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Surgical Technique
CLAVICLE OPEN REDUCTION
AND INTERNAL FIXATION
INDICATIONS
• Fractures of the clavicle shaft
• Malunions of the clavicle
• Non-unions of the clavicle
TABLE OF CONTENTS
3 PATIENT POSITIONING
4 SURGICAL APPROACH/EXPOSURE
4 FRACTURE REDUCTION
5 PLATE SELECTION
6 PLATE CONTOURING
7 SCREW FIXATION
8 CLOSURE
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1 PATIENT POSITIONING
The patient is placed in a beach chair position. The following order ensures a
secure patient. Flex the middle of the table; then slight trendelenburg; flex again
IMPORTANT
Proper patient positioning and
until the back is about 60 degrees to the floor; finally drop the feet to slightly
draping are essential to facilitate
below parallel. Slide the patient’s involved lateral chest wall until it is parallel to
exposure and ease of upper
the table with the entire arm free to move off the table. Place a double sheet or
extremity manipulation throughout
bolster under the involved scapula to lift slightly off the table, which facilitates
the procedure.
posterior draping. The head is secured in a neutral position, slightly turned to
the opposite side. Great care is necessary to secure the head in this position
with a head holder or taped over padding. A scalene block is preferred with or
without general anesthesia.
The arm is prepped and draped in a sterile fashion such as with a medium
impervious stockinette wrapped in Coban (3M) to the mid-biceps area. Multiple
U-drapes are secured to expose the clavicle to the mid-line medially, below
the spine of the scapula posteriorly; and just below the chin medially. Take
precaution to avoid draping too far laterally as it is not uncommon to need to
extend the incision medially for comminuted fractures.
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2 SURGICAL APPROACH/EXPOSURE
After outlining the entire clavicle, including the fracture pattern, the acromion
and the distal superior border of the scapular spine, make an incision at the
IMPORTANT
When treating comminuted
inferior border of the clavicle, centered at the fracture. Extend through the thin
fractures, care should be taken to
plastysma muscle and identify it for later closure, as failure to do so can result in
maintain soft tissue attachments
inadequate soft tissue over the repair in addition to producing asymmetry with
to all fragments when possible to
neck motion. It is difficult to avoid cutting one or more supraclavicular sensory
promote bone healing.
nerves, so patients should be informed of likely variable anterior chest numbness
postoperatively. Follow the pectoralis fascia to its insertion on the inferior border
of the clavicle and use sharp dissection of the periosteum to expose the medial
and lateral fracture ends. The medial end is usually more superficial and the
first edge to be palpated, as the distal fragment is often still attached to the
strong coracoclavicular ligaments. If it is not possible to maintain soft tissue
attachment to any smaller comminuted fragments, place them in sterile saline
on the back table for later reconstruction.
3 FRACTURE REDUCTION
Reduction is facilitated by the surgeon elevating and manipulating the upper
extremity to bring the fracture ends together. This restores normal length and
anatomic curvature to the clavicle. An assistant can hold the large fragments
NOTE
Manipulation of the arm and
shoulder may assist in reduction.
in reduction with the bone forceps. Any butterfly fragments should be
reassembled and secured to the larger fragment with 2.5mm fragment screw
NOTE
fixation (1.9mm drill bit and guide) if possible, to reduce the fracture pattern
Instrumentation for the 2.5mm
to two fragments. The screws can be countersunk and the headless design
fragment screws is color coded
allows for placement under the plate.
gold for ease of identification.
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PLATE SELECTION
Select the proper length plate to allow at least three screw holes/slots with six
IMPORTANT
cortices of fixation on each side of the fracture.
With comminuted fractures, a
The plate is placed with the more rigid central portion over the fracture site and
longer plate is required to span
the fragments and still provide at
may be rotated or moved in any direction to find the best stable provisionary fit.
least three screw holes/slots and
Placement is not limited to any one surface.
six cortices of fixation on each
side of the comminuted area.
NOTE
When used on mid-shaft fractures,
the plate has the unique advantage
of not requiring pre-bending or
removal for intraoperative bending
after provisional placement on the
reduced fracture. Screw insertion
will contour the plate ends to the
bone and produce a low profile
final position.
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5 PLATE CONTOURING
For most fractures, the bone plate may be placed on the clavicle in the flat
condition and allowed to self-contour as the bone screws are inserted and
tightened from the center outward, medially and laterally. The final position
will often find the plate on two or three surfaces, adding to stability.
NOTE
The self-contouring feature of
the plate eliminates the need to
remove the plate for bending. Once
the provisionary fit is determined,
The plate may be contoured with the bending irons for malunions and
screw insertion may begin.
surgeon preference.
IMPORTANT
Avoid sharp bends and bending
the plate back and forth as these
can weaken the plate.
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6 SCREW FIXATION
Use the 2.4mm drill bit and drill guide to predrill bicortically for the 4mm bone
screws. Use caution not to plunge through the inferior surface of the clavicle
IMPORTANT
The subclavian vein lies in close
as the subclavian vein is in close proximity under the medial half of the clavicle.
proximity to the inferior surface
Proper screw length is determined using the depth gauge. The depth gauge
of the clavicle in its medial half.
is designed to insert through the plate hole or slot and rest directly on the near
Avoid excessive drill and screw
cortex of the clavicle to achieve the correct reading. To ensure that a full diameter
penetration beyond the distal
screw thread is engaging the far cortex, select the next longer screw length.
cortex, while protecting with an
inferior retractor.
NOTE
The drill guide is also designed to
insert through the plate hole or slot
when drilling for the bone screws.
The plate can be held in place with a bone clamp and the first screw is placed as
close to the fracture as possible in a way that will solidly catch two cortices. This
screw is not tightened completely at this point. The second screw is now placed
on the opposite side of the fracture and fully tightened. The first screw is now
fully tightened. One or both ends of the plate may be raised from the clavicle or
extend anteriorly or posteriorly. There is no need to remove and bend the plate.
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6 SCREW FIXATION (continued)
Continue to insert the remaining screws working toward both ends of the plate.
NOTE
The screws placed toward the ends of the plate will be inserted with angulation,
Drill the screw holes (through
relative to the plate, to bend and twist the plate into anatomic conformance with
the plate hole or slot) at an angle
the surface of the clavicle. Drill the screw holes according to classic AO technique.
roughly perpendicular to the
bone surface. This is particularly
important at the ends of the plate
where the bone surface and
plate surface may not be parallel.
Screws placed in this manner will
bend and twist the plate to meet
flush with the clavicle.
NOTE
As successive screw insertion
contours the plate, previously
inserted screws may require
retightening. Check all screws
(Drill Guide omitted for clarity.)
prior to closing.
Check and retighten all previously inserted screws with each new screw insertion.
With a comminuted fracture, the area of comminution may be too fragmented
to engage with bone screws, and the screw holes above the fragments
commonly remain empty.
7 CLOSURE
After copious irrigation with a pulse lavage, close the periosteum and
reattach the pectoralis fascia, followed by closure of the platysma and
skin. Sling immobilization for comfort for the first week.
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