Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 mbdmedical.com 2 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. mbdmedical.com 3 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. mbdmedical.com 4 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. mbdmedical.com 5 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. mbdmedical.com 6 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. mbdmedical.com 7 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. mbdmedical.com 8 52 Highland Avenue, Suite B • Bethlehem, PA 18017 T. 610.954.7901 • F. 610.954.7904 • mbdmedical.com CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. CST-001, Rev. A