From the Guidelines
During dissection for a midshaft clavicle fracture, several critical neurovascular structures must be carefully identified and protected, including the subclavian vessels, the brachial plexus, and the supraclavicular nerves, to minimize the risk of injury and ensure optimal patient outcomes, as emphasized in recent clinical practice guidelines 1.
Key Structures to Protect
- The subclavian vessels (artery and vein) run posterior to the clavicle and are at risk during deep dissection, especially when manipulating fracture fragments.
- The brachial plexus lies in close proximity to the clavicle posteriorly and inferiorly, and injury can result in significant upper extremity neurological deficits.
- The supraclavicular nerves cross the operative field superficially and should be preserved to prevent postoperative sensory deficits in the anterior chest and shoulder region.
- The lung apex is relatively close to the surgical field, particularly in thin patients, and care must be taken to avoid pleural injury which could lead to pneumothorax.
- The internal jugular vein and thoracic duct (on the left side) are also in the vicinity and require protection.
Surgical Considerations
Careful subperiosteal dissection and appropriate retraction techniques help minimize the risk of injury to these vital structures during surgical management of midshaft clavicle fractures, as supported by high-quality evidence from recent studies 1.
Clinical Decision-Making
The American Academy of Orthopaedic Surgeons clinical practice guidelines provide a strong recommendation on surgical versus nonsurgical treatment of displaced clavicle fractures in adults, emphasizing the importance of careful consideration of individual patient factors and values in making treatment decisions 1.
From the Research
Structures to be Careful with During Dissection
When performing a dissection for a midshaft clavicle fracture, several structures need to be carefully identified and protected to avoid complications. These include:
- Subclavian artery: This artery is at risk of injury, particularly with comminuted or displaced fractures 2, 3.
- Subclavian vein: The subclavian vein can be injured, leading to hemorrhage, hematoma, or pseudoaneurysm 4, 3.
- Brachial plexus: The brachial plexus is a network of nerves that can be injured, resulting in complete brachial plexus palsy 4.
- Neurovascular structures: These structures are at risk of injury during instrumentation of the clavicle, particularly with screw placement 5.
Precautions During Dissection
To minimize the risk of injury to these structures, precautions should be taken during dissection, including:
- Careful identification and protection of the subclavian artery and vein 2, 3.
- Gentle handling of the brachial plexus to avoid injury 4.
- Precise placement of screws to avoid contact with neurovascular structures 5.
- Consideration of limb abduction to 90° to increase the distance between the neurovascular structures and the clavicle 5.