fracture of bone

this video will go over the basics ofmidshaft clavicle fractures and will show a technique of intramedullaryfixation the prevalence of clavicle fractures isconsidered to be between 2.6 percent and 5 percent of all adult fractures and 35 percent and 44percent of all shoulder girdle fractures the incidence is approximately 29 to 64 per 100,000 people per year the injury usually results from amoderate to high energy impact to the

point of the shoulder this can be due to a fall from a heightor a motor vehicle accident sports like hockey skiing and mountainbiking or horse riding are usually associatedwith the risk of suffering this injury a direct impact injury to the clavicleis rarely seen to be the cause the fracture fractures can be classified as suggestedby robinson type one fractures are those of the medialone-third and type three of those of the lateralone third

type two fractures include the variousextents of mid shaft fractures with 2a including cortical alignmentfractures and 2b displaced fractures displaced shortened comminuted fractures areconsidered to be seen most frequently advantages of intramedullary fixation includes smaller incisions and less soft tissue dissection as well as providing relative stability which enhances callus formation also

a lower risk of supraclavicular nerve injury a lower refractory rate and a faster union rate have been shown withintramedullary fixation by hurst and millet at the aaosm meeting in 2009 the indications for fixing claviclefractures as published by mckee's group in 2008include healthy active patients between the ages of 16 to60 with complete displacement and two or more centimeters ofshortening for midshaft clavicle fractures

severe displacement with skin tenting orimminent skin breakthrough as well as open fractures concomitant near vascular injuries floating shoulders with displacedfractures and obvious deformities areindications for surgery contraindications for surgery are activeinfections in the surgical field prior irradiation burns debilitating medical conditions high risk of non-compliance and elderlypatients with sedentary lifestyles

possible complications of surgicaltreatment include hardware failure or prominent hardware requiring revisionprocedures or hardware removal also fractures after or before hardwareremoval and your neurovascular injuries can be seen rarely infections pneumothorax orair embolism do occur in 2009 hurst and colleagues showed in a series of61 patients with intramedullary fixation midshaft clavicle fracturesan overall complication rate of 30 percent and a nonunion rate of9.8 percent

in 2007 the canadianorthopedic trauma society under mckee published an the overall complicationrate of 37 percent and a nonunion rate of 3.2percent with plate fixation of midshaftclavice fractures in a similar number of patients later in 2010 hurst and colleagues published outcomedata on a series of 53 patients with 100 percent displaced midshaft clavicle fractures

here 27 were treated nonoperatively and 26 underwent intramedullary fixation in the non operative group 26 percent had to go on tofurther surgery whereas only 7.7 percentof the intramedullary fixation group had to be revised overall the intramedullary group was moresatisfied and had better overall dash and ases scores although no statisticaldifferences were present

the following case shows a surgicaltechnique of intramedullary fixation of the clavicle pin this is a minimally invasive techniquefor midshaft clavicle fractures in this case a seventy-year-old highlyactive gentlemen injured himself while skiing he broke his right clavicletore his trapezius and subclavius muscles on the right side acutely extended a chronicrotator cuff tear dislocated the long head of the bicepstendon out of its grove and tore his labral all on the right shoulder

the pre-op x-ray show a completedisplaced shortened and comminuted fracture of the right clavicle it was decided to fix this fracture withan intramedullary clavicle pin the operation is performed in the vchair position with a c arm draped into the field this is needed for intraoperativeradiographic assessment the fracture side is prepped draped andmarked in routine fashion prior to incision the appropriate pin sizeis determined by holding up the various sized tabs and viewing them withfluoroscopy approximately 90 percent of the time weuse a three millimeter diameter pin

a curvilinear skin incision is made overthe fracture in line with longer lines subcutaneous flaps are developed supraclavicular nerves are protected if they are seen next the trapezius and subclaviusmuscles are split in line with their fibers first the medial fragment is tapped withthe predetermined sized blunt tap sometimes a drill can be useful beforetapping but care should be taken not topenetrate the intramedular

fragment tap placement is checked underfluoroscopy next the lateral fragment is drilled again care should be taken to have theright angle before drilling out of the lateral posterior cortex correct placement is confirmed with fluoroscopy it is important to tap the lateral fragmentto ensure that the pin can be appropriately seeded prior to the reduction the pin is then prepared for insertion

the blunt medial end is placed into thepower drill so that the sharp lateral end of the pin can be drilled out of thelateral posterior cortex of the lateral the skin is incised just above where thepin exits and the pin is driven out care should be taken so that the pinexits superior to the spine of the scapula next the drill is changed to the lateralpart of the pin the pin is backed up the fracture is reducedand the pin is driven into the medial fragment drill the pin far enough to reduce thefracture and then assemble the locking mechanism laterally

for this procedure is to estimatehow far the pin needs to travel into the medial fragment to reduce a fracture and then to coldweld the nuts in the appropriate place outside of the skin the pin is cut flesh and any sharpedges are removed with a tool before burying it under the skin then the lateral wrench is used to drivethe pin completely into the medial fragment reducing the fracture number 5 poly sutures are passedaround the clavicle to shuttle double

number 2 absorbable sutures as many sutures as needed are passedaround in the same fashion the number 2 sutures are then tied withthe racking half hitch knot to the communite fragments back into place to complete the reduction the construct is then backed up with anumber of half hitches the reduction is checked once more and thepin is driven in with a lateral wrench until the nuts come to rest at theposterior lateral cortex of the clavicle fluoroscopy from different angles isused to confirm reduction

muscular layers are closed in aroutine fashion in this case we proceed with routinearthroscopic repair of the rotator cuff and the bicep tendon this is not demonstrated in this video on a post operative bilateral x-ray one can measure the length of the fixedbone and compare to the unaffected side for stable fractures our standardrehabilitation protocol includes full active and passive render motion fromday one after operation

strengthening from week four andreturn to full activities at week six when the fracture is clinically andradiographically stable for unstable fractures only full passiverange of motion in the supine position is allowed for the first two weeks active range of motion should be delayedto week two or three strengthening is started at week four andfull activities can be resumed after clincial and radiographically proof of stabilityafter six weeks removal of clavicler pin the pin is routinely removed afterthree to four months when healing has

been confirmed clinically and radiographically in the following example a twenty-year-old female had her left clavicle fixed three months prior to removalprocedure healing has been confirmed clinicallyand radiographically the removal procedure is performed inv chair position with mild sedation local anesthetic is injected under the skinover the posterior lateral tip of the clavicle or the nuts that were buried the skin is carefully incised and thesoft tissues around the nuts are carefully dissected

next a medial wrench is taken and placed onthe nuts a few turns are made by hand before apower driver is attached the pin is carefully removed theincision is irrigated and the complete hardware removed as well as stability is confirmed under fluoroscopy our standard rehabilitation protocolafter pin removal is full active and passive range of motion immediately butno heavy lifting or loading for four weeks at four weeks post removal stability isconfirmed clinically and radiographically and after that the patient is cleared forreturn to full actvities