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

Step-by-Step Procedure for Clavicle Fracture Plating

Plate fixation is the recommended surgical approach for displaced midshaft clavicle fractures in adults, offering higher union rates and better early patient-reported outcomes compared to nonsurgical treatment. 1

Preoperative Considerations

• Patient Selection:

  • Indications for surgical fixation include:
    • Displacement of one or more shaft width
    • Shortening of more than 1 cm in length
    • High physical activity requirements
    • Displaced midshaft fractures in adults 1, 2
  • Consider patient factors:
    • Smoking increases nonunion risk and leads to inferior outcomes 1
    • Adolescents may not benefit from surgical treatment 1

• Imaging:

  • Obtain upright radiographs as they are superior for demonstrating the degree of displacement compared to supine views 1

• Plate Selection:

  • Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal and deformation 1
  • Consider anterior inferior plating which may lead to lower implant removal rates compared to superior plating 1
  • Options include:
    • Single superior or anterior plate
    • Low-profile dual plating (2.0 mm plate superiorly and 2.4/2.7 mm plate anteriorly) 2

• Anesthesia Options:

  • General anesthesia (traditional approach)
  • WALANT (Wide-Awake Local Anesthesia No Tourniquet) using 1% lidocaine with 1:100,000 epinephrine and sodium bicarbonate 3, 4

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient in a beach-chair or semi-sitting position 5
• Prepare and drape the affected shoulder and upper chest area

Step 2: Incision and Approach

• Make a transverse skin incision along the anteroinferior aspect of the clavicle 5
• If using WALANT technique, inject 40 mL of solution:
  • 10 mL subcutaneously along the clavicle
  • 30 mL subperiosteally at multiple intervals and directions 3

Step 3: Fracture Exposure

• Dissect through subcutaneous tissue and platysma
• Identify and elevate the deltotrapezial fascia
• Expose the fracture site while preserving soft-tissue attachments to the extent possible 5
• Identify and prepare the fracture fragments

Step 4: Fracture Reduction

• Reduce the fragments by direct or indirect manipulation
• Maintain the reduction with:
  • Reduction clamps
  • Temporary Kirschner wires
  • Mini-fragment plates 5
• For comminuted fractures, consider bridging the comminuted zone to allow secondary fracture healing

Step 5: Plate Application and Fixation

• Apply the contoured plate to either:
  • Superior surface (traditional)
  • Anterior surface (may have lower implant removal rates)
  • Both surfaces for dual plating technique 2
• Obtain at least 6 cortices of fixation on each side of the fracture
• Use a combination of strategic nonlocking and locking screws
• For dual plating technique:
  • Place 2.0 mm plate on superior surface
  • Place 2.4/2.7 mm plate on anterior surface
  • Secure each plate with minimum two screws on each side of fracture 2
• Consider a lag screw for simple fractures if absolute stability can be achieved 2

Step 6: Intraoperative Imaging

• Obtain an intraoperative anteroposterior radiograph to confirm:
  • Proper reduction of fracture
  • Appropriate plate and screw positioning
  • Restoration of clavicle length and alignment 5

Step 7: Wound Closure

• Close the wound in separate layers:
  • Deltotrapezial fascia
  • Platysma
  • Subcutaneous tissue
  • Skin 5
• Apply sterile dressings

Postoperative Management

• Apply a sling for comfort
• Allow immediate full range of motion of the shoulder up to 90° without weight bearing for 6 weeks 2
• After 6 weeks, permit full range of motion and weight bearing 2
• Follow-up radiographs to assess fracture healing
• Consider implant removal after fracture healing if symptomatic (can be performed under local anesthesia) 6

Important Considerations and Pitfalls

• Plate Selection: Manufacturer-contoured anatomic plates have lower rates of implant removal and deformation 1
• Plate Positioning: Anterior inferior plating may lead to lower implant removal rates compared to superior plating 1
• Comminution: Plate fixation may be of benefit over intramedullary nailing in the presence of fracture comminution 1
• Bone Stimulation: Low-intensity pulsed ultrasonography (LIPUS) should not be used as it does not accelerate healing or lower nonunion rates 1
• Dual Plating: Consider low-profile dual plating for midshaft fractures to provide superior stability with less implant irritation 2
• Anesthesia Options: WALANT technique is a viable alternative to general anesthesia with good pain control and potentially fewer risks for patients with medical comorbidities 3, 4