Open Reduction and Internal Fixation of Clavicle Fractures
Laura E. Scordino, MD
Thomas M. DeBerardino, MD
Dr. DeBerardino or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Genzyme, and the Musculoskeletal Transplant Foundation; serves as a paid consultant to or is an employee of Arthrex; serves as an unpaid consultant to Advanced Biomedical Technologies; has stock or stock options held in Advanced Biomedical Technologies; and has received research or institutional support from Arthrex and the Musculoskeletal Transplant Foundation. Neither Dr. Scordino nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
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Clavicle fractures are common, accounting for 2.6% to 5.0% of adult fractures.1,2,3 Historically, clavicle fractures were thought to heal with predictability while being managed almost exclusively nonsurgically. This treatment was based largely on two retrospective studies performed in the 1960s by Neer4 and Rowe5 that suggested that surgical treatment actually resulted in an increased number of nonunions and complications compared with nonsurgical treatment.
Today, with improved surgical techniques, growing evidence indicates that early surgical treatment may be beneficial in appropriately selected patients. In fact, in a recent prospective multicenter randomized clinical trial by the Canadian Orthopaedic Trauma Society,6 a comparison of nonsurgical treatment and plate fixation of midshaft clavicle fractures revealed that plate fixation resulted in significantly better radiographic outcomes; Constant scores; Disability of the Arm, Shoulder, and Hand (DASH) scores; functional outcomes; and cosmetic scores.
Clavicle fractures are generally classified based on the location of the fracture within the clavicle as well as the degree of comminution and angulation. The classification devised by Allman7 is commonly used; it categorizes clavicle fractures as proximal, midshaft, or distal. The location of the fracture within the clavicle and the degree of displacement, angulation, and comminution all play a role in determining treatment recommendations.3,8,9
Overall, fractures of the midshaft make up about 70% to 80% of all clavicle fractures, whereas those of the lateral or distal portion make up approximately 21% and medial-end fractures approximately 2% to 3%.1,8,9,10 Midshaft fractures occur more commonly as a result of high energy and in a younger patient population and are more commonly displaced, whereas lateral and medial-end fractures occur more commonly in the elderly and are nondisplaced.2,8,9
Overall surgical indications include open fractures, “floating shoulder,” impending skin necrosis, associated neurovascular injuries, and multiply injured trauma patients.3,8 More recently, studies have suggested that improved outcomes are associated with surgical fixation of fractures with shortening greater than 15 to 20 mm, with 100% displacement, or with comminution.6
Orthogonal views of the clavicle are the best means of evaluating the fracture. The fracture should be evaluated for location within the clavicle, displacement, comminution, angulation, and associated fractures to the scapula and the proximal humerus. Evaluation of an AP radiograph of the chest should include not only the clavicle fracture itself but also associated chest injury, including rib fractures, pneumothorax, or hemothorax.
Other views that can supplement the initial views include the apical oblique view (affected shoulder tilted 45° anterior and x-ray beam 20° cephalad), which may help diagnose minimally displaced fractures.11 This view also can help in judging the adequacy of reduction in the operating room. The abduction lordotic view (x-ray beam angled 25° cephalad with shoulder abducted above 135°) is useful to evaluate healing after internal fixation.12 Other radiographs that may be obtained include a stress view for a lateral clavicle fracture to evaluate for acromioclavicular joint separation and the integrity of the coracoclavicular ligaments.
In addition to radiographs, preoperative CT scans of the clavicle are being increasingly used. They are used particularly for evaluation of nonunions as well as medial-end fractures extending into the sternoclavicular joint.
Room Setup/Patient Positioning
The surgical technique for midshaft clavicle fractures is described here. Many surgical procedures are available for clavicle fracture fixation, depending on surgeon preference and fracture characteristics.