What is the treatment for a clavicular fracture with skin tenting?

Treatment of Clavicular Fracture with Skin Tenting

Clavicular fractures with skin tenting require urgent surgical intervention through open reduction and internal fixation (ORIF) to prevent skin necrosis and potential conversion to an open fracture.

Understanding Skin Tenting in Clavicular Fractures

Skin tenting occurs when a sharp, displaced bone fragment pushes against the skin from underneath, creating tension that can lead to skin breakdown. While traditionally considered a theoretical risk, evidence shows this is a real complication:

• Skin tenting can progress to skin necrosis and convert a closed fracture to an open one 1
• Adolescent cases have demonstrated that initially intact skin can subsequently develop open lesions at fracture sites when managed non-operatively 1
• This complication is most common with vertically angulated sharp fragments or comminuted fractures 1

Surgical Management Algorithm

Immediate Surgical Intervention

1. Urgent ORIF is indicated for clavicular fractures with skin tenting 2, 1
2. Surgical options include:
   • Plate fixation (preferred for comminuted fractures) 3, 2
   • Intramedullary nailing (alternative option) 3, 2
   • In select cases, excision of the bony spike without fixation may be considered 4

Surgical Technique Considerations

• Plate position: Anterior inferior plating may lead to lower implant removal rates compared to superior plating 2
• Plate type: Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal and deformation 2
• For distal clavicle fractures: Consider transacromial pins with tension band wire for superior fixation 5

Evidence Supporting Surgical Intervention

The American Academy of Orthopaedic Surgeons (AAOS) provides strong recommendations for surgical treatment of displaced clavicle fractures 3, 2:

• Surgical treatment results in higher union rates and better early patient-reported outcomes
• Faster time to union with surgical treatment allows earlier return to work/activities
• Plate fixation is particularly beneficial in the presence of fracture comminution

Special Considerations

Risk Factors to Address

• Smoking: Increases nonunion risk and leads to inferior outcomes 3, 2
• Age: Adolescents with skin tenting should still receive surgical intervention despite general recommendations for conservative management in this age group 1

Post-Surgical Management

• Immobilization with a sling is preferred over figure-of-eight bracing 2
• Low-intensity pulsed ultrasonography (LIPUS) should not be used as it does not accelerate healing 3, 2

Potential Complications

• Without surgical intervention, skin tenting can progress to skin necrosis and open fracture 1
• Surgical complications may include infection, hardware prominence, and need for hardware removal
• Pin migration can occur with certain fixation methods (43% with traditional transacromial Kirschner wire fixation vs. 7% with tension band wire) 5

Pitfalls to Avoid

1. Delay in surgical intervention: Skin tenting is an urgent indication for surgery, not a "wait and see" situation
2. Underestimating the risk: Skin tenting is more than a theoretical risk and can lead to open fractures if not addressed promptly 1
3. Inadequate fixation: Choose appropriate fixation method based on fracture pattern (plate for comminuted fractures) 3, 2
4. Ignoring patient factors: Address modifiable risk factors like smoking that can impact healing 2

Remember that while most clavicular fractures can be managed non-operatively, skin tenting represents a specific indication for urgent surgical intervention to prevent serious complications.