What is the step by step procedure for treating a fracture of the lateral third clavicle using plating?

Step-by-Step Procedure for Lateral Third Clavicle Fracture Fixation Using Plating

Surgical fixation with a superiorly placed locking plate, augmented with a coracoclavicular sling, is the recommended approach for displaced lateral third clavicle fractures to ensure optimal stability and prevent plate failure. 1, 2

Preoperative Planning and Assessment

1. Fracture Pattern Identification
   • Evaluate radiographs (preferably upright views) to assess displacement and fracture pattern 3
   • Confirm disruption of coracoclavicular ligament complex, which is common in lateral third fractures 3
   • Select appropriate plate based on fracture pattern and distal fragment size

Surgical Procedure

Step 1: Patient Positioning and Setup

• Position patient in beach chair or supine position with a bump under the affected shoulder
• Place image intensifier for optimal intraoperative visualization 1
• Prepare and drape the affected shoulder and upper chest area

Step 2: Surgical Approach

• Make a "bra-strap" incision centered over the fracture site 1
• Incise skin, subcutaneous tissue, and platysma
• Identify and protect the supraclavicular nerves
• Expose the fracture site by elevating the periosteum

Step 3: Fracture Reduction

• Debride the fracture site of hematoma and soft tissue interposition
• Reduce the fracture anatomically using reduction clamps
• Temporarily stabilize with K-wires if needed 1

Step 4: Plate Selection and Application

• Select a precontoured locking plate appropriate for the lateral clavicle 4
• Position the plate superiorly on the clavicle 1
• Ensure adequate distal fragment capture with at least 3 screws when possible

Step 5: Plate Fixation

• Secure the plate with proximal bicortical screws in the medial fragment
• Place distal locking screws in the lateral fragment 1
• Confirm reduction and hardware position with fluoroscopy

Step 6: Coracoclavicular Ligament Augmentation

• Add coracoclavicular sling augmentation to prevent plate failure and lateral screw pullout 2
• Options include suture cerclage, suture anchors, or specialized coracoclavicular fixation devices

Step 7: Wound Closure and Dressing

• Irrigate the wound thoroughly
• Close in layers: periosteum, subcutaneous tissue, and skin 1
• Apply sterile dressing and place arm in a sling

Postoperative Management

1. Immediate Postoperative Care

   • Maintain arm in a sling for 2-4 weeks
   • Begin early passive range of motion exercises as tolerated

2. Rehabilitation Protocol

   • Weeks 0-2: Pendulum exercises and passive range of motion
   • Weeks 2-6: Progressive active-assisted range of motion
   • Weeks 6-12: Strengthening exercises when radiographic healing is evident
   • Return to full activities typically by 12 weeks

Important Considerations and Pitfalls

• Potential Complications:

  • Acromioclavicular joint injury during plate placement can lead to joint instability 2
  • Plate pullout may occur if coracoclavicular sling augmentation is not used 2
  • Hardware irritation may necessitate later removal

• Technical Pearls:

  • Manufacturer-contoured anatomic plates are preferred over non-contoured plates due to lower rates of implant removal 3
  • Anterior inferior plating may lead to lower implant removal rates compared to superior plating 5
  • Ensure adequate screw purchase in the distal fragment, which is often small and osteoporotic

• Outcomes:

  • Surgical fixation of displaced lateral clavicle fractures improves union rates compared to non-surgical management 3
  • Studies show high union rates with good-to-excellent functional outcomes following lateral clavicle fracture fixation 1
  • Typical union time is approximately 4-6 months 4

By following this systematic approach, surgeons can achieve stable fixation of lateral third clavicle fractures with optimal functional outcomes and reduced complication rates.