What is the step by step procedure for treating a fracture of the lateral third of the clavicle using plating and mercilene (polyethylene terephthalate) tape?

Surgical Procedure for Lateral Third Clavicle Fracture Using Plating and Mersilene Tape

The surgical management of lateral third clavicle fractures using plating combined with Mersilene tape provides superior outcomes by addressing both bony fixation and coracoclavicular ligament disruption, which is essential for these unstable fractures. 1

Preoperative Planning

• Review upright radiographs to accurately assess displacement (superior to supine views) 1
• Select appropriate implants:
  • Manufacturer-contoured anatomic plates (recommended over non-contoured plates) 1
  • Mersilene (polyethylene terephthalate) tape for ligament augmentation
  • Consider anterior-inferior plate placement for lower implant removal rates 1

Anesthesia Options

• Traditional general anesthesia is common
• WALANT (Wide-Awake Local Anesthesia No Tourniquet) is a viable alternative using:
  • 1% lidocaine with 1:100,000 epinephrine and 10:1 sodium bicarbonate
  • Total of 40 mL: 10 mL subcutaneously along clavicle and 30 mL subperiosteally 2

Surgical Technique

Step 1: Patient Positioning and Preparation

• Position patient in beach chair or supine with towel between scapulae
• Prepare and drape the affected shoulder and upper chest
• Mark surgical landmarks (clavicle, coracoid process)

Step 2: Surgical Approach

• Make a longitudinal incision along the superior aspect of the clavicle, centered over the fracture site
• Carefully dissect through subcutaneous tissue to expose the fracture
• Identify and protect the supraclavicular nerves
• Expose the coracoid process for later Mersilene tape passage

Step 3: Fracture Reduction

• Debride the fracture site of hematoma and interposed soft tissue
• Reduce the fracture anatomically using reduction clamps
• Temporarily hold reduction with K-wires if necessary

Step 4: Plate Application

• Select an appropriately sized anatomic pre-contoured plate
• Position the plate (anterior-inferior placement may be preferable to reduce hardware irritation) 1
• Ensure adequate screw purchase in the distal fragment, which is crucial as it is often small and osteoporotic 1
• Secure the plate with a minimum of two cortical or locking screws on each side of the fracture 3
• Consider using a lag screw if the fracture pattern allows for absolute stability 3

Step 5: Mersilene Tape Augmentation

• Pass the Mersilene tape around the coracoid process using a curved passer
• Create a sling from the coracoid to the clavicle, mimicking the function of the disrupted coracoclavicular ligaments 4
• Secure the tape to the clavicle through drill holes or around the plate
• Tension the tape appropriately to maintain reduction of the clavicle relative to the coracoid

Step 6: Wound Closure

• Irrigate the wound thoroughly
• Close the periosteum and soft tissues over the plate when possible
• Close subcutaneous tissues and skin in layers
• Apply sterile dressing and arm sling

Postoperative Management

• Immobilization with a sling (preferred over figure-of-eight bracing) 1
• Limited range of motion (up to 90°) without weight bearing for 6 weeks
• After 6 weeks, progress to full range of motion and gradual return to activities 3
• Radiographic follow-up at 2,6, and 12 weeks to assess healing

Important Considerations

• Ensure adequate fixation of the distal fragment, which is often small and osteoporotic 1
• The combined technique addresses both the bony injury and ligamentous disruption that characterizes unstable lateral clavicle fractures
• Mersilene tape augmentation helps prevent vertical displacement of the medial fragment when the coracoclavicular ligaments are disrupted 4
• Avoid low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing 1
• Counsel patients who smoke about increased nonunion risk and inferior outcomes 1

This combined approach of plating with Mersilene tape augmentation has shown good clinical and radiological outcomes with high union rates for displaced lateral third clavicle fractures 5, 4.