Surgical Technique

Midshaft clavicle fractures require planning and careful manipulation

The clavicle plays a protective role in the upper body. When it is considered in that way, the need to treat clavicle fractures appropriately and in a timely manner takes on a whole new meaning since the clavicle has several muscles attached to it and it provides the framework for muscles surrounding the shoulder girdle. Its cosmetic appearance, with neurovascular structures right beneath it, is also critical for the orthopedic surgeon to recognize and appreciate.

Changing indications

When Charles S. Neer II, MD, studied these midshaft fractures in a large number of patients, 0.1% failed to heal. Carter R. Rowe, MD, noted in one of his reviews that healing was not a problem for clavicle fractures. Therefore, nonunion of midshaft clavicle fractures is a rare outcome. In fact, the orthopedic textbooks tend to focus mostly on the indications, which include neurovascular problems, skin tenting, older fractures or a floating shoulder.

However, these indications are changing in conjunction with the different types of injury mechanisms being seen, including more high energy injuries, and with the different types of patients who present with these fractures, many of whom have high expectations for their treatment.

Christopher S. Ahmad

Christopher S.
Ahmad

There is a new potential for problems with nonoperative treatment of clavicle fractures in some patients, particularly those who want guaranteed pain relief and demand that their normal function be restored.

As a result, there is interest in the features of individual clavicle fractures. More recent studies showed that nonunion rates with clavicle fractures can reach 25%. In addition, union does not necessarily mean a good result. There are newer, more sensitive scoring systems we can use to assess our patients’ outcomes more closely.

In research by Nowack and colleagues that involved more than 200 patients, the investigators identified the risk factors for poor outcome. In a 10-year period, they found that almost half of patients felt they were not fully recovered after a clavicle fracture. Many of them had pain. A large percentage was dissatisfied with the cosmesis of the shoulder girdle, and one-third noted they had weakness problems. Therefore, it is important to understand who is most at risk for such problems such as those patients with fractures with 15-mm to 20-mm shortening or vertically displaced fragments, which is a common fracture configuration.

Displacement is frequently reported with midshaft clavicle fractures, where contact between medial and lateral fragments is absent on anteroposterior (AP) and lateral radiographs. Those displaced fractures are at the most risk of problems due to pain and cosmesis, which investigators have highlighted in several studies in the literature. Among the latest thinking in this area is that a certain amount of shortening, about 15 mm to 20 mm, and the lack of cortical apposition of the lateral and medial fragments on two views is reason enough to treat the fracture operatively. A multicenter, randomized study by the Canadian Orthopaedic Trauma Society showed that 1 year after treatment, the operative group returned to function sooner and had better overall function than the group treated nonoperatively.

These findings give us reason to operate on these patients. We also now have a selection of specific plates that are designed to the contour of the clavicle. They make it easier to manage these fractures with surgery.

Surgical technique

When deciding how to treat a midshaft clavicle fracture, I suggest getting two views: an AP and a 45° cephalic tilt view. I then scan those films for a fracture pattern of vertically displaced fragments and fractures without bony contact of the transverse fragments and 15 mm to 20 mm of shortening.

The contraindications for surgery are patients who are high risk, abuse alcohol, are prone to infection or have compromised soft tissues due to previous radiation or burns, or individuals with medical comorbidities. A patient who is unwilling to participate in necessary postoperative rehabilitation is someone for whom surgery is contraindicated.

There are a few options for the incision. In most cases, I use a transverse incision made underneath the clavicle’s bony prominence. It is extensile, so that the incision can be made as far medial and lateral as possible. Another type of incision is similar to Langer’s Lines and is more like a strap type incision. It has the potential for improved cosmesis and causing less injury to the supraclavicular nerves.

I use a transverse skin incision to divide the muscle platysma. It is important to identify the supraclavicular nerves whenever possible so you can protect them during surgery. This step is followed by a subperiosteal dissection, which should be done with care, making the flaps as thick as possible. This helps with the skin closing later and avoids issues related to prominence.

Figure 1. A comminuted clavicle fracture is exposed and the segmental fragment is reduced to the medial clavicle with a clamp.

Figure 1. A comminuted clavicle fracture is
exposed and the segmental fragment is
reduced to the medial clavicle with a clamp.

