Open Reduction and Internal Fixation of Clavicular Fractures
Chapter 20
Open Reduction and Internal Fixation of Clavicular Fractures
J. Todd R. Lawrence
R. Justin Mistovich
DEFINITION
The clavicle, from the Latin clavicula, which means “little branch,” is possibly named for the similarly bent hoopstick Roman children used to trundle a hoop.
Pediatric clavicle fractures are one of the most common childhood injuries and the most common obstetric fracture.10, 13, 15
Clavicle fractures are classified by anatomic region: proximal third, middle third, and distal third. Pediatric clavicle fractures can also be physeal injuries, involving the medial or lateral physis. These injuries are the pediatric equivalent to adult acromioclavicular and sternoclavicular dislocations.9, 11
ANATOMY
The clavicle forms through intramembranous ossification laterally and endochondral ossification medially. Ossification begins at 4 to 6 weeks of gestation.
The medial secondary ossification center appears at 18 to 20 years of age and does not fuse until approximately 25 years of age.4
Thus, the clavicle is the first bone to ossify and the last bone to fuse.
The middle third of the clavicle is the thinnest portion of the bone and subsequently is most likely to fracture.3 The platysma muscle covers the clavicle.
The subclavius, sternocleidomastoid, and pectoralis major insert onto the medial end of the clavicle, whereas the trapezius and deltoid insert onto the lateral end.
The acromioclavicular, coracoclavicular, costoclavicular, and sternoclavicular ligaments stabilize the clavicle and assist in its role as a strut connecting the axial and appendicular skeleton.
The supraclavicular nerves are deep to the platysma, providing sensation to the anterior chest wall.
The subclavian artery, subclavian vein, and brachial plexus are intimately associated with the inferior aspect of the medial clavicle.
PATHOGENESIS
Clavicle fractures most often result from a direct impact to the apex of the shoulder causing a lateral to medial compression.4
Because both the thinnest part of the bone and the change in shape from convex to concave occur in the middle third of the clavicle, fractures occur most commonly at this location.3
Obstetric-related fractures result from axial compression during birth and are correlated with higher birth
weight and forceps delivery.7
NATURAL HISTORY
Controversy remains in the literature regarding nonoperative treatment versus operative fixation of displaced midshaft clavicle fractures in the adolescent patient with studies supporting both modalities.2, 4, 5, 6, 8, 10, 12,
14, 16
Adult studies have demonstrated measurable shoulder dysfunction associated with shortening greater than 15 to 20 mm.
Some studies in adolescents have demonstrated no nonunions and no significant negative clinical results from nonoperative treatment even with greater than 2 cm of shortening.
Other studies in adolescents, however, have demonstrated negative effects on overall satisfaction, functional, and cosmetic scores when patients with shortened fractures were treated nonoperatively.
The risks and benefits as well as the most current literature should be discussed with patients and their families to reach a consensus regarding preferred treatment.
Nonoperative treatment may result in a bump at the site of union. This typically remodels over the subsequent 1 or 2 years but may remain prominent in some cases (FIG 1).
Significant malunions may result in brachial plexopathy secondary to compression.
PATIENT HISTORY AND PHYSICAL FINDINGS
Children with clavicle fractures will often use the contralateral arm to support the affected arm.
To minimize posterosuperior displacement by the sternocleidomastoid and trapezius, children may tilt their heads toward the fracture.
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FIG 1 • A. Radiograph of a shortened, displaced midshaft clavicle fracture that was treated nonoperatively in an adolescent. B. In a radiograph made at 2 months after initial injury, the patient has an exuberant healing response with callus and a resultant bump at the site of the fracture.
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FIG 2 • Patient with right clavicle fracture. A. Skin contusion with puckering and tenting and thus threatened pressure necrosis. B. Radiograph demonstrating the displaced, shortened middle-third clavicle fracture with the medial fragment spike approaching the skin. C. Radiograph after fixation and healing.
Carefully examine the skin for tenting or puncture (FIG 2).
Perform a full neurologic and vascular assessment of the involved limb to rule out brachial plexopathy or vascular injury.
Clavicle fractures in the neonate may present as a pseudoparalysis of the involved limb due to the pain associated with movement.
IMAGING AND OTHER DIAGNOSTIC STUDIES
An anteroposterior (AP) radiograph may not identify subtle fractures.
The modified Garth apical oblique view, obtained with 20-degree cephalic tilt and 45 degrees of chest rotation away from the film cassette, can be more effective at detecting nondisplaced middle-third fractures.
