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.
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.
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.
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.
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.
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.
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.
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:
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.
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
Bending of the wrist forward, backwards and in a circular motion
Movement of an open hand from side to side
Squeezing the shoulder blades together, while shoulders remain relaxed
Phase II: Two to six weeks after surgery
Pendular exercises can be started when pain starts to subside.
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:
Flexion with arms on table
Flexion with ball on wall
Sub-maximal isometric exercises with:
External rotation (1)
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.
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.