From the Guidelines
Surgical plating of a midshaft clavicle fracture is the recommended treatment approach, as it provides immediate stability, allows for early mobilization, and is particularly beneficial for displaced fractures, shortening greater than 2cm, or comminuted fractures where non-operative management might lead to malunion or nonunion. The procedure begins with patient positioning in a beach chair or supine position under general anesthesia. After sterile preparation and draping, 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 fracture site is identified, and the periosteum is carefully elevated to expose the fracture fragments while preserving soft tissue attachments. Any hematoma is evacuated, and the fracture ends are debrided of soft tissue to allow for anatomic reduction. The fracture is then reduced using bone reduction clamps or forceps to restore normal length and alignment.
A pre-contoured anatomic plate (typically 3.5mm) is selected and positioned on the superior or anterosuperior surface of the clavicle, as manufacturer-contoured anatomic clavicle plates have lower rates of implant removal or deformation compared with other plates 1. Temporary fixation with K-wires may help maintain the reduction while the plate is secured. The plate is fixed to the bone using cortical screws (typically 3.5mm), with at least three screws placed on each side of the fracture for adequate stability. Interfragmentary compression screws may be used for oblique fractures.
Some studies suggest that anterior inferior plating of midshaft clavicle fractures in adults may lead to lower implant removal rates compared with superior plating 1. However, the choice of plating approach should be individualized based on the specific fracture pattern and patient anatomy. After confirming proper reduction and fixation with fluoroscopy, the wound is irrigated, and a layered closure is performed. The platysma is closed with absorbable sutures, followed by subcutaneous tissue and skin closure.
Post-operatively, patients typically wear a sling for comfort for 1-2 weeks, followed by progressive range of motion exercises. Weight-bearing restrictions are maintained for 6-8 weeks until radiographic evidence of healing is observed. Surgical treatment of displaced midshaft clavicle fractures in adult patients is associated with higher union rates and better early patient-reported outcomes than nonsurgical treatment 1. This approach provides a strong recommendation for surgical treatment, unless a clear and compelling rationale for an alternative approach is present.
Key steps in the procedure include:
- Patient positioning and preparation
- Incision and exposure of the clavicle
- Fracture reduction and fixation
- Plate selection and placement
- Wound closure and post-operative care
- The use of pre-contoured anatomic plates and anterior inferior plating approaches may help optimize outcomes. The overall goal of the procedure is to provide a stable and anatomically reduced fracture, allowing for early mobilization and minimizing the risk of complications.
From the Research
Step-by-Step Procedure for Fracture Midshaft Clavicle by Plating
The treatment of midshaft clavicle fractures using plating 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 skin incision is made over the clavicle, and the fracture site is exposed 3.
- Reduction of the fracture: The fracture is reduced, and the bone fragments are aligned properly 4.
- Plate fixation: A plate is fixed to the clavicle using screws to stabilize the fracture 2, 4.
- Verification of reduction: The reduction is verified using intraoperative imaging, such as fluoroscopy or X-rays 3.
- Closure: The incision is closed, and the patient is taken to the recovery room 2.
Considerations for Plating
When using plating for midshaft clavicle fractures, several factors should be considered:
- Plate position: The plate can be positioned superiorly or anteroinferiorly, with superior plating generally providing greater stiffness and strength during bending loads 4.
- Plate type: Pre-contoured superior locking plates are available for fixation and can provide excellent outcomes 2.
- Biomechanical properties: Plate fixation seems to form a more robust construct than intramedullary fixation in terms of stiffness and failure loading 4.
Potential Complications
Potential complications of plating for midshaft clavicle fractures include:
- Hardware irritation: This is a common complication, occurring in up to 24.1% of patients 2.
- Dysesthesia around the surgical scar: This can occur in up to 17.2% of patients 2.
- Non-union: This is a potential complication, although operative treatment can reduce the risk of non-union compared to conservative treatment 5.
- Re-operations: Operative treatment is associated with an increased risk of re-operations 5.