What is the step-by-step procedure for treating a fracture clavicle by plating?

From the Guidelines

The surgical treatment of a clavicle fracture by plating involves several key steps, with the most critical aspect being the positioning of the plate, which should be done anteriorly to minimize implant removal rates, as suggested by the American Academy of Orthopaedic Surgeons in their 2023 clinical practice guideline summary 1. The procedure begins with the patient positioned supine with a bump between the scapulae and administered general anesthesia. An incision is made along the superior aspect of the clavicle, centered over the fracture site, typically 6-8 cm in length. After dissection through subcutaneous tissue, the platysma muscle is divided, and the fracture site is exposed while protecting the underlying neurovascular structures.

• The fracture is then reduced anatomically using reduction clamps or temporary K-wires.
• A pre-contoured anatomic plate (typically a 3.5mm dynamic compression plate or a pre-contoured clavicle-specific plate) is positioned on the anterosuperior surface of the clavicle, as anterior inferior plating may lead to lower implant removal rates compared with superior plating 1.
• The plate is secured with cortical screws (3.5mm), ensuring at least three screws on each side of the fracture for optimal stability. Key considerations in the decision to operate include the type of fracture, with displaced fractures (>2cm shortening or displacement), comminuted fractures, or fractures with skin tenting that risks open conversion being particularly indicated for surgical intervention, as they have higher rates of nonunion and symptomatic malunion with non-surgical treatment 1. After confirming proper reduction and fixation with fluoroscopy, the wound is irrigated and closed in layers.
• Postoperatively, the arm is placed in a sling for comfort for 1-2 weeks,
• followed by progressive range of motion exercises,
• and strengthening exercises typically begin at 6 weeks, with return to full activities around 3 months. This procedure provides immediate stability, allowing for earlier mobilization compared to non-operative treatment, and is supported by high-quality evidence showing higher union rates and better early patient-reported outcomes after surgical treatment of displaced clavicle fractures in adults 1.

From the Research

Preoperative Preparation

• The patient is typically prepared for surgery under general anesthesia or local anesthesia, with the choice of anesthesia depending on the patient's preferences and medical history 2.
• The use of regional anesthesia, such as an interscalene brachial plexus block and a modified superficial cervical plexus block, has been shown to be safe and effective for clavicle fracture surgery 3.
• The patient's clavicle fracture is classified according to the AO Fracture Classification system to guide the surgical decision-making process 4.

Surgical Procedure

• The surgical procedure for plating a clavicle fracture typically involves making an incision over the clavicle and dissecting the surrounding tissue to expose the fracture site.
• A plate is then selected and contoured to fit the clavicle, and screws are inserted to secure the plate to the bone.
• The use of a single plate or dual plates depends on the fracture pattern and the surgeon's preference, with both techniques providing adequate stability 5.
• The wide-awake local anesthesia no tourniquet (WALANT) technique has been used successfully for plating of clavicle fractures, allowing for a more minimally invasive approach 4.

Postoperative Care

• After the surgery, the patient is typically monitored for any complications and given pain medication as needed.
• The use of regional anesthesia has been shown to provide effective postoperative analgesia, reducing the need for additional pain medication 3.
• The patient is usually allowed to resume normal activities gradually, with the goal of returning to full function as soon as possible.
• Follow-up appointments are scheduled to monitor the patient's progress and remove the plate if necessary, which can be done under local anesthesia or general anesthesia, depending on the patient's preference 2.

Key Considerations

• The choice of anesthesia and surgical technique depends on the individual patient's needs and medical history.
• The use of regional anesthesia and minimally invasive techniques can help reduce recovery time and improve patient outcomes.
• The classification of the clavicle fracture according to the AO Fracture Classification system helps guide the surgical decision-making process and ensures the best possible outcome for the patient 4, 6.