Rockwood Children CH19

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

❑❑ Assess reduction and screw lengths with direct visualization and/ or fluoroscopic imaging in multiple planes ❑❑ Repair periosteum to tighten CC and acromioclavicular ligaments. Rarely apply supplemental fixation to CC ligaments utilizing suture around coracoid and clavicle if fixation is marginal ❑❑ Irrigate wound and close periosteum ❑❑ Meticulous skin closure with absorbable suture ❑❑ Apply sling or shoulder immobilizer The implant choice will depend on the age and size of the patient, as well as the size and location of the fracture frag- ments. Fixation with low-profile anatomic distal locking plates can be used for older adolescents with fractures that have a distal fracture fragment large enough to accommodate multi- ple screws, which may be locking screws, or a combination of cortical and locking screws. If there is not adequate bone on the distal fragment or in the rare case of a complete AC joint dislocation with no distal bony fragment, a hook plate may be used (Fig. 19-9), but has the disadvantage of requiring second- ary surgery for hardware removal once healing is confirmed. Younger adolescents or preadolescents with robust periosteum may require only suture-based fixation, with three potential fixation constructs: (1) suture repair of the periosteum only, in cases in which a thick enough cuff of superior periosteum can provide adequate stabilization of the proximal fragment; (2) suture repair in which high-strength nonabsorbable figure- of-eight sutures are placed through the thick inferior perios- teum/CC ligament complex and wrapped around the clavicle or through small superior-to-inferior drill holes through the distal aspect of the proximal fragment, with overlying superior peri- osteal repair; or (3) suture repair through small drill holes in the distal and proximal bone fracture fragments, with overlying superior periosteal repair. For younger patients with smaller clavicle sizes who undergo plate fixation, utilization of modular hand instrumentation or mini-fragment locking plates (Synthes, Inc., West Chester, PA) may be warranted. Distal radius plate fixation has also been suggested by placement of the 2.4-mm locking screws in the distal clavicle fragment. 72 K-wire fixation is rarely utilized, but should be supple- mented with a dorsal tension band, utilizing either suture or wire. Threaded wires are also rarely used, but have been described to lessen the risk of K-wire migration. 6,73,87,93 Additional fixation of the CC ligaments has been suggested to decrease the chance of nonunion in adults, and may be appli- cable to the older adolescent. This has been performed utilizing suture or soft tissue tendon grafts. 49,156 In addition, arthroscopic techniques, utilizing suture, the Tightrope system (Arthrex, Naples, FL), or a double-button device, to stabilize the CC liga- ments have also been reported in adults. 14,29,116,122 Some authors have proposed placement of a screw between the coracoid and clavicle; however, this requires screw removal following frac- ture union. 10,37,40,68,92,161 Neither of these techniques are used very often in children or adolescents. Operative treatment of distal clavicle fractures has excellent results with regard to union rates, especially in children and adolescents. The most common postoperative complication is hardware irritation requiring secondary removal surgery. Because utilization of smooth wires about this region can lead to

❑❑ Contralateral side of fracture

Fluoroscopy location

❑❑ Nonabsorbable suture, anatomic distal clavicle plates, hook plates, mini-fragment, or modular hand locking plates ❑❑ Entire shoulder girdle region and ipsilateral limb are prepped and draped into the field to allow for traction and manipulation ❑❑ Medially, the ipsilateral sternoclavicular joint should be included in the operative field

Equipment

Draping

It is necessary to determine preoperatively what the plan for fix- ation is going to be as numerous techniques can be performed to stabilize the distal clavicle. Ideally, multiple options are available at the time of surgical intervention including various nonabsorb- able suture options, specialty distal clavicle locking plates, and hook plates. The position the patient will be in during the proce- dure needs to be discussed with the anesthesiologist and operat- ing room staff, especially if the beach chair position is being used. Positioning The patient can be positioned in either the beach chair position (i.e., ∼ 60 degrees of head elevation) with the head and neck tilted away, a “sloppy beach chair” position (i.e., 45 degrees of head elevation), or supine on a radiolucent table. With either posi- tion, a bump should be placed behind the scapula. The entire shoulder girdle, beginning at the medial edge of the clavicle, and the entire limb should be prepped and draped in the operative field to allow for movement of the limb which facilitates fracture reduction and fixation. A sterile area above the shoulder adja- cent to the head is maintained to allow for the surgeon to work both inferior and superior to the clavicle and shoulder. Surgical Approach An incision in Langer skin lines over the distal third of the clav- icle and AC joint should be made. Once the skin is divided, the subcutaneous tissue, fascia, and periosteum are incised to maintain a thick flap. Subperiosteal dissection is then carried out from nonfractured clavicle out to the fracture site to expose the fracture fragments.

Technique

✔ ✔ ORIF of Distal Clavicle Fractures: KEY SURGICAL STEPS

❑❑ Skin incision over distal 1/3 of clavicle and acromion in line with Langer lines ❑❑ Electrocautery through subcutaneous tissue, fascia, and periosteum directly onto the clavicle ❑❑ Expose fracture site in a subperiosteal manner while preserving the acromioclavicular and CC ligaments ❑❑ Reduce fracture fragments with reduction clamps and temporary K-wire fixation if necessary ❑❑ Apply distal clavicle plate on superior aspect of distal clavicle