Images: Ahmad CS

At this point, the technique calls for typical fracture work. You reduce the fracture and often manipulating the extremity can assist fracture reduction. If you lift the patient’s arm up, you can frequently maneuver or manipulate the distal fragment to contact the proximal fragment, which can be controlled with the reduction clamps (Figure 1). Provisional fixation can be achieved with small K-wires.

Once the reduction is complete, it is time to select the optimal plate for the case from the many now available that have different contours and lengths. Some plates are applied to the anterior clavicle cortex, and others are specifically designed for use at the most lateral aspect of the clavicle. In addition, some plates are designed with limited bone contact. They have a lower profile, which avoids adding height to the prominence, and they have tapered ends. Other plates include locking mechanisms.

Here is a clavicle fracture reduction, and the plate was selected after trying different ones for this case (Figure 2). I use clamps to hold the reduction while I attempt to get any oblique or intermediate fragments into place. One tip I have found helpful when it was difficult to get the plate to sit in place in the proper contour, is to try using an opposite shoulder plate. Clavicle plates are left- and right-shoulder specific. You should keep trying plates at this point, considering each one as a possibility until you get the right one that provides optimal contouring and has a sufficient number of screw holes on both sides of the fracture for applying good fixation.

Figure 2. A completed fixation with a well-fixed contoured plate and segmental fragments fixed with screws and cerclage sutures is shown. The supraclavicular nerve is also preserved.

Figure 2. A completed fixation with a
well-fixed contoured plate and segmental
fragments fixed with screws and cerclage
sutures is shown. The supraclavicular
nerve is also preserved.

The next step is to address the intermediate fragments by using screws when the fragment is large enough to create compression. Often, small bone fragments can be well reduced using sutures that go circumferentially around the clavicle and plate. These fragments should have their soft tissue attachments retained, which adds vascularity to the area.

A combination of locking and nonlocking screws, and standard open reduction and internal fixation techniques can be used for plate and fracture fixation. Plunging past the inferior cortex of the bone must be avoided or protected with appropriate retractor placement to protect the neurovascular structures that lie underneath it. Some special retractors are available, and I find them helpful to avoid disrupting the neurovascular structures in this type of situation.

I used a locking drill guide to help place the drill and introduce the locking screws. It allows you to get as far medial and lateral as you need to for strong fixation. We like to cover the plates with soft tissue and then repair the platysma; however, do not overtighten the platysma repair because it occasionally can result in neck restriction for patients, which can require extra physical therapy postoperatively to loosen up that area.

I recommended getting intraoperative radiographs to ensure your fixation and screw placement is satisfactory before you end the procedure.

Rehabilitation protocols

Rehabilitation after midshaft clavicle fracture surgery can be somewhat aggressive. You should use an occlusive dressing so that patients can shower and start moving their elbow and hand right away, but they should avoid aggressive overhead activities. Many of my patients resume activities fairly quickly, especially the cyclists who get on their bikes and ride the next day after surgery.

What we do try to do is slow down patients so they have completely returned to sports and regular activities by 3 months to 4 months postoperatively.

Of note, postoperative stiffness is not usually a problem with this procedure because it does not involve the glenohumeral joint. The surgery is done outside of the joint and therefore, patients usually do not experience any residual stiffness.

In younger patients who fracture their clavicles, managing the fracture is different. Jay Keener, MD, described to me the technique I now use. I used it for the case of this 14-year-old girl who fell from her bike and had an open apophysis (Figure 3). The magnitude of displacement and shortening was severe for such a young patient. She had the appearance of being tight in the fracture area, with her shoulder seemingly pushed all the way in.

Figure 3. This teenage female patient had a non-comminuted middle-third clavicle fracture with extreme displacement.

Figure 3. This teenage female patient had a non-comminuted middle-third clavicle fracture with extreme displacement.

Because of her young age, we had the choice of fixing the fracture with a plate or an intramedullary (IM) device, such as a flexible titanium nail. We used the latter (Figure 4,). Here is the operating room setup with a C-arm. A case like this requires exquisite imaging during the surgical procedure. Therefore, the C-arm comes in from the opposite or ipsilateral side with the surgeon standing on the opposite side of the patient (Figure 5).

Figure 4. Insertion of a flexible nail from medial to lateral using flouroscopic guidance is shown.

Figure 4. Insertion of a flexible nail from medial to lateral using flouroscopic guidance is shown.

