Although the literature and textbooks tend to prefer conservative treatment for #clavicle #fractures and believe that despite the presence of malunion, it does not significantly affect the shoulder and upper limb function; some studies even believe that the nonunion rate of surgical treatment of clavicle fractures is higher than that of conservative treatment. However, in clinical practice, most orthopedic surgeons still recommend surgical treatment for displaced clavicle fractures due to the poor patient experience of conservative treatment with “” bandage fixation, the patient’s demand for improvement in local appearance, and the potential disputes that may exist in conservative treatment.
▲ The figure shows the most common injury mechanisms of clavicle fractures, direct violence (above), and indirect violence (below) (Source: Traumatology and Orthopedics Department, General Hospital of PLA).
Locking plate internal fixation is currently the most common surgical method for adult clavicle fractures. According to the biomechanics of the clavicle, placing the plate above the clavicle is the most ideal position, which is also the most convenient and most commonly used position in clinical practice. However, for some thin patients, the internal implant is easy to bulge on the body surface, causing psychological and physical discomfort; during the operation, the upper plate needs to be drilled from top to bottom, which has a high risk of damaging the blood vessels and nerves below the clavicle.
▲ Model diagram of the supraclavicular plate (Source: Traumatology and #Orthopedic #Surgery, PLA General Hospital)
▲ Protection of the supraclavicular nerve and placement of the supraclavicular plate. (Source: References)
Some scholars designed the use of anterior clavicle plates for the following purposes:
Avoid local implant bulge or implant pressing on the skin;
Avoid damage to nerves and blood vessels below the clavicle during surgery;
The shape of the anterior clavicle is more regular than that of the upper part, and the reconstruction plate is convenient for shaping (currently there is no such problem with anatomical plates).
The surgical operation plan for the anterior clavicle plate is basically the same as that for the upper clavicle plate, and part of the deltoid muscle and pectoralis major muscle insertion point need to be peeled off during surgery.
▲ The steel plate in front of the clavicle, the arrow indicates the supraclavicular nerve. (Source: Reference)
In terms of implant removal, foreign patients basically do not consider removing internal fixation in the absence of complications. Therefore, many literatures analyze “implant removal” as a postoperative complication. Foreign scholars compared the incidence of symptomatic implant removal with the upper and anterior plates, and found that the anterior plate is an independent risk factor for reducing symptomatic implant removal. This means that the upper plate may increase the risk of symptomatic implant removal.
The article included 71 patients, 32 of whom were fixed with supraclavicular plates, and 39 with anterior plates. The symptomatic implant removal rate of the superior plate (53.8%) was higher than that of the anterior plate (28.1%).
Although the literature results suggest the use of anterior plate fixation, the following points should be noted in clinical work:
The literature is only a suggestion, not mandatory, and not an authoritative standard;
The anterior plate and the medial nail also have the risk of damaging the posterior apex;
The surgical plan should be formulated in combination with the platform of the unit and the personal industry influence. Whether the same surgical technique is considered “innovative” or “messy” depends on the platform you are on. It is recommended to choose carefully.
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