ORIF - Compression plate with lag screw

The goal of treatment for a simple two-part fracture of the shaft of the clavicle is direct bone healing. This requires anatomical reduction and absolute stability.

Note: This is the most common pattern. The deforming force on the medial end is the pull of the muscles and the deforming force on the lateral side is the weight of the upper extremity.

Beware of the major neurovascular bundle (subclavian artery, vein, and brachial plexus) running directly beneath the midshaft of the clavicle.

Other types of deformities may occur if the coracoclavicular ligaments are disrupted (eg, superior displacement of the lateral fragment).

Absolute stability can be optimally achieved by inserting a lag screw through the plate after primary axial compression.

We will here show the procedure with a precontoured clavicular plate which has both a bend and a twist built into it.

However, if a precontoured clavicular plate is not available, there are other options.

A straight plate may be used if it fits the clavicle (conventional or angle stable). If it does not, then it needs to be contoured.
This is best achieved with a slight twist at the midportion of the plate. This results in the lateral plate being applied superiorly and the medial portion anteriosuperiorly. A reconstruction plate which is easier contour may be used in smaller patients where the forces working on the plate are not as great.

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

For this procedure an anterior approach is normally used.

Using the fracture interdigitations as a gauge for the reduction, obtain control over the proximal and distal fragments using reduction clamps. Apply gentle traction using a lobster clamp on the lateral fragment or the free draped arm and a derotation force, typically to the lateral fragment, to anatomically reduce the fracture.

Maintaining provisional stability with an additional pointed clamp is helpful prior to the plate application. The clamp is ideally placed away from any eventual screw and plate placement.

The use of K-wires to assist in reduction and temporary stability prior to plate application has been described. However, this is not recommended as the surrounding vital neurovascular structures are in close proximity and would be at risk for injury.

The plate is then fixed with a single bicortical position screw medially or laterally depending on the fracture pattern. The plate alignment and fracture reduction is confirmed.

A second eccentrically positioned screw is then applied on the opposite fragment in compression mode.

If the fracture line is amenable to lag screw fixation through the plate, then further compression can be achieved. Inserting the screw through the plate adds torsional stability.

Before fully tightening the lag screw, the axial compression has to be released slightly to allow additional interfragmentary compression.
The loosened screw is then retightened.

The remaining screws are then inserted in neutral position. Typically, a minimum of three bicortical screws in each segment is sufficient.

Note: Occasionally 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 screws).

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:

• 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.

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

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:

• External rotation
• Internal rotation

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

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.

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.