With control, I made a hole to cannulate the medial aspect of the clavicle. Next, we drive a flexible pin across the fracture and get this stable axially (Figure 6). Since the fracture was not comminuted, it lined up beautifully and the original clavicle length could be restored. This patient eventually healed rapidly. You can easily take care of shortening with an IM technique like that.

Figure 5. This is the operative set-up for intramedullary flexible nailing of the clavicle.

Figure 5. This is the operative set-up for
intramedullary flexible nailing of the clavicle.

Using another set-up, you can cannulate and expand the hole in order to get into the medial fragment. However, if you are unable to get into the lateral fragment for some reason, you can make a small incision over the fracture, and use it line up the fracture correctly.

Using pins is another option to consider for midshaft clavicle fracture fixation: the bigger the pin, the better. Typically you would use a 2.0-mm pin, but if the size of the bone permits using a bigger pin, that is even better. However, keep in mind that small boned patients need small pins. Fixation with pins also means you need the right equipment to cut the pin. These cases often achieve good axial stability and heal rapidly.

Figure 6. This postoperative X-ray demonstrates a well-reduced clavicle and intramedullary flexible nail in place.

Figure 6. This postoperative X-ray demonstrates a well-reduced clavicle and intramedullary flexible nail in place.

In summary, the goals of midshaft clavicle fracture repair are avoiding shortening and, if using a plate, contouring it as best you can to the patient’s bony anatomy. If significant shortening of about 20 mm or more occurs and the patient has symptoms, I recommend performing a lengthening corrective osteotomy and refixing the fracture to take care of the problem. The osteotomy cut should follow how the fracture originally healed. The lateral and medial parts should be repositioned and plated to achieve an appropriate length of the clavicle. The indications for open reduction and internal fixation of midshaft clavicle fractures are changing, but it is important to note they have not changed much over the years in those fractures without bony contact.

Reference:
Canadian Orthopaedic Trauma Society. J Bone Joint Surg Am. 2007; 89(1):1-10.
For more information:
Christopher S. Ahmad, MD, can be reached at Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, 622 W. 168th St., PH-11-Center, New York, NY 10032; email: csa4@columbia.edu.
Disclosure: Ahmad is a paid consultant for Arthrex Inc.

 

The clavicle plays a protective role in the upper body. When it is considered in that way, the need to treat clavicle fractures appropriately and in a timely manner takes on a whole new meaning since the clavicle has several muscles attached to it and it provides the framework for muscles surrounding the shoulder girdle. Its cosmetic appearance, with neurovascular structures right beneath it, is also critical for the orthopedic surgeon to recognize and appreciate.

Changing indications

When Charles S. Neer II, MD, studied these midshaft fractures in a large number of patients, 0.1% failed to heal. Carter R. Rowe, MD, noted in one of his reviews that healing was not a problem for clavicle fractures. Therefore, nonunion of midshaft clavicle fractures is a rare outcome. In fact, the orthopedic textbooks tend to focus mostly on the indications, which include neurovascular problems, skin tenting, older fractures or a floating shoulder.

However, these indications are changing in conjunction with the different types of injury mechanisms being seen, including more high energy injuries, and with the different types of patients who present with these fractures, many of whom have high expectations for their treatment.

Christopher S. Ahmad

Christopher S.
Ahmad

There is a new potential for problems with nonoperative treatment of clavicle fractures in some patients, particularly those who want guaranteed pain relief and demand that their normal function be restored.

As a result, there is interest in the features of individual clavicle fractures. More recent studies showed that nonunion rates with clavicle fractures can reach 25%. In addition, union does not necessarily mean a good result. There are newer, more sensitive scoring systems we can use to assess our patients’ outcomes more closely.

In research by Nowack and colleagues that involved more than 200 patients, the investigators identified the risk factors for poor outcome. In a 10-year period, they found that almost half of patients felt they were not fully recovered after a clavicle fracture. Many of them had pain. A large percentage was dissatisfied with the cosmesis of the shoulder girdle, and one-third noted they had weakness problems. Therefore, it is important to understand who is most at risk for such problems such as those patients with fractures with 15-mm to 20-mm shortening or vertically displaced fragments, which is a common fracture configuration.

