Session I - Upper Extremity

Open Reduction and Anterior-Inferior Plating of Middle-Third Fractures and Nonunions of the Clavicle

Cory Collinge, MD; Scott Devinney, DO; Dolfi Herscovici, DO; Thomas DiPasquale, DO; Roy Sanders, MD; Florida Orthopaedic Institute, Tampa FL

Hypothesis: While the vast majority of clavicular shaft fractures heal well with nonoperative treatment, certain fractures will require operative intervention. The reported results of surgical treatment using standard approaches, however, have shown a high complication rate. When indicated, we have treated injuries to the clavicle using a modified approach, namely anterior inferior plating. When this method is used, instrumentation is directed away from potentially dangerous anatomy and implant prominence may be lessened. The purpose of this study is to review our results using this technique.

Methods: Indications for surgical intervention of a middle third clavicular fracture in our study included: 1) a floating shoulder, 2) open and/or impending open fractures, 3) marked shortening of the clavicle affecting normal shoulder function, and 4) an established and painful nonunion. Using our trauma registry, we identified 55 patients that met these criteria between 1992 and 1998 and underwent ORIF of the clavicle using anterior inferior plating. Thirty-four patients were treated for acute fracture and 21 for nonunion using this method. Many of the acute fractures were the result of high-energy trauma, including 27 with floating shoulder injuries. The mean age of patients was 33 years (range 13-72). Our surgical approach included a direct anterior approach, subperiosteal dissection of the clavipectoral tissues in an inferior direction, and anterior inferior plating using a contoured 3.5 mm dynamic compression or reconstruction plate and lag screw(s). All screws were aimed postero-superiorly. Nonunions were measured preoperatively against the normal side and when needed, a structural ICBG was used in conjunction with the plating. Postoperatively all patients were allowed to move without heavy lifting. Full return of activities was permitted once healing had occurred, typically by three months postoperatively. Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment and the SF-36 general health survey.

Results: There were 38 patients with sufficient hospital and radiographic records available for follow-up of at least 12 months (Range 12-78 mo). Clinical and radiographic union was present at a mean of 9.1 weeks (range 6-18 wks). There was 1 failed fixation and 1 nonunion, both occurring in patients treated for acute fracture. Both healed after revision surgery, thus, the ultimate union rate was 100%. Two patients, both with open fractures, suffered postoperative infections, which were successfully treated with I&D and antibiotics. There were no other complications of surgery. Two patients underwent elective hardware removal for irritable hardware soon after fracture healing. At final examination, 4 of 38 patients described minimal tenderness over some area of the implants, and none desired elective hardware removal. No female patients had difficulty wearing bra straps and no patients complained of backpack strap pain or other irritations when wearing clothing about the shoulder. Shoulder motion was excellent in nearly all acute fracture patients, except for a consistent mild decrease in internal rotation. The mean shoulder motion of patients undergoing ORIF for nonunion was slightly more limited. The American Shoulder and Elbow Surgeons shoulder assessment scores were 94 (out of 100) for acute fracture patients without brachial plexus injury, and 85 for those treated for nonunion. At most recent follow-up, the acute fracture population had SF-36 results similar to normative scores of the general population, while patients treated with ORIF for nonunion demonstrated a lower aggregate physical component score.

Discussion: Most clavicular shaft fractures heal well with non-surgical treatment. However, when indicated, surgical treatment has had varying results and complication rates have been high. We have used a method of ORIF using anterior inferior placement of a stiff plate and lag screws. We have demonstrated good clinical results with a low complication rate. Advantages of this technique may include: instrumentation directed away from anatomical structures at risk; screws with a longer excursion, and therefore more purchase; and inferior placement of the plate that results in little, if any, irritation of the skin by the implants.

Conclusions: Anterior inferior plating of acute midshaft clavicle fractures and clavicle fracture nonunions result in early healing, few complications and excellent return of function. We recommend this technique for all those fractures that require internal fixation.