Rockwood Children CH19

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

laterality of the fracture, the sports played, and the tolerance level for a malunion that is likely to demonstrate a full return to function, but perhaps along an unpredictable timeline. To date, no studies in adolescent populations have demonstrated clear superiority of operative treatment over nonoperative treatment, given the significantly lower rates of nonunion and symptom- atic malunion in adolescents relative to adults.

Open Reduction and Internal Fixation or Intramedullary Fixation Preoperative Planning ✔ ✔ Operative Treatment of Midshaft Clavicle

Fractures: PREOPERATIVE PLANNING CHECKLIST

❑❑ Standard table capable of going into beach chair position ❑❑ Supine beach chair position with head and neck tilted away ❑❑ Bump placed behind the scapula

OR table

In addition, the plate is less prominent in this location. Supe- rior placement of the plate is technically easier and allows for better resistance of the biomechanical forces acting to displace the fracture. Positioning Options for positioning during ORIF of clavicle fractures include using the beach chair position (i.e., ∼ 60 degrees), hav- ing the patient supine, or different degrees of torso elevation in between the two, that is, “sloppy beach chair” positioning (e.g., ∼ 45 degrees). With either position, a bump may be placed behind the scapula to bring the fracture fragments forward for ease of dissection. Surgical Approach ORIF is performed via a direct surgical approach to the clavicle using a skin incision that follows Langer lines. In an attempt to avoid problems, by having the incision directly over the plate, and to improve aesthetics, incise the skin on the inferior aspect of the clavicle, 32 or even up to 1 to 2 cm distal to the clavi- cle, with proximal dissection to the fracture site. Once the skin is incised, the platysma is dissected, revealing the underlying cutaneous supraclavicular nerves as they cross the clavicle, which should be identified and protected to avoid chest wall numbness, dysesthesias, or neuromas. Meticulous subperios- teal dissection is then carried out to expose the fracture site while ensuring maintenance of the soft tissue attachments to any malrotated or segmental fracture fragments. Preservation of the integrity of the periosteum, which may be torn at the site of the fracture, is critical to the postfixation closure of this layer, which will aid in optimization of bone healing and minimiza- tion of hardware irritation. The posterior periosteal sleeve also protects the underlying neurovascular structures. Intramedullary fixation is performed by making a similar approach using a small incision over the fracture site to expose Figure 19-6.  Radiograph of a right midshaft clavicular fracture treated with an intramedullary elastic nail, which subsequently went on to frac- ture. (Reprinted with permission fromWaters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

Position/positioning aids

❑❑ Contralateral to fracture

Fluoroscopy location

❑❑ Surgeon’s choice of implant

Equipment

❑❑ Shoulder girdle, entire clavicle, and ipsilateral limb are prepped and draped into the field to allow for visualization traction and manipulation ❑❑ Medially, the ipsilateral sternoclavicular joint should be included in the operative field

Draping

As with any procedure that will use implants, it is imperative to have the desired hardware available before proceeding to the operating room. Options for treatment of pediatric and ado- lescent clavicle fractures include anatomically designed clavicle plates, standard nonlocking and locking plates, and intramed- ullary devices including pins, wires, screws, and elastic nails. Intramedullary fixation has the potential benefits of requir- ing less soft tissue stripping at the fracture site, better aesthetics with smaller skin incisions, easier hardware removal, less poten- tial for hardware irritation, and less bony weakness following hardware removal compared with plate fixation. However, the ability to resist torsional forces is less with intramedullary fixa- tion compared with plating which can result in fracture of the intramedullary implant (Fig. 19-6). Furthermore, the potential for the intramedullary device to migrate is a major concern for many surgeons, thus limiting its usage. More modern intra- medullary devices with locking potential have decreased con- cerns regarding migration of traditional Kirschner-wire (K-wire) constructs, but are more likely to require secondary hardware removal surgeries to avoid soft tissue irritation at the posterior lateral clavicle entry sites. If plate fixation is being planned, one must determine what the preferred location of the plate will be, anteroinferior or superior. Anteroinferior plates have the advantage of perform- ing drilling in a posterosuperior direction, and thus the drill is not directed toward the surrounding neurovascular structures.