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Comminuted clavicle fracture – ORIF with Stryker Variax 2 locking plate

    Overview

    Learn the Comminuted clavicle fracture – internal fixation with Stryker Variax 2 locking plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Comminuted clavicle fracture – internal fixation with Stryker Variax 2 locking plate surgical procedure.
    Clavicle fractures are common accounting for around 4% of all fractures and up to 44% of fractures of the shoulder girdle of which the middle third is by far the most common site. The management of such injuries can be difficult and outcome can be unsatisfactory. There has been reported non-union rate of displaced mid-shaft clavicle fractures of between 15 and 20%. This can be reduced significantly with surgical intervention. Whilst there is risk and some potential complications with any surgical intervention the published results demonstrate that plate and screw fixation can be performed safely to give a good outcome with improved patient satisfaction and a reduction in the non-union rate compared to conservatively managed fractures.
    There are many implant companies with clavicle specific plates. Described here is the use of the Stryker VariAx 2 clavicle locking plate system. These contoured and sided plates are available for lateral injuries, superior shaft fractures and for use along the anterior face of the clavicle. The plates and screws are made of different grades of titanium allowing the harder locking screws to cut their own thread within the softer material of the plate and their position can be adjusted up to three times. Screws are available in sizes 3.5 and 2.7 in both non-locking and locked varieties. The clavicle set also provides useful instruments to facilitate exposure with periosteal elevation, fracture reduction in terms of clamps and wires as well as plate holding clamps.

    Indications

    INDICATIONS
    Surgical fixation of clavicle fractures is a source of recent significant debate, research and ongoing discussion within the shoulder & trauma surgery communities.
    The indications for internal fixation of a clavicle fracture are relative. The vast majority of such fractures will unite with conservative measures. The advent of contoured fracture specific locking plates have been useful in the management of such injuries. Several recent high profile publications have looked at the outcomes from randomised trials of fixation of these. I believe that patients should be considered for surgery in the presence of a comminuted , displaced and mid-shaft fracture such as is presented here. One absolute indication though for surgery would be an open injury with penetration of the skin. Tenting or threat to the skin is a relative indication as is significant shortening of the shoulder girdle due to overlap of the fracture fragments.
    In my unit we adopt a policy of initial conservative management until the acute injury has settled and then a fracture clinic review by senior trauma or shoulder surgeon to assess progress within the first two weeks. In some patients the initial pain has settled significantly such that they are quite happy to pursue a non-operative course. A second group of patients will be struggling with pain and deformity in which case we offer surgical intervention.
    SYMPTOMS & EXAMINATION
    It is important to ascertain that this was a normal shoulder prior to the injury . The fracture usually results from a fall onto or direct blow to the shoulder girdle. This often happens as a result of sport or leisure activities particularly mountain bikes or contact collision team ball sport such as rugby. Patients present with pain and associated swelling around the region of the clavicle. Initially they will be reluctant to move the shoulder however it is important to ascertain whether there is still glenohumeral movement. Care must be taken to avoid assuming that the obvious fracture in the clavicle is the only injury in the shoulder. Previous shoulder trauma or indeed intervention should be ascertained. At the initial presentation clinical assessment of the rest of the shoulder girdle can be very difficult due to the acute pain. Important features to assess and document are the neurovascular status of the upper limb.
    IMAGING
    2 view plain radiograph X-rays are mandatory. Cross sectional imaging may be indicated if there is concern about a fracture towards the medial end and the sternoclavicular joint as this is notoriously difficult to image with plain X-rays. CT scans or indeed MRI scans can be useful looking for occult injuries around the shoulder and should be assessed on a case-by-case basis. Should there be any concerns as to the vascular status of the upper limb then close liaison with local vascular surgery colleagues is important and consideration should be given to angiography or contrast imaging.
    ALTERNATIVE OPERATIVE TREATMENT
    The technique described here is a superior contoured plate but alternatives would be anterior plating or an intramedullary device.
    NON-OPERATIVE MANAGEMENT
    It would be quite acceptable to propose non-operative treatment in such a patient with immobilisation in a sling or figure of 8 bandage or brace allowing underarm hygiene and encouraging elbow wrist and hand movements. Pendular shoulder exercises should be started early and then as pain settles active assisted shoulder movements can be commence. Most patient with such an injury will require sling immobilisation for the best part of the first four weeks and may struggle to be free from the sling until six weeks. Continued conservative management with graduated physiotherapy rehabilitation to concentrate on regaining range of shoulder motion prior to strengthening is well established.
    CONTRAINDICATIONS
    Patients’ co-morbidities and medical state should be assessed as to whether they are fit enough for surgery under general anaesthetic. Patients should be compliant with a post-operative regime as described. The state of the skin should be carefully assessed in the initial period to ensure that there is no soft tissue and skin abrasions over the site of surgical incision as this would be a relative contraindication to immediate surgery. Often surgery will be postponed or delayed due to the presence of fresh skin contusions or abrasions.

