Step-by-Step Procedure for Midshaft Clavicle Fracture Plating
Plate fixation is the recommended surgical approach for displaced midshaft clavicle fractures, offering higher union rates and better early patient-reported outcomes compared to nonsurgical treatment. 1
Preoperative Considerations
Patient Selection: Ideal candidates include:
- Patients with displacement of one or more shaft width
- Shortening of more than 1 cm in length
- High physical activity requirements
- Fractures with skin tenting (requires urgent intervention)
Imaging: Obtain upright radiographs to accurately demonstrate fracture displacement
- Consider CT scan for complex or comminuted fractures 1
Surgical Procedure
1. Patient Positioning and Preparation
- Position patient in beach chair or supine position with a bump under the affected shoulder
- Prepare and drape the affected shoulder and upper chest area
- Administer appropriate anesthesia (general anesthesia typically preferred)
2. Surgical Approach
- Make an incision along the superior aspect of the clavicle, centered over the fracture site
- Alternative: Consider minimally invasive plate osteosynthesis (MIPO) technique which has shown good outcomes with smaller incisions 2
- Carefully dissect through subcutaneous tissue, identifying and protecting the supraclavicular nerves
- Expose the fracture site by elevating the periosteum
3. Fracture Reduction
- Reduce the fracture anatomically using reduction clamps
- For complex fractures, temporary external fixation can facilitate reduction during the procedure 3
- Ensure proper length, rotation, and alignment
4. Plate Application
- Plate Selection: Use manufacturer-contoured anatomic clavicle plates
- Anterior-inferior plating may lead to lower implant removal rates compared to superior plating 1
- Position the plate along the superior or anterior-inferior surface of the clavicle
- Secure the plate temporarily with reduction clamps
5. Fixation
- Drill and place screws in the lateral fragment first
- Ensure adequate screw purchase in the distal fragment, as it is often small and osteoporotic 1
- Place screws in the medial fragment
- Use locking screws for enhanced stability, especially in comminuted fractures
- Typically, a minimum of three screws on each side of the fracture is recommended
6. Wound Closure
- Irrigate the wound thoroughly
- Close the periosteum over the plate when possible
- Close subcutaneous tissue and skin in layers
- Apply sterile dressing
Postoperative Management
1. Immediate Postoperative Care
- Immobilize in a sling for comfort
- Manage pain appropriately
- Obtain postoperative radiographs to confirm reduction and hardware position
2. Rehabilitation Protocol 1
- Weeks 1-2: Gentle passive range of motion exercises as tolerated
- 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
Potential Complications and Pitfalls
- Hardware irritation: May require plate removal after fracture healing
- Infection: Rare but serious complication requiring prompt treatment
- Nonunion: More common in smokers; counsel patients accordingly 1
- Neurovascular injury: Careful dissection and protection of neurovascular structures is essential
Special Considerations
- Smoking significantly increases nonunion risk and leads to inferior outcomes 1
- For adolescent patients (18 years and younger), surgical benefits may be less pronounced except in cases with skin tenting 1
- Avoid low-intensity pulsed ultrasonography (LIPUS) as it does not accelerate healing 1
The minimally invasive plate osteosynthesis technique has shown promising results with shorter immobilization periods, rapid return to sports, and low complication rates 2, 3. This approach may be considered as an alternative to conventional open reduction and internal fixation in appropriate cases.