A new approach for plate fixation of midshaft clavicular fractures
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
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Cited by (44)
Surgical Treatment Options
2018, Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to SportSurgical treatment options: Mid-shaft fracture
2017, Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to SportAnteroinferior versus superior plating of clavicular fractures
2016, Journal of Shoulder and Elbow SurgeryThe comminuted midshaft clavicle fracture: A biomechanical evaluation of plating methods
2011, Clinical BiomechanicsCitation 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.
The use of precontoured plates for midshaft clavicle fractures is not always the best course of treatment
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