    Setup

    In the semi-sitting or beach chair position the patient is secured with their head on the head ring of a shoulder specific table attachment. Intravenous antibiotics are administered by the anaesthetist. Intermittent calf compression is used for thromboembolic prophylaxis during the procedure. A narrow moveable arm table is used on the operated side to rest the arm in a comfortable position. The shoulder should be placed on to a radiolucent part of the operating table to allow easy access for image intensifier and images during surgery or for checking the final position of fracture reduction and metalwork.

    Operation – 1

    Plain AP radiograph demonstrating comminuted mid-shaft fracture of left clavicle.

    Second image showing wide displacement of fracture and proximity of proximal shaft spike to overlying skin.

    Patient positioned in beach chair with head secured on head ring, shoulder in line with radiolucent part of operating table and operated arm resting on a moveable narrow arm board.

    Relevant bony anatomy is marked including position of the proposed incision inferior to the clavicle and hence away from the superficial bone.

    Second image confirming marking of the manubriosternal notch and acromioclavicular joint with the proposed incision site.

    Superior view of left shoulder showing skin marks. Note dry clean abrasion over distal clavicle away from proposed surgical incision.

    Whole upper limb is prepared with Chlorhexidine solution. Adhesive sterile drapes are placed across the base of the neck to the medial clavicle leaving the entire shoulder girdle exposed.

    Proposed incision site is infiltrated with 0.5% Bupivacaine with Adrenaline (10-20ml)

    The skin is incised and care is taken through the superficial layers to then identify the supraclavicular nerves (N) running transversely across the wound. Care can be taken to preserve the nerves but it is almost inevitable that they get damaged to some degree leaving the patient with a patch of numbness about which they should be warned during the consent process prior to surgery.

    Further sharp dissection directly perpendicular to the skin allows elevation of a thick fasciocutaneous tissue flaps. Care should be taken to continually identify the bony fragments by palpation allowing cutting directly down on to bone. In this case the large butterfly fragment is identified (B). The site of the fracture is identified and cleared of blood clot. Ensure that comminuted fragments retain as much soft tissue attachment as possible.

    Incise directly onto clavicle periosteum and reflect anteriorly and posteriorly with a periosteal elevator. West’s self-retainers hold tissues apart during mobilisation of fragments and identification of reduction options.

    Bone fragments are cleared of blood clot and fibrous tissue using periosteal elevators and picks.

    Using a combination of pointed and crocodile-type bone reduction forceps fragments can be mobilised and opposed to bring together reduction.

    In this case the decision was made to lag the largest butterfly fragment to the lateral clavicle using anterior to posterior (AP) 2.7mm interfragmentary screws. The butterfly fragment is held reduced to the lateral clavicle with a pointed reduction forceps and a small Homan’s retractor is placed posteriorly. Using the drill guide for the 2.0mm drill from front to back the first drill hole is created. In this situation lag screws could also be considered in which case the anterior cortex would be over drilled with the 2.8 drill. This would allow further compression at the fracture site.

    A depth gauge is placed into first drill hole to ascertain length of screw required.

    The Stryker VariAx 2 system uses either 2.7 or 3.5 screws which can be either locking or non-locking variety. Both screws and plates are manufactured with titanium but the screws are of a harder grade and hence cut their own thread into the relatively softer titanium plate creating the locked screw. These can be used in a variable angle on three separate occasions.

    Selected screw inserted into the butterfly fragment from anterior to posterior.

    A second more lateral drill hole is now created.

    A second self-tapping 2.7mm screw is inserted to fix the butterfly fragment to the lateral clavicle.

    The lateral clavicle is now reduced to the medial fragment and held with the crocodile reduction forceps.

    The Stryker VariAx 2 clavicle plate set has a variety of lengths of pre-contoured shapes for both left and right clavicles. Select the most appropriate size. The straight mid-shaft plates are shown here. There are specific anterior and lateral clavicle plates also available.

    An appropriate sized plate is selected and placed on the superior surface of the clavicle held with the specific plate holding clamp and temporarily secured laterally with a single K-wire into a lateral wire hole.

    3.5mm non-locking screws are selected for the medial shaft fragment. 2.6mm drill and guide are used with a broad flat Homan’s retractor beneath the clavicle protecting the underlying neurovascular structures.