Rockwood's serendipity view, taken with 40-degree cephalic tilt, is helpful for visualization of medial third fractures.
The Zanca view, obtained with half-normal penetration and 15-degree cephalic tilt, is helpful to identify lateral physeal fractures.
Radiographs obtained with 45 degrees of caudal tilt can help identify AP displacement.
A radiograph of the bilateral clavicles can be helpful in estimating the degree of shortening as well as providing a comparison view for subtle deformities.
Although often not necessary to obtain a diagnosis, a computed tomography (CT) scan, if obtained as a component of a trauma workup, can help with understanding the three-dimensional nature of the deformity and may also demonstrate potential vascular compression.
DIFFERENTIAL DIAGNOSIS
Congenital pseudarthrosis of the clavicle: Almost all cases are on the right side unless situs inversus is present.
Cleidocranial dysostosis
Acromioclavicular or sternoclavicular sprain or dislocation
NONOPERATIVE MANAGEMENT
Over 200 nonoperative protocols have been described for clavicle fractures, but when nonoperative indications are met, a simple sling results in typically excellent outcomes.1
There is no benefit to a figure-of-eight brace over a sling.
A closed reduction should not be attempted, as there is no closed means to reliably maintain a reduction in addition to the potential for neurovascular injury.
SURGICAL MANAGEMENT
Although controversy remains regarding the proper modality of treatment with respect to displaced midshaft fractures, absolute indications for operative treatment include the following:
Open fractures Threatened skin necrosis
Multitrauma patients who would benefit from fixation for their ambulatory and transfer needs
Multiple methods have been described for operative fixation of clavicle fractures, including intramedullary pin or screw fixation, flexible intramedullary rod fixation, and superior and anterior plating.
Because of the small diameter of the medullary canal in the pediatric clavicle, intramedullary fixation can be technically difficult in the pediatric patient.
The authors' preferred technique in pediatric clavicle fracture fixation is plate fixation. The plate can either be placed superiorly or anteriorly.
Preoperative Planning
Review imaging studies to understand the fracture pattern and deformity.
Note that the pediatric clavicle may be too small to use standard precontoured clavicle locking plates. Reconstruction plates contoured to the specific patient are an excellent option. Measure appropriate dimensions on radiographs and ensure that a backup fixation system is available.
Positioning
The patient can be positioned either supine or in the beach-chair position. The authors prefer the beach-chair position for ease of obtaining imaging.
A rolled small towel can be placed between the shoulder blades to assist with obtaining the reduction and correct shortening.
The fracture is directly visualized, and C-arm should not be needed for reduction aid. Confirmatory C-arm imaging can be used during the case, and a flat plate x-ray can be obtained at the conclusion of the case if desired.
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TECHNIQUES
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Exposure
Make an incision in line with the long axis of the clavicle. This should be slightly anterior or inferior to the clavicle to avoid having the incision directly over the fixation hardware.
Incise the platysma, leaving clean margins to repair and cover the plate.
Identify and preserve the medial and lateral supraclavicular nerves. These branches will run perpendicular to the clavicle, just deep to the platysma.
Expose the fracture and enough of the preferred plating surface (anterior or superior) while taking care to preserve as much periosteum and soft tissue attachments as possible.
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Fracture Reduction and Plating
Taking care to avoid damage to inferior structures, reduction clamps may be used to facilitate reduction.
If the fracture pattern permits, a lag screw can be used for both holding reduction and improving the overall stability of the construct.
A plate can be fitted either anteriorly or superiorly.
Superior plating puts the inferior neurovascular structures at greater risk of potential injury with drilling screw holes (TECH FIG 1A,B).
Anterior plating requires partial detachment of the pectoralis major and deltoid origins and greater overall soft tissue stripping but may provide advantages with decreased hardware prominence (TECH FIG 1C,D).
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TECH FIG 1 • A. Radiograph of a shortened, displaced midshaft clavicle fracture. B. Postoperative radiograph demonstrating good healing following precontoured superior plate fixation. C. Radiograph of a shortened, displaced midshaft clavicle fracture in a different patient. D. Postoperative radiograph demonstrating good healing following anterior plate fixation.
Pediatric hardware considerations are as follows:
2.7-mm screws may be a better match than 3.5-mm screws for the size of the pediatric bone. A rule of thumb is that the screw should not exceed 33% to 40% of the width of the bone.
There should be at least six cortices of fixation on either side of the fracture. Given the relative good quality of pediatric bone, locking screws are not usually necessary.
