Rockwood Children CH19

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SECTION TWO • Upper Extremity

only the ends of fracture fragments. An additional percutaneous incision is placed over the superolateral part of the clavicle to place the intramedullary device in an antegrade manner.

favor closure of the overlying fascial layer and platysma layer, to optimize soft tissue coverage over the subcutaneous plate. Final assessment of the supraclavicular nerves is performed to be certain they are intact and without entrapment. A meticu- lous dermal layer and subcuticular closure is then performed to obtain the best cosmetic result possible and decrease the chance of wound complications. Sterile dressings are applied followed by placement of the patient into a sling. Intramedullary Fixation ✔ ✔ Intramedullary Fixation of Midshaft Clavicle Fractures: KEY SURGICAL STEPS ❑❑ Skin incision in line with Langer lines ❑❑ Dissection of platysma ❑❑ Exposure of fracture site ❑❑ Drilling of the medial segment of the fracture in preparation for device placement ❑❑ Drilling of distal fragment medullary canal and then posterior lateral cortex ❑❑ Placement of intramedullary device in a retrograde manner through fracture site ❑❑ Reduction of fracture fragments ❑❑ Advancement of device antegrade across the fracture ❑❑ Closure A skin incision is made overlying the fracture site in line with Langer lines. The platysma is dissected, and supracla- vicular cutaneous nerves are identified and protected. The fracture site is exposed in a subperiosteal manner. The soft tissue attachments to malrotated and comminuted fragments are preserved. The intramedullary canal of the medial frac- ture fragment is drilled in preparation for device placement, with care taken to ensure no violation of the anterior medial cortex occurs. The distal fragment medullary canal and then the posterior lateral cortex are drilled so that the drill can be visualized just beneath the skin. A percutaneous skin incision is made where the drill is tenting the skin. The intramedullary device is placed in a retrograde manner through fracture site to exit through posterior lateral skin incision. Fracture frag- ments are reduced, and the device is advanced in an antegrade manner across the fracture. If available, device-specific mecha- nisms are placed to prevent migration or permit compression. The periosteum, overlying fascial layers, platysma layer, and skin are closed. A sling or shoulder immobilizer is applied.

Technique Open Reduction and Internal Fixation ✔ ✔ ORIF of Midshaft Clavicle Fractures: KEY SURGICAL STEPS

❑❑ Skin incision in line with Langer lines ❑❑ Dissection of platysma ❑❑ Exposure of fracture site ❑❑ Reduction of fracture ❑❑ Plate application ❑❑ Assessment of reduction ❑❑ Closure

We use the sloppy beach chair position at 45 degrees and make our skin incision approximately 1 to 1.5 cm inferior to the clavicle. Following exposure of the fracture fragments, reduc- tion is performed utilizing bone holding forceps. It is imper- ative to restore the length and contour of the clavicle during the reduction process. This may require utilization of smooth wires, suture, or interfragmentary screws. Because comminuted fractures are among the more common fractures that, overall, undergo operative fixation, interfragmentary fixation of a free fragment with a 2.0- or 2.7-mm lag screw is helpful in turn- ing a three-part or four-part fracture into a two-part fracture amenable to optimal plate placement. Once the reduction is near-anatomic, the plate is applied on the superior aspect of the clavicle. During drilling and screw placement, we protect the underlying neurovascular structures by placement of a mallea- ble retractor inferior to the clavicle. Following provisional plate placement, fluoroscopic imaging and/or direct visualization is utilized to assess the plate position to ensure avoidance of far-medial or far-distal eccentric screw or plate position, which can increase the change of peri-implant fracture and hardware irritation. Compression techniques with eccentric drilling within the oblique holes of the plate are considered critical to an anatomic final reduction and optimization of healing rates. Final biplanar fluoroscopic views are used to confirm optimal screw length and establish a radiographic postoperative base- line for future assessment of healing of the fracture. The wound is then thoroughly irrigated and the periosteum closed. We

Author’s Preferred Treatment for Midshaft Clavicle Fractures (Algorithm 19-1)

Most pediatric and adolescent clavicle fractures are treated nonoperatively with immobilization for 6 weeks. Patients then undergo home or formal rehabilitation to restore range of motion and strength before resuming full activities. Oper- ative treatment is performed for open fractures, fractures at risk for skin necrosis, and fractures associated with neuro- logic or vascular injury (Fig. 19-7). For completely displaced

fractures with significant shortening clearly greater than 20 mm, or severely comminuted fractures, a shared deci- sion-making process is pursued with the patient and family. Based on research demonstrating exceedingly low nonunion rates and symptomatic malunion rates in adolescents, even in the face of significant shortening, nonoperative treatment is generally recommended. For such fractures in the dominant