From the Guidelines
The surgical procedure for open reduction and internal fixation (ORIF) of a midshaft clavicle fracture with plating is the recommended treatment, as it provides stable fixation and allows for early mobilization, resulting in high union rates and better early patient-reported outcomes, as supported by the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1.
Preoperative Preparation
The procedure begins with proper patient positioning in a beach chair position with a bump between the scapulae. After administering appropriate anesthesia (typically general), the surgical site is prepped and draped in sterile fashion.
Surgical Technique
An incision is made along the superior aspect of the clavicle, centered over the fracture site, typically 7-10 cm in length. The subcutaneous tissue is dissected, and the platysma muscle is divided to expose the clavicle. The periosteum is carefully elevated to expose the fracture while preserving soft tissue attachments. Any hematoma is evacuated, and the fracture ends are identified and debrided of interposed tissue.
Reduction and Fixation
The fracture is then reduced anatomically using reduction clamps or temporary K-wires. Once satisfactory reduction is achieved, a precontoured plate (typically a 3.5mm dynamic compression plate or anatomically designed clavicle plate) is positioned on the superior or anterosuperior surface of the clavicle. The plate is temporarily secured with K-wires, and proper positioning is confirmed with fluoroscopy. Screws are then placed through the plate into the clavicle, with at least three screws on each side of the fracture to provide adequate stability.
Postoperative Care
After fixation, the wound is irrigated, and a layered closure is performed with absorbable sutures for deep layers and either absorbable sutures or staples for the skin. A sterile dressing is applied, and the arm is placed in a sling for comfort. Postoperatively, early range of motion exercises are typically started within the first week, with restrictions on heavy lifting for 6-12 weeks until radiographic healing is evident.
Key Considerations
- The use of precontoured plates may result in lower rates of implant removal or deformation compared with other plates 1.
- Anterior inferior plating may lead to lower implant removal rates compared with superior plating 1.
- The procedure provides stable fixation that allows for early mobilization and typically results in high union rates for displaced midshaft clavicle fractures, as supported by the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1.
From the Research
Step-by-Step Procedure for Fracture Midshaft Clavicle by ORIF with Plating
The procedure for open reduction and internal fixation (ORIF) with plating for midshaft clavicle fractures involves several steps:
- Preoperative preparation: The patient is prepared for surgery, which includes administering anesthesia and positioning the patient on the operating table 2.
- Incision and exposure: A surgical incision is made over the clavicle, and the fracture site is exposed 3.
- Reduction and fixation: The fracture is reduced, and a plate is applied to the clavicle to stabilize the fracture 4.
- Plate fixation: The plate is fixed to the clavicle using screws, and the fracture is stabilized 5.
- Wound closure: The wound is closed, and the patient is taken to the recovery room 6.
Postoperative Care and Rehabilitation
After the surgery, the patient is monitored for any complications and is started on a rehabilitation program:
- Pain management: The patient is given pain medication to manage postoperative pain 2.
- Immobilization: The arm is immobilized in a sling to allow the fracture to heal 3.
- Rehabilitation: The patient is started on a rehabilitation program to regain strength and range of motion in the shoulder 4.
- Follow-up: The patient is followed up with regular check-ups to monitor the healing of the fracture and to remove the plate if necessary 5, 6.
Potential Complications and Outcomes
The potential complications of ORIF with plating for midshaft clavicle fractures include:
- Implant irritation: The plate and screws can cause irritation to the surrounding tissues 5, 6.
- Infection: There is a risk of infection with any surgical procedure 6.
- Nonunion: The fracture may not heal properly, leading to nonunion 5.
- Malunion: The fracture may heal in an abnormal position, leading to malunion 3.
- The outcomes of ORIF with plating for midshaft clavicle fractures are generally good, with high rates of fracture union and good functional outcomes 2, 4, 6.