Elsevier

Injury

Volume 36, Issue 10, October 2005, Pages 1166-1171
Injury

A new approach for plate fixation of midshaft clavicular fractures

https://doi.org/10.1016/j.injury.2005.03.007Get rights and content

Summary

The majority of midshaft clavicle fractures unite uneventfully. Although the indications for operative intervention are limited and reported complication rates high, there are circumstances in which surgery is required. We describe a new, infraclavicular surgical approach to the clavicle used in a series of 89 patients over 9 years. Average time to union was 13.5 weeks. There was one case of deep infection and one of non-union, both of which resolved with further treatment. These results compare very favourably with previously published series and we submit that this operative approach allows safe management of an otherwise potentially hazardous procedure.

Introduction

Fractures of the clavicle are common, the incidence having been recently shown to be 29.3 per 100,000 of adult population per annum, 69.2% of these being in the midshaft.15 These injuries have traditionally been treated conservatively as Neer, in 1960, suggested that only 0.1% of clavicle fractures treated non-operatively fail to unite.12 More recent work, concentrating on midshaft clavicle fractures in adults has revealed a far higher rate of non-union (15%) and patient dissatisfaction with the final result (31%) with conservative management.8

Accepted absolute indications for surgical intervention in midshaft clavicle fractures include open fractures and fractures associated with skin compromise, neurological or vascular injury.14 Relative indications are fractures with greater than 20 mm of shortening,8 wide displacement of fragments2, 16 for patients with associated chest injuries on the intensive care unit, high-energy injuries, a floating shoulder and ununited fractures.1, 3, 4, 5, 6, 7, 9, 10, 13, 17

Despite these indications suggesting that up to 15% of midshaft clavicle fractures may require operative intervention, surgery for these injuries has a bad reputation because of the reported high complication rate (23% or more), particularly infection, wound breakdown, non-union and implant failure.2, 11, 17

The high incidence of complications encountered via the traditional direct surgical approach to the clavicle led the senior author (ADP) to develop an infraclavicular approach. This aims to preserve soft tissue attachments and allow for the wound to not be in contact with the plate, whilst maintaining good surgical access and providing a more cosmetically acceptable scar.

Section snippets

Patients and methods

Between January 1992 and March 2001, approximately 3000 patients attended the Norfolk and Norwich Hospital with clavicle fractures. Eighty-nine underwent surgical treatment for midshaft clavicle fractures using the infraclavicular approach. Four patients failed to attend for follow-up, three were transferred to other hospitals and one died of causes unrelated to the clavicle surgery. This left 81 patients with complete follow-up data. The average age of these patients was 34.4 years (S.D.

Technique

Under general anaesthesia, the patient is placed supine in the beach-chair position with 20° head up and the head on a head ring. The head is turned and the neck flexed away from the side of the operation to allow for ease of instrumentation. A sand bag is placed behind the shoulder at the midpoint of the clavicle. The surgical field is prepared and the patient draped allowing access to the clavicle. By pushing gently in the supra-clavicular fossa with the ulnar border of the hand, the skin of

Results

All patients were followed up until clinical and radiological union had occurred. We defined radiological union as visible bridging callus or absence of a visible fracture line. The average time to union was 13.5 weeks (S.D. 7.2 weeks). There were two major complications. In one patient treated for non-union, the reconstruction plate broke at 2 months and the fracture again failed to unite. A revision procedure was performed, using a DCP with iliac crest autograft and the fracture united 18

Discussion

In Neer's original series,12 only three of 2235 (0.1%) clavicle fractures treated conservatively failed to unite. Two of 45 (4.6%) treated operatively failed to unite. He stated that “the most important causal factor in non-union of fractures of the middle third has been improper open surgery. Local tissue damage, soft part stripping, removal of valuable bone, inadequate internal fixation and infection were frequent features of these operative procedures.” This paper is often used as an

References (17)

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    Citation Excerpt :

    Advantages of inferior plate placement include a stable fixation directed away from infraclavicular vessels (Collinge et al., 2006) and low incidence of implant prominence problems (Collinge et al., 2006; Kloen et al., 2002; Stufkens & Kloen, 2009). In the largest series, Coupe et al. (2005) treated 89 patients with non-locked inferior plating, with one reported case of infection and one of non-union (complication rate of 2.2%). Collinge et al. (2006) reported one fixation failure, one non-union, and two hardware removals (6.8% complication rate) in 58 patients with midshaft fracture treated with 3.5 mm locked reconstruction plates.

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