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

Step-by-Step Procedure for Midshaft Clavicle Fracture Plating

Plate fixation is the recommended surgical approach for displaced midshaft clavicle fractures, with manufacturer-contoured anatomic plates preferred due to lower rates of implant removal and deformation, and anterior inferior plating potentially leading to lower implant removal rates compared to superior plating. 1, 2

Preoperative Planning

1. Imaging Assessment

   • Obtain upright radiographs to accurately demonstrate fracture displacement
   • Consider CT scan of both clavicles for complex or comminuted fractures
   • For complex cases, consider 3D printing models of both the fractured and uninjured clavicle to aid in preoperative planning 3, 4

2. Plate Selection

   • Choose a manufacturer-contoured anatomic clavicle plate (preferred over non-contoured plates) 1, 2
   • Consider anterior inferior plating position (may lead to lower implant removal rates compared to superior plating) 1, 2
   • For comminuted fractures, plate fixation is particularly beneficial over intramedullary nailing 2
   • If using 3D-printed models, precontour the plate on the model before surgery 3, 4

Surgical Procedure

1. Patient Positioning and Preparation

   • Position patient in beach-chair or supine position with a bump between scapulae
   • Prepare and drape the affected shoulder and upper chest
   • Administer appropriate anesthesia (general or regional block)

2. Approach Options

   Standard Open Approach:

   • Make an incision along the superior aspect of the clavicle, centered over the fracture site
   • Incise the skin, subcutaneous tissue, and platysma
   • Identify and protect the supraclavicular nerves to minimize postoperative dysesthesia
   • Elevate the periosteum to expose the fracture site

   Minimally Invasive Plate Osteosynthesis (MIPO) Approach:

   • Make two small vertical incisions (medial and lateral to fracture site)
   • Create a submuscular tunnel between incisions
   • This approach results in lower rates of dysesthesia, better cosmetic results, and higher patient satisfaction 5

3. Fracture Reduction

   • Reduce the fracture anatomically using reduction clamps
   • For comminuted fractures, ensure proper length, alignment, and rotation
   • In cases with 3D-printed models, use the uninjured side model as a template for reduction 3, 4

4. Plate Application

   • Position the precontoured plate (anterior-inferior position preferred) 1, 2
   • For MIPO technique, slide the plate through the submuscular tunnel 5
   • Temporarily secure the plate with K-wires or clamps

5. Screw Fixation

   • Drill and place locking screws in the plate
   • Ensure adequate screw purchase in the distal fragment, which is often small and osteoporotic 2
   • Place at least three screws on each side of the fracture for stable fixation
   • For comminuted fractures, consider longer plates with more screws

6. Final Assessment

   • Verify fracture reduction and plate position with fluoroscopy
   • Ensure proper screw length and position
   • Check for any hardware prominence that might cause soft tissue irritation

7. Wound Closure

   • Irrigate the wound thoroughly
   • Close the periosteum and platysma if opened
   • Close subcutaneous tissue and skin in layers
   • Apply sterile dressing and arm sling

Postoperative Management

1. Immediate Care

   • Immobilize in a sling for comfort
   • Initiate early pendulum exercises as tolerated
   • Manage pain appropriately

2. Rehabilitation Protocol

   • Weeks 1-2: Gentle passive range of motion exercises
   • Weeks 2-6: Progress to active-assisted range of motion
   • After 6 weeks: Begin strengthening exercises if radiographic healing is evident
   • Return to full activities typically at 3-4 months based on healing

3. Follow-up Schedule

   • 2 weeks: Wound check and suture removal
   • 6 weeks: Radiographic assessment of healing
   • 12 weeks: Assess for union (average time to union is 12-13 weeks) 4, 6
   • Consider implant removal after complete healing if symptomatic

Important Considerations and Pitfalls

• Avoid figure-of-eight bracing for immobilization; sling is preferred 1, 2
• Do not use low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing or lower nonunion rates 1, 2
• Counsel patients who smoke about increased nonunion risk and inferior outcomes 1, 2
• Be cautious with adolescent patients (18 years and younger) as they may not benefit from surgical treatment compared to nonsurgical management 1, 2
• Consider plate removal complications - refracture after implant removal is a significant risk, particularly with plate fixation 6
• Ensure adequate screw purchase in the distal fragment to prevent hardware complications 2