Step-by-Step Procedure for Clavicle Fracture Plating
Plate fixation is the recommended surgical approach for displaced midshaft clavicle fractures with displacement of one or more shaft width, shortening of more than 1 cm in length, or in patients with high physical activity requirements, as it offers higher union rates and better early patient-reported outcomes compared to nonsurgical treatment. 1
Preoperative Considerations
- Evaluate fracture pattern using upright radiographs, which are superior for demonstrating the degree of displacement compared to supine views 1
- Consider manufacturer-contoured anatomic clavicle plates, which have lower rates of implant removal and deformation 1
- Anterior-inferior plating may lead to lower implant removal rates compared to superior plating 1
- Assess for risk factors that may affect outcomes:
Anesthesia Options
- Traditionally performed under general anesthesia
- Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a viable alternative 2, 3
- Solution: 1% lidocaine, 1:100,000 epinephrine, and 10:1 sodium bicarbonate
- Total of 40 mL injected (10 mL subcutaneously along clavicle, 30 mL subperiosteally)
- Provides effective pain control during operation and early postoperative period
- Particularly beneficial for patients with medical comorbidities or difficult intubation 3
Surgical Procedure
Step 1: Patient Positioning
- Place patient in beach-chair, semi-sitting position 4
Step 2: Incision and Exposure
- Make a transverse skin incision along the anteroinferior aspect of the clavicle 4
- Expose the fracture site while preserving soft-tissue attachments to the extent possible 4
- Identify and prepare the fragments (unless comminuted) 4
Step 3: Fracture Reduction
- Reduce fragments by direct or indirect manipulation 4
- Maintain reduction using:
- Clamps
- Kirschner wires
- Mini-fragment plates 4
- For comminuted zones, consider bridging to allow secondary fracture healing 4
Step 4: Plate Application and Fixation
- Apply a contoured plate to the superior or anterior surface of the clavicle 4
- Obtain at least 6 cortices of fixation on each side of the fracture using strategic nonlocking and locking screws 4
- Working length of the plate is more important than the number of screws or cortices 4
Alternative: Low-Profile Dual Plating Technique
- Especially suitable for midportion clavicle fractures 5
- Use a 2.0 mm low-profile mini plate on the superior surface
- Use a 2.4 or 2.7 mm plate on the anterior surface
- Fixate each plate with minimum of two cortical or locking screws on each side of the fracture
- Consider lag screw if absolute stability can be obtained in simple fractures 5
Step 5: Intraoperative Imaging
- Obtain a single intraoperative anteroposterior radiograph of the clavicle 4
Step 6: Wound Closure
- Close the wound in separate layers:
- Deltotrapezial fascia
- Platysma
- Skin 4
- Apply sterile dressings and a sling
Postoperative Management
- Patient may be discharged on the same day if the injury is isolated 4
- Allow immediate full range of motion of the affected shoulder 4
- Standard functional regime:
- Free mobilization up to 90° without weight bearing for 6 weeks
- After 6 weeks, allow free range of motion and weight bearing 5
- Patient is expected to regain full function and strength once healing occurs 4
Important Considerations
- Urgent surgical intervention is recommended for fractures with skin tenting to prevent skin necrosis and potential conversion to open fracture 1
- Immobilization with a sling is preferred over figure-of-eight bracing 1
- Low-intensity pulsed ultrasonography (LIPUS) should not be used as it does not accelerate healing or lower nonunion rates 1
- For implant removal, both local and general anesthesia are acceptable options based on patient preference 6