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Closure
Close the platysma over the plate.
Close the subcutaneous tissue and skin in layers.
We recommend a running subcuticular closure with an absorbable stitch for cosmesis as well as ease of postoperative office management in the pediatric patient.
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PEARLS AND PITFALLS |
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Chest wall ▪ Attempt to preserve the supraclavicular nerves. hypoesthesia
Painful, ▪ Anterior plating may result in better cosmesis and less palpable hardware, prominent especially in patients with a smaller soft tissue envelope. hardware
Neurologic ▪ Use gentle reduction maneuvers to avoid brachial plexus neurapraxia. risks
Vascular ▪ Maintain steady control of the drill, avoid plunging when drilling screw holes, and |
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risks protect the inferior aspect of the clavicle with a retractor, especially medially. |
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POSTOPERATIVE CARE
A sterile dressing is placed. Patients are placed in a simple sling.
Patients remove the sling several times daily for gentle elbow, wrist, and hand range-of-motion exercises.
The sling is discontinued at 4 weeks. Patients may begin gentle shoulder range-of-motion exercises at 4 to 6 weeks.
Patients remain restricted from heavy contact activities, repetitive overhead activities, or any pursuit that puts them at risk for a hard fall for at least 3 months, until full clinical and radiographic healing has been observed.
Hardware removal is not required but can be offered to symptomatic patients at 1 year postoperatively.
OUTCOMES
Multiple authors have recorded excellent clinical outcomes in the pediatric population with high satisfaction rate and return to prior level of athletic performance.10, 12
These operative outcomes, however, must be viewed in the light of recent studies that report minimal functional deficits even in clavicle fractures with significant shortening and resulting malunion that were treated nonoperatively.2, 16
COMPLICATIONS
Prominent and symptomatic hardware, especially with backpack use or other shoulder straps is common following operative treatment and is often a reason for hardware removal.
Infection is rare and can be minimized with preoperative antibiotics, wound irrigation prior to closure, and meticulous soft tissue handling and closure.
Skin breakdown is a risk with the subcutaneous nature of the clavicle. Consider making the incision somewhat anterior and inferior so the healing wound is not directly over the prominence of the plate.
Neurovascular complications, although anatomically possible, are rare with gentle reduction and cautious drilling and screw placement.
Patients should be counseled preoperatively regarding the risk of chest wall numbness from injury to the supraclavicular nerves.
Nonunion is rare in the pediatric population. The clinical significance of malunion, especially as it relates to the results of nonoperative treatment, continues to be debated in the literature.
REFERENCES
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Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;58(1):71-74.
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Bae DS, Shah AS, Kalish LA, et al. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop 2013;33(5):544-550.
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Browner BD, Jupiter J, Levine A, et al. Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 3, vol 1. Philadelphia: Saunders, 2003.
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Caird MS. Clavicle shaft fractures: are children little adults? J Pediatr Orthop 2012;32(suppl 1):S1-S4.
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Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89(1):1-10.
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Carry PM, Koonce R, Pan Z, et al. A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members. J Pediatr Orthop 2011;31(1):44-49.
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Cohen AW, Otto SR. Obstetric clavicular fractures. A three-year analysis. J Reprod Med 1980;25(3):119-122.
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Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg 1997;79(4):537-539.
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Koch MJ, Wells L. Proximal clavicle physeal fracture with posterior displacement: diagnosis, treatment, and prevention. Orthopedics 2012;35(1):e108-111.
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Namdari S, Ganley TJ, Baldwin K, et al. Fixation of displaced midshaft clavicle fractures in skeletally immature patients. J Pediatr Orthop 2011;31(5):507-511.
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Ogden JA. Distal clavicular physeal injury. Clin Orthop Relat Res 1984;(188):68-73.
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Pandya NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in adolescents: facts, controversies, and current trends. J Am Acad Orthop Surg 2012;20(8):498-505.
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Park MS, Chung CY, Choi IH, et al. Incidence patterns of pediatric and adolescent orthopaedic fractures according to age groups and seasons in South Korea: a population-based study. Clin Orthop Surg 2013;5(3):161-166.
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Randsborg PH, Fuglesang HF, Røtterud JH, et al. Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years. J Pediatr Orthop 2014;34(4):393-399.
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Rubin A. Birth injuries: incidence, mechanisms, and end results. Obstet Gynecol 1964;23:218-221.
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Schulz J, Moor M, Roocroft J, et al. Functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fractures. J Bone Joint Surg Am 2013;95(13):1159-1165.