    Once again the depth gauge is used to measure the length of the required screw.

    A 3.5mm non-locking screw has already been inserted medially and the same process used to drill for the far lateral screw. This step shows insertion of the far lateral screw.

    Operation – 2

    A further non-locking screw has been placed medially and this shows drilling of the second lateral drill hole.

    The second lateral drill hole is measured using the depth gauge.

    Insertion of second lateral non-locking screw.

    A third lateral hole has been drilled. As this was at the site of the butterfly fragment fixation with two AP screws, the decision was made to measure for a locked screw at this position.

    Insertion of locking screw between the two A-P screws can be seen. Threads just beneath the screw head can be seen which will be fixed into the plate by cutting their own path.

    The final most medial screw (non-locking 3.5) has been inserted. This shows the final position of the fracture reduction and fixation.

    The image intensifier C-arm can be positioned from the opposite side of the patient. This can be adjusted to get two views through the radiolucent table with the patient in the sitting position. Image intensifier monitors can be seen showing the images obtained.

    Intraoperative image intensifier image is showing reduction of fracture including the two AP screws with the locked screw inbetween. The further comminuted fragments inferiorly have been left in acceptable alignment with the fixed bone.

    The image intensifier is placed more vertical to get second intraoperative image.

    Second intraoperative image showing reduction of the fracture and overall position of the metalwork.

    Sutures are selected for closure of the wound starting with No 1 Vicryl (Ethicon) followed by No 0 Vicryl (Ethicon) and 3-0 Monocryl (Ethicon) for the subcutaneous closure of the skin.

    Following thorough washout and confirmation of haemostasis using diathermy, the deepest layer is closed with interrupted No 1 Vicryl stitches into deep fascia and periosteum ensuring that the metalwork is covered completely.

    Ensure that the plate is completely covered in closing this layer.

    Watertight repair of deepest layer covering hardware reduces risk of wound problems.

    Superficial fascia and fat is closed with continuous No 0 Vicryl.

    This opposes the skin edges.

    3-0 Monocryl is used for subcuticular closure of the skin with no knots. Start 1cm away from the end of the incision into the apex of the incision and run subcuticularly towards the apex of the other end.

    Both ends of the Monocryl suture can then be pulled to ensure a good apposition of skin edges.

    The wound is then covered with Steristrip paper adhesive strips.

    A waterproof adhesive dressing placed over the Steristripped wound.

    Check plain radiographs are taken at 2 weeks in fracture clinic at same time as wound check, trimming ends of absorbable sutures and instructions for mobilisation.

    Second post-operative radiograph showing reduction of fracture and position of hardware and
    in good alignment.

    Post Operative

    Prior to discharge from hospital the patient is instructed in underarm hygiene and mobilisation of elbow, wrist and hand. Active shoulder mobilisation is permitted avoiding elevation of arm above shoulder height for first three weeks. Review in fracture clinic at two weeks allows inspection of the wound following removal of Steristrips. The free ends of the absorbable Monocryl suture are then trimmed at skin level. Check X-rays are taken at this stage. The patient is allowed to wean from the sling as comfort allows over the next two weeks, increasing active shoulder mobilisation but avoiding lifting and resistance until comfort at four weeks. Discard sling at four weeks. Continue with graduated active shoulder mobilisation with physiotherapy instruction until eight weeks. If X-rays are satisfactory at eight weeks can return to full activities as comfort allows.

    Recommended Reading

    Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. Canadian Orthopaedic Trauma Society. J Bone Joint Surg [Am] 2007;89-A:1-10
    Locked intramedullary fixation versus plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial. Ferran NA, Hodgson P, Vannet N, Williams R, Evans RO. J Shoulder Elbow Surg 2010; 19:783-789
    Open reduction and plate fixation versus nonoperative treatment for displaced mid-shaft clavicular fractures: a multicenter, randomized, controlled trial. Robinson CM, Goudie EB, Murray IR et al. J Bone Joint Surg [Am] 2013;95-A:1576-1584
    Early versus delayed operative intervention in displaced clavicle fractures. Das A, Rollins KE, Elliott K, Johnston P, van Rensburg L, Tytherleigh-Strong GM, Ollivere BJ. J Orthop Trauma 2014;28:119-123
    The Clavicle Trial:a multicenter randomized controlled trial comparing operative with nonoperative treatment of displaced midshaft clavicle fractures. Ahrens PM, Garlick NI, Barber J, Tims EM, Clavicle Trial Collaborative Group. J Bone Joint Surg [Am] 2017; 99-A:1345-1354

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