Authors of section

Authors

Jonas Andermahr, Michael McKee, Diane Nam

Executive Editor

Joseph Schatzker

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ORIF - Lag screw with neutralization plate

1. Introduction

The goal of treatment for a wedge or multifragmentary fracture of the shaft of the clavicle requires restoration of appropriate alignment and length of the clavicle. This may be achievable by absolute and/or relative 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, by far the more important 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.

orif lag screw with neutralization plate

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

orif lag screw with neutralization plate

Lag screws

The optimal inclination of the screw in relation to a simple fracture plane is 90°.

If amenable, one lag screw should also be inserted through the plate, which will add torsional stability.

orif lag screw with neutralization plate

Neutralization plate

Lag screw fixation alone is typically insufficient to withstand the normal physiologic forces. A neutralization plate is required for additional stability to distribute the forces and allow early mobilization.

orif lag screw with neutralization plate

Plate alternatives

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

orif compression plate

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 anterosuperiorly. A reconstruction plate which is easier to contour may be used in smaller patients where the forces working on the plate are not as great. It is too weak for larger patients.

Biomechanically, anterosuperior or anterior plates result in mechanically stronger fixation. The exact placement of the plate will depend on the fracture pattern and the position of the fracture.

orif compression plate

Plate length

Plate length is determined by the fracture pattern and location. If possible 3 holes proximal and 3 holes distal to the fracture region should be used.

orif lag screw with neutralization 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 an anterior approach is norally used.

orif compression plate

3. Reduction and fixation

Plate application

The plate is fixed with a single bicortical position screw medially or laterally depending on the fracture pattern.

orif lag screw with neutralization plate

Lag screw insertion

If the fracture line of the wedge is amenable to lag screw fixation through the plate, optimal compression is achieved. Inserting the screw through the plate adds torsional stability.

If the wedge cannot be fixed as above, then it should be reduced and fixed to each of the main fragments in succession with smaller cortical screws used as lag screws.
The heads should be recessed as much as possible if they come to lie under the plate.
Another combination would be that the wedge is lagged to one of the main fragments and the other fracture plane is placed under axial compression as described in the beginning of this section. The wedge depicted in this illustration has subclavius attached to it and depends on the muscle for its viability. Thus, when fixing this wedge with lag screws, outmost care must be taken not to devitalize the wedge.

orif lag screw with neutralization plate

Compression plating of remaining simple fracture

The fracture pattern is now reduced to a simple fracture.

A screw is inserted in the lateral segment in compression mode.

orif lag screw with neutralization plate

Further screws can then be inserted in the lateral segment in neutral mode.

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).

diaphyseal wedge intact bending wedge

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