Displacement is frequently reported with midshaft clavicle fractures, where contact between medial and lateral fragments is absent on anteroposterior (AP) and lateral radiographs. Those displaced fractures are at the most risk of problems due to pain and cosmesis, which investigators have highlighted in several studies in the literature. Among the latest thinking in this area is that a certain amount of shortening, about 15 mm to 20 mm, and the lack of cortical apposition of the lateral and medial fragments on two views is reason enough to treat the fracture operatively. A multicenter, randomized study by the Canadian Orthopaedic Trauma Society showed that 1 year after treatment, the operative group returned to function sooner and had better overall function than the group treated nonoperatively.

These findings give us reason to operate on these patients. We also now have a selection of specific plates that are designed to the contour of the clavicle. They make it easier to manage these fractures with surgery.

Surgical technique

When deciding how to treat a midshaft clavicle fracture, I suggest getting two views: an AP and a 45° cephalic tilt view. I then scan those films for a fracture pattern of vertically displaced fragments and fractures without bony contact of the transverse fragments and 15 mm to 20 mm of shortening.

The contraindications for surgery are patients who are high risk, abuse alcohol, are prone to infection or have compromised soft tissues due to previous radiation or burns, or individuals with medical comorbidities. A patient who is unwilling to participate in necessary postoperative rehabilitation is someone for whom surgery is contraindicated.

PAGE BREAK

There are a few options for the incision. In most cases, I use a transverse incision made underneath the clavicle’s bony prominence. It is extensile, so that the incision can be made as far medial and lateral as possible. Another type of incision is similar to Langer’s Lines and is more like a strap type incision. It has the potential for improved cosmesis and causing less injury to the supraclavicular nerves.

I use a transverse skin incision to divide the muscle platysma. It is important to identify the supraclavicular nerves whenever possible so you can protect them during surgery. This step is followed by a subperiosteal dissection, which should be done with care, making the flaps as thick as possible. This helps with the skin closing later and avoids issues related to prominence.

Figure 1. A comminuted clavicle fracture is exposed and the segmental fragment is reduced to the medial clavicle with a clamp.

Figure 1. A comminuted clavicle fracture is
exposed and the segmental fragment is
reduced to the medial clavicle with a clamp.

Images: Ahmad CS

At this point, the technique calls for typical fracture work. You reduce the fracture and often manipulating the extremity can assist fracture reduction. If you lift the patient’s arm up, you can frequently maneuver or manipulate the distal fragment to contact the proximal fragment, which can be controlled with the reduction clamps (Figure 1). Provisional fixation can be achieved with small K-wires.

Once the reduction is complete, it is time to select the optimal plate for the case from the many now available that have different contours and lengths. Some plates are applied to the anterior clavicle cortex, and others are specifically designed for use at the most lateral aspect of the clavicle. In addition, some plates are designed with limited bone contact. They have a lower profile, which avoids adding height to the prominence, and they have tapered ends. Other plates include locking mechanisms.

Here is a clavicle fracture reduction, and the plate was selected after trying different ones for this case (Figure 2). I use clamps to hold the reduction while I attempt to get any oblique or intermediate fragments into place. One tip I have found helpful when it was difficult to get the plate to sit in place in the proper contour, is to try using an opposite shoulder plate. Clavicle plates are left- and right-shoulder specific. You should keep trying plates at this point, considering each one as a possibility until you get the right one that provides optimal contouring and has a sufficient number of screw holes on both sides of the fracture for applying good fixation.

Figure 2. A completed fixation with a well-fixed contoured plate and segmental fragments fixed with screws and cerclage sutures is shown. The supraclavicular nerve is also preserved.

Figure 2. A completed fixation with a
well-fixed contoured plate and segmental
fragments fixed with screws and cerclage
sutures is shown. The supraclavicular
nerve is also preserved.

The next step is to address the intermediate fragments by using screws when the fragment is large enough to create compression. Often, small bone fragments can be well reduced using sutures that go circumferentially around the clavicle and plate. These fragments should have their soft tissue attachments retained, which adds vascularity to the area.

A combination of locking and nonlocking screws, and standard open reduction and internal fixation techniques can be used for plate and fracture fixation. Plunging past the inferior cortex of the bone must be avoided or protected with appropriate retractor placement to protect the neurovascular structures that lie underneath it. Some special retractors are available, and I find them helpful to avoid disrupting the neurovascular structures in this type of situation.

