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Authors

Jonas Andermahr, Michael McKee, Diane Nam

Executive Editor

Joseph Schatzker

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ORIF - Pre-contoured distal plate

1. Introduction

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.

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.

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 superior approach is norally used.

orif hook plate

3. Reduction

Fracture assessment

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

Pitfall: it 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.

orif pre contoured distal plate

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.

orif pre contoured distal plate

Temporary fixation

Following accurate reduction temporary fixation with a K-wire directed from anterior to posterior can be performed.

orif pre contoured distal plate

Alternatively (and preferentially), if fracture configuration permits, a lag screw can be placed at this point.

orif pre contoured distal plate

4. Fixation

Plate selection

A precontoured distal clavicle plate is then chosen and applied with as many screws as possible in the distal fragment.

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.

orif pre contoured distal plate

In a limited resource environment, a 3.5 mm pelvic reconstruction plate can be used in this setting. The plate alone would fail, and therefore its stability has to be supplemented by inserting a screw through the plate into the base of the coracoid. This has to be kept in mind when choosing the optimal placement of the plate.

orif pre contoured distal plate

Placement and temporary securement of the plate

The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through 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.

orif pre contoured distal plate

Alternative 1: Application in compression mode

If fracture pattern is amenable to compression, the plate can be applied in compression mode. To do this, screws are placed in the distal fragment to secure the plate to the distal fragment. Typically, cancellous screws are used in the distal fragment.

orif pre contoured distal plate

Then, a compression screw is inserted in the shaft of the plate to compress the fracture site.

orif pre contoured distal plate

Alternative 2: Application in neutralization mode with lag screw through plate

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.

orif pre contoured distal plate

Pearl: Additional stability

Redisplacement of the shaft fragment can be further prevented by the insertion of a coracoclavicular screw inserted through the plate and then into the coracoid. One must aim for the posterior base portion of the coracoid. Due to the intrinsic motion between the clavicle and the coracoid this screw will eventually loosen or break, but will provide 6-8 weeks of added fixation before failure. The placement of this screw is at the surgeon's discretion when added stability is deemed necessary.

lateral displaced fracture with cc disrupted extraarticular

Alternatively, a sling of autograft/allograft tendon or heavy suture may be passed around the clavicle and under or through the base of the coracoid as further reinforcement of the plate construct to prevent superior migration of the clavicular shaft.

Alternative techniques for ligament repair can be found here:

orif pre contoured distal plate

5. Check of osteosynthesis

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.

6. 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