- indications for surgery:
- open fracture
- gross displacement of fracture w/ tenting of skin
- fractures w/ signficant medialization (causing medialization of the shoulder girdle);
- ref: Fixation of Displaced Midshaft Clavicle Fractures in Skeletally Immature Patients
- surgical considerations:
- subclavian artery (axillary artery begins as it crosses the first rib)
- brachial plexus (esp lower trunk damage (C8, T1);
- look for posterior cord injury
- Injury to the brachial plexus by a fragment of bone after fracture of the clavicle.
- Clavicular caution: An anatomic study of neurovascular structures.
- Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report.
- floating shoulder:
- multiple authors have reported excellent results with healing rates greater than 99% for variety of immobilization techniques;
- incidence of nonunion, malunion, NV complications total < 1%;
- single disruptions of SSSC have uniformly good results with nonoperative treatment;
- double disruptions of SSSC are a combination of innocuous injuries which create instability for UE best surgically treated
- ORIF simpler fracture reduces other injury satisfactorily
- Surgical Choices:
- intra-medullary clavicular fixation:
- Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting..
- plate fixation: (Synthes Clavicle Products)
- consider unicortical fixation with a Synthese 3.5 mm pelvic reconstruction locking plate (unicortical
screws will not risk injury to the deep neurovascular structures; (axillary artery)
- post op exam includes neurovascular check - check for full abduction and ext rotation (inorder to
test for thoracic outlet syndrome);
- careful to note potential vascular complications;
- A radiological study to define safe zones for drilling during plating of clavicle fractures
- Safe drilling angles and depths for plate-screw fixation of the clavicle: avoidance of inadvertent iatrogenic subclavian neurovascular bundle injury.
- Patient Position Is Related to the Risk of Neurovascular Injury in Clavicular Plating: A Cadaveric Study.
- The Anatomy of the Clavicle and its In Vivo Relationship to the Vascular Structures: a 2D and 3D Reconstructive Study using CT Scans.
- advantages of anteroinferior plating:
- include less hardware prominence and the ability of the surgeon to direct instrumentation away from infraclavicular
- Anteroinferior plating of midshaft clavicular nonunions.
- Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.
- Neurovascular Risks of Anteroinferior Clavicular Plating
- Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating
- Anterior-inferior plating of middle-third fractures of the clavicle
- Superior versus anteroinferior plating of the clavicle revisited: a mechanical study
- superior plate fixation:
- provides better stability at the fracture site;
- ref: Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study.
Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle
Open reduction and internal fixation of clavicular fractures.
Low-contact dynamic compression plating of the clavicle.
Fractures of the distal clavicle: a case for fixation.
Osteosynthesis of irreducible fractures of the clavicle with 2.7-MM ASIF plates.
Plating of fresh clavicular fractures: results of 122 operations.
Late-onset brachial plexus paresis caused by subclavian pseudoaneurysm formation after clavicular fracture.
Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial.
Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails.
Anomalous external jugular vein: clinical concerns in treating clavicle fractures
Axillary artery pseudoaneurysm after plate osteosynthesis for a clavicle nonunion: A case report and literature review
Anatomic relationships after instrumentation of the midshaft clavicle with 3.5-mm reconstruction plating: an anatomic study.
Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials.
Hook plate fixation of acute displaced lateral clavicle fractures: mid-term results and a brief literature overview
- Non Union following surgery:
- Nonunion after clavicle osteosynthesis: High incidence of Propionibacterium acnes.