Rockwood Children CH19

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SECTION TWO • Upper Extremity

Figure 19-9.  A: Radiograph of a displaced intra-articular lateral clavicle fracture where the lateral aspect of the medial fragment was entrapped in the trapezius muscle. B: Postoperative radiograph demonstrating fixation utilizing a hook plate. Removal of the implant is planned. (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.) A B

migration of the wires into areas including the lung, abdomen, spine, trachea, and vascular structures, smooth K-wires should be avoided if possible; or, can be left outside of the skin and removed at 4 weeks. 91,124,149 Tension band wiring is particularly prone to symptoms requiring a second procedure for removal. Using nonabsorbable suture as a tension band can lessen the risk of hardware irritation but suture granulomas can also be irritating and require subsequent removal at times. 83 Union rates with plate fixation have been reported to be as high as 100%. 25,47 Two studies have found that hook plate usage in adults yielded higher rates of return to work and sports partic- ipation and a lower complication rate than other techniques, 43,83 but a more recent study showed superior outcomes and lower complications with distal locking plates, compared with hook plates. 39 We advocate removal of the hook plate in an adolescent when the fracture is healed to avoid secondary complications.

A direct approach to the fracture site is performed using a Langer skin line. Following sharp incision of the skin, electrocautery is utilized to divide the subcutaneous tis- sue, fascia, and periosteum. A periosteal elevator or scalpel is then used to elevate the periosteum off of the clavicle while preserving the AC and CC ligament attachments. The fracture fragments are then exposed and irrigated free of hematoma and debris in preparation for reduction. For younger adolescents and preadolescents, if the superior periosteum is found to be robust enough, reduction of the proximal fragment and suture repair of the periosteum is preferred. If the stability of this con- struct appears questionable, high-strength nonabsorb- able figure-of-eight sutures are placed through the thick inferior periosteum/CC ligament complex and wrapped around the clavicle or placed through small superi- or-to-inferior drill holes through the distal aspect of the proximal fragment, with additional overlying supe- rior periosteal repair. For older adolescents, fixation of a distal clavicle fracture is ideally performed using an anatomically contoured distal clavicular locking plate and screw construct, assuming there is enough bone lat- erally for stable fixation. If the fragment is too small for these implants, we attempt to perform fixation utilizing mini-fragment or modular hand locking plates (Synthes, Inc., West Chester, PA). If plate fixation is not an option, interosseous suture fixation of the fracture fragments can be performed, with the suture through the distal fragment also brought through the strong AC ligament complex, to provide

Authors’ Preferred Treatment for Distal Clavicle Fractures

Our preferred technique is to treat nearly all distal clavicle fractures in the pediatric and adolescent populations with nonoperative measures. Patients are placed into a sling for 6 weeks and then advanced to active range of motion, presuming union has occurred. Operative intervention is reserved for open fractures, fractures with skin compromise, fractures with associated neurovascular injury requiring operative intervention, displaced intra-articular fractures, and significantly displaced fractures, especially those dis- placed posteriorly with entrapment in trapezius muscle.