This procedure is extremely difficult and should not be performed except by very expert upper extremity surgeons.
The goal of treatment
The goal of treatment for a multifragmentary fracture of the shaft of the clavicle requires restoration of the appropriate alignment length and rotation.
This may be achieved with a minimally invasive plate osteosynthesis technique (MIPO). It requires less soft tissue dissection, preserves blood supply and biology to improve healing.
We will here show the procedure with a precontoured clavicular plate.
Note: Even a precontoured plate may also require some additional contouring.
The use of the image intensifier is also required to verify the correct application of the plate when using a MIPO technique.
When the fracture location is more lateral or more medial, the bone quality near the metaphysis may not offer sufficient screw purchase. In these instances, a plate offering additional screw fixation may be required (eg, longer plate, periarticular plate, locking head screws).
In MIPO of clavicular fractures, the following reduction techniques are useful:
Shoulder manipulation with inline traction and an external rotation movement often helps to reduce the fracture. (The shoulder should be draped free.)
Pointed reduction clamps can be used either percutaneously or through small stab incisions.
If the fracture zone is extensive and normal anatomic landmarks cannot be restored, one uses a pre-contoured plate which is then fixed to the medial side first, as this side cannot tolerate malalignment. The lateral end of the clavicle is then reduced to the plate by manipulation. Once reduced, the reduction is maintained with a percutaneous applied clamp, and the lateral end of the plate is fixed to the clavicle with one screw. C-arm control of the reduction is then carried out. If deemed satisfactory, fixation of the plate on the medial and lateral end of the plate is completed.
The superior surface of the lateral fragment is flat and readily identified. Reduction of the plate to the superior flat surface of the lateral segment will often restore the correct rotation.
The precontoured plate is inserted through the skin incision medially or laterally into a subcutaneous tunnel over the clavicle. Two positions are possible, superiorly or anteriorly.
Cortex screws are inserted first, one on each end of the plate, to bring the plate close to bone.
Fracture reduction and plate position is checked. If satisfactory, additional cortical and/or locking screws are inserted to complete the fixation.
If the fracture reduction and plate position are not satisfactory, the screws may be loosened and reduction procedure repeated.
The aftercare can be divided into 4 phases:
Inflammatory phase (week 1–3)
Early repair phase (week 4–6)
Late repair and early tissue remodeling phase (week 7–12)
Remodeling and reintegration phase (week 13 onwards)