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.