Authors of section

Authors

Jonas Andermahr, Michael McKee, Diane Nam

Executive Editor

Joseph Schatzker

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MIO - Bridge plate

1. Introduction

Caution!

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.

mio bridge plate

Plate selection

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.

mio bridge plate

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).

orif pre contoured distal plate

2. Patient preparation and approach

Patient preparation

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

Approach

For this procedure a MIO anterior approach is used.

mipo   anterior approach

3. Reduction and fixation

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.)

flexible intramedullary nail

Pointed reduction clamps can be used either percutaneously or through small stab incisions.

mio bridge plate

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.

mio bridge plate

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.

mio bridge plate

Plate application

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.

mio bridge plate

Cortex screws are inserted first, one on each end of the plate, to bring the plate close to bone.

mio bridge plate

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.

diaphyseal multifragmentary fragmentary segmental

4. Aftercare

Wound care

Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.

Implant removal

Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.

Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.

Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

Sleeping

The patient should sleep wearing the sling on his/her back or on the non-injured side.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.


nonoperative treatment

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.

It may be more comfortable sleeping in a sitting or semi reclined position.


nonoperative treatment

Hygiene

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.


 
nonoperative treatment

Dressing

Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

diaphyseal multifragmentary fragmentary segmental

Progressive exercises

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The phases of nonoperative treatment are thus:

  • Temporary immobilization
  • Passive/assisted range of motion
  • Active range of motion
  • Progressive resistance exercises

Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.

This is followed by gentle range of motion exercises.

Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.

nonoperative treatment

Phase I: Day one after surgery

After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:

  • Straightening and flexion of the elbow
  • Open and closure of the hand
  • Squeezing of a soft ball
nonoperative treatment

  • Bending of the wrist forward, backwards and in a circular motion
  • Movement of an open hand from side to side

nonoperative treatment

  • Squeezing the shoulder blades together, while shoulders remain relaxed

nonoperative treatment

Phase II: Two to six weeks after surgery

Pendular exercises can be started when pain starts to subside.

nonoperative treatment

Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

Activated assisted range of motion exercises are started with:

  • External rotation
  • Internal rotation

nonoperative treatment

  • Flexion with arms on table
  • Flexion with ball on wall

nonoperative treatment

Sub-maximal isometric exercises with:

  • Internal rotation
  • External rotation (1)
  • Abduction (2)
  • Extension

Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.


nonoperative treatment

Phase III: Six to twelve weeks after surgery

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.


nonoperative treatment