certain patient- and fracture-specific characteristics that when present predispose to poor outcomes in conservatively treated middle third clavicle fractures. Fracture-specific characteristics that have been shown to lead to poor outcomes include displacement, shortening greater than or equal to two centimeters, and comminution. Patient-specific characteristics associated with poor outcomes include female sex, advanced age, and use of tobacco products.


Surgical Techniques



Plating

Open reduction and internal fixation can be achieved with superior or anterior-inferior plate positioning. Newer plate technology allows for pre-contoured plates that are lower profile and allow locking fixation in selected cases.

The surgical approach for clavicle fractures is done with the patient in the supine position with the head of the bed elevated approximately 30°. Prior to the surgical incision, an image intensifier is positioned to allow for both AP and cephalic tilt views of the clavicle. A linear incision is made parallel to the clavicular shaft. Full-thickness skin and subcutaneous flaps should be raised to the level of the platysma. The platysma is divided in order to expose the fractured clavicle. When anterior-inferior plating is the preferred method, the insertions of the pectoralis major and deltoid are released subperiosteally to allow for application of the plate. The senior author prefers anterior-inferior plating when possible due to decreased incidence of soft tissue irritation and necessity of hardware removal [18].

Fracture reduction requires restoration of length, rotation, and angulation of the clavicle. The fracture ends are identified and when possible, serrated clamps are used to provisionally hold the fracture reduced. In cases in which the fracture line is transverse, a pointed tenaculum can facilitate reduction of the fracture. Fracture reduction is often maintained through the use of mini-fragment screws. This technique is ideal in oblique fractures and in those with large butterfly fragments (Fig. 7.5a–d). Commercially available pre-contoured plates fit a large portion of the population and are lower profile, which lessens plate prominence and may reduce the chance of plate removal [19].

When open reduction with plate fixation is elected, the next decision the surgeon must make is where to place the implant. Over the past decade, anterior-inferior clavicle plating for the treatment of displaced mid-shaft fractures has become increasingly popular. Good results have been reported with both superior and anterior-inferior plating locations; however, the literature provides mixed data regarding which position makes the construction more stable [18, 20, 21]. Iannotti et al. [22] found that 3.5 mm Recon plates applied superiorly provided stiffer and more rigid constructs, but did not find any differences in load to failure between positions. A recent study from Partal and George [23] in a saw bones model reported no difference in axial or torsional stiffness, but a more stable bending stiffness for the AI plating. Favre [24] found that AI plating is less likely to fail during normal physiological loading. Additionally, AI plating is thought to decrease the risk of neurovascular damage since drilling in the anterior-inferior to posterior direction presumably keeps the screws away from the underlying neurovascular bundle. However, the current literature evaluating this theory in detail is inconclusive regarding which location is safer with regards to screw proximity to the adjacent neurovascular structures [25, 26]. Patients undergoing superior plating are more likely to complain of implant prominence and it was recently reported that the anterior-inferior plating significantly decreases the rate of secondary intervention, thus reducing the costs and risk of an additional surgery [2729].


Intramedullary Fixation

Given the rate of implant prominence and need for subsequent hardware removal seen with plate fixation of clavicle fractures, there has been renewed interest in intramedullary fixation. Recently, two RCTs [30, 31] compared intramedullary versus plate fixation and found similar DASH scores at 1 year follow-up, comparable time to union, and similar complication rates. However, intramedullary devices (cannulated screws, flexible nails, and clavicle specific pins) have been shown to be biomechanically inferior to plates, especially with increasing comminution [32]. When compared to non-operative treatment, intramedullary fixation yields higher union rates and DASH scores. Nonetheless, the rate of medial protrusion of the nail has been reported to be as high as 18% [33, 34]. The use of small diameter smooth pins is contraindicated due to the potential for pin migration.


Distal Third (AO/OTA 15-C)


Fractures of the lateral third account for 10–15% of clavicle fractures. Neer classified them in three types. Type I, occurs lateral to the coracoclavicular (CC) ligaments. The mainstay of treatment in this group is conservative. Type II fractures are divided in two subsets. Type IIA with the fracture line medial to intact CC ligaments and, Type IIB with the fracture occurring either between a ruptured conoid and intact trapezoid, or lateral to both ligaments torn. Type II fractures have an inherent high rate of nonunion (22–42%) when treated with closed methods [3539] due to distraction of the proximal fragment by the muscle attachments. Therefore, a more aggressive approach is recommended. The use of a superior locked plate with reconstruction of the CC ligaments in the acute setting results in a high fracture union with a low rate of complications [40]. Hook plate fixation [41] is a valid alternative, but often requires reoperation for implant removal due to irritation of the subacromial bursa and superior rotator cuff. Surgical intervention may be deferred in low demand patients as many of these patients will go on to develop asymptomatic nonunion [3639]. Type III corresponds to intra-articular fractures of the AC joint with stable CC ligaments. As the ligamentous structures remain intact, nonoperative treatment is preferred.

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Jan 18, 2018 | Posted by in RHEUMATOLOGY | Comments Off on Midshaft Clavicle Injuries: Operative Management

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