Rockwood Children CH19

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SECTION TWO • Upper Extremity

A

B

C

D

Figure 19-7.  A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

Potential Pitfalls and Preventive Measures

between the bone and surrounding neurovascular structures. Subsequently, retractors can be placed in this layer and direct visualization can be used during the drilling and screw place- ment process to avoid damaging the neurovascular structures. Maintenance of soft tissue attachments to comminuted or malrotated small fragments will aid the surgeon in the reduction process. Furthermore, if these fragments are completely devoid of soft tissue attachments, devitalization may cause bony union to be delayed or not occur. Wound complications can be prevented by utilizing the infe- rior skin incision rather than a direct approach to the clavicle. In addition, a meticulous layered closure at the end of the pro- cedure will permit the best cosmetic outcome while minimizing the chance of wound issues. Outcomes Despite the high incidence of pediatric clavicle fractures and the fact that the vast majority of these fractures are treated nonopera- tively, limited data exist regarding the outcomes of these injuries. Generally, union rates from 95% to 100% have been reported with nonoperative treatment. 54,78,150 A recent study of 185 ado- lescent clavicle fractures with a median age of 14.4 years, 38% of which were completely displaced, demonstrated only 1 case of

Midshaft Clavicle Fractures: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Neurovascular injury/ pneumothorax

• Utilize subperiosteal dissection • Place retractors inferiorly when drilling from superior to inferior direction • Maintain soft tissue attachments to comminuted or malrotated fragments • Maintain soft tissue attachments to comminuted or malrotated fragments • Anatomically reduce and stabilize segmental fractures

• Delayed union/ nonunion

• Malunion

The most dreaded intraoperative complication would be dam- age to a neurovascular structure or creation of a pneumothorax. Both of these exceedingly rare iatrogenic complications can be prevented by utilizing meticulous technique during the expo- sure of the fracture fragments and drilling/screw placement during the plate application. When exposing the fracture frag- ments, it is imperative to stay subperiosteal to create a layer