ORIF - Pre-contoured distal plate

Most distal clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial management typically requires temporary immobilization for comfort followed by gradual increase in activity.

Operative fixation is indicated for selected cases of displaced distal clavicle fractures in high demand patients. Plate fixation is a preferred technique if distal clavicular bone purchase is adequate.

Precontoured anatomic plates with locking capabilities facilitate and optimize fixation in the distal fragment.

The avulsed fragment should be included in the plate screw fixation whenever possible. Most often it is too small to accommodate a screw, in this case the dislocation forces are neutralized using an additional suture anchor, or a hook plate.

While hook plate fixation is an option for those fractures with inadequate distal screw purchase, the high rate of plate irritation and subsequent need of removal of hook plates makes anatomic plate fixation preferred if technically feasible.

Pitfall: The typical mode of failure of distal clavicle fixation is pullout of the distal fixation with redisplacement of the shaft. It is mandatory for the operating surgeon to obtain sufficient distal fixation consistent with the expected compliance and healing potential of the patient such that union will occur prior to potential hardware failure. If, in the opinion of the operating surgeon, this is not obtainable with conventional plate fixation, convert to hook plate fixation.

This procedure is normally performed with the patient either in a beach chair or a supine position.

For this procedure a superior approach is normally used.

Following reflection of the deltoid, the distal clavicle fracture site is identified and cleared of any hematoma or debris.

Pitfall: it is important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to stability of the small distal clavicular fragment.

A sterile 18 gauge needle is used to identify the acromioclavicular joint. This allows the surgeon to determine accurately the size and integrity of the distal clavicular fragment. Assessment is then performed to determine whether conventional plate fixation is possible, or if hook plate fixation is required.

Reduction can be performed using fracture clamps on the proximal and distal fragments, with downward and anterior pressure on the proximal fragment and superiorly directed force on the shoulder girdle and attached distal fragment.

Alternatively, a ball spiked pusher may be utilized to align the fragments.

Following accurate reduction, temporary fixation with a K-wire directed from lateral to medial, trans fixating the AC joint, the small lateral fragment to the main medial fragment.

An anatomical precontoured plate for the distal clavicle is chosen for fixation. Advantages of these plates include the insertion of multiple (locked or unlocked) screws in the distal fragment to maximize fixation. Use the guide jigs to help you determine the predetermined pattern of locking screws which may also increase fixation strength.

While fixation is typically weakest in the distal fragment, it is important to assure proximal fixation with at least 3 bicortical screws in the shaft fragment.

If desired threaded drill sleeves can be used to insert locking screws in a preset pattern in the distal fragment.

The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through preset holes in the plate or with a reduction clamp.

Pitfall: It is important to avoid screw penetration into the acromioclavicular joint. If there is any doubt an intraoperative radiograph can confirm plate position.

Alternatively if fracture configuration permits, a lag screw can be inserted across the fracture site through the plate. Following this step, remaining screws in the plate may be inserted. It is important that the inferior fragment with its attached CC ligaments is included in the fixation.

K-wire is removed.

Superior displacement of the shaft fragment can be resisted through the placement of a suture anchor inserted into the coracoid base. The fibre wire is then used to prevent superior displacement of the clavicle.

If a suture anchor is not available, clavicle can also be secured to the coracoid using a cerclage fiber passed under the coracoid. If necessary one can use a tendon (auto or allograft).

Alternative techniques for ligament repair can be found here:

• Ligament repair

At the conclusion of fixation the fracture site, plate and screws are carefully checked to ascertain accurate reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains regarding these findings, an intraoperative radiograph should be taken for confirmation.

The aftercare can be divided into 4 phases:

1. Inflammatory phase (week 1–3)
2. Early repair phase (week 4–6)
3. Late repair and early tissue remodeling phase (week 7–12)
4. Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.