PAGE BREAK

I used a locking drill guide to help place the drill and introduce the locking screws. It allows you to get as far medial and lateral as you need to for strong fixation. We like to cover the plates with soft tissue and then repair the platysma; however, do not overtighten the platysma repair because it occasionally can result in neck restriction for patients, which can require extra physical therapy postoperatively to loosen up that area.

I recommended getting intraoperative radiographs to ensure your fixation and screw placement is satisfactory before you end the procedure.

Rehabilitation protocols

Rehabilitation after midshaft clavicle fracture surgery can be somewhat aggressive. You should use an occlusive dressing so that patients can shower and start moving their elbow and hand right away, but they should avoid aggressive overhead activities. Many of my patients resume activities fairly quickly, especially the cyclists who get on their bikes and ride the next day after surgery.

What we do try to do is slow down patients so they have completely returned to sports and regular activities by 3 months to 4 months postoperatively.

Of note, postoperative stiffness is not usually a problem with this procedure because it does not involve the glenohumeral joint. The surgery is done outside of the joint and therefore, patients usually do not experience any residual stiffness.

In younger patients who fracture their clavicles, managing the fracture is different. Jay Keener, MD, described to me the technique I now use. I used it for the case of this 14-year-old girl who fell from her bike and had an open apophysis (Figure 3). The magnitude of displacement and shortening was severe for such a young patient. She had the appearance of being tight in the fracture area, with her shoulder seemingly pushed all the way in.

Figure 3. This teenage female patient had a non-comminuted middle-third clavicle fracture with extreme displacement.

Figure 3. This teenage female patient had a non-comminuted middle-third clavicle fracture with extreme displacement.

Because of her young age, we had the choice of fixing the fracture with a plate or an intramedullary (IM) device, such as a flexible titanium nail. We used the latter (Figure 4,). Here is the operating room setup with a C-arm. A case like this requires exquisite imaging during the surgical procedure. Therefore, the C-arm comes in from the opposite or ipsilateral side with the surgeon standing on the opposite side of the patient (Figure 5).

Figure 4. Insertion of a flexible nail from medial to lateral using flouroscopic guidance is shown.

Figure 4. Insertion of a flexible nail from medial to lateral using flouroscopic guidance is shown.

With control, I made a hole to cannulate the medial aspect of the clavicle. Next, we drive a flexible pin across the fracture and get this stable axially (Figure 6). Since the fracture was not comminuted, it lined up beautifully and the original clavicle length could be restored. This patient eventually healed rapidly. You can easily take care of shortening with an IM technique like that.

Figure 5. This is the operative set-up for intramedullary flexible nailing of the clavicle.

Figure 5. This is the operative set-up for
intramedullary flexible nailing of the clavicle.

Using another set-up, you can cannulate and expand the hole in order to get into the medial fragment. However, if you are unable to get into the lateral fragment for some reason, you can make a small incision over the fracture, and use it line up the fracture correctly.

Using pins is another option to consider for midshaft clavicle fracture fixation: the bigger the pin, the better. Typically you would use a 2.0-mm pin, but if the size of the bone permits using a bigger pin, that is even better. However, keep in mind that small boned patients need small pins. Fixation with pins also means you need the right equipment to cut the pin. These cases often achieve good axial stability and heal rapidly.

Figure 6. This postoperative X-ray demonstrates a well-reduced clavicle and intramedullary flexible nail in place.

Figure 6. This postoperative X-ray demonstrates a well-reduced clavicle and intramedullary flexible nail in place.

In summary, the goals of midshaft clavicle fracture repair are avoiding shortening and, if using a plate, contouring it as best you can to the patient’s bony anatomy. If significant shortening of about 20 mm or more occurs and the patient has symptoms, I recommend performing a lengthening corrective osteotomy and refixing the fracture to take care of the problem. The osteotomy cut should follow how the fracture originally healed. The lateral and medial parts should be repositioned and plated to achieve an appropriate length of the clavicle. The indications for open reduction and internal fixation of midshaft clavicle fractures are changing, but it is important to note they have not changed much over the years in those fractures without bony contact.

Reference:
Canadian Orthopaedic Trauma Society. J Bone Joint Surg Am. 2007; 89(1):1-10.
For more information:
Christopher S. Ahmad, MD, can be reached at Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, 622 W. 168th St., PH-11-Center, New York, NY 10032; email: csa4@columbia.edu.
Disclosure: Ahmad is a paid consultant for Arthrex Inc.