Clavicle Fracture | IM Fixation with a Clavicle Pin | Broken Collarbone | Vail, CO


Uploaded by shoulderspecialists on 30.11.2010

Transcript:
this video will go over the basics of midshaft clavicle fractures and will
show a technique of intramedullary fixation
the prevalence of clavicle fractures is considered to be between 2.6
percent
and 5 percent of all adult fractures
and 35 percent and 44 percent of all shoulder girdle fractures
the incidence is approximately 29 to 64
per 100,000 people per year
the injury usually results from a moderate to high energy impact to the
point of the shoulder
this can be due to a fall from a height or a motor vehicle accident
sports like hockey skiing and mountain biking
or horse riding are usually associated with the risk of suffering this injury
a direct impact injury to the clavicle is rarely seen
to be the cause the fracture
fractures can be classified as suggested by robinson
type one fractures are those of the medial one-third
and type three of those of the lateral one third
type two fractures include the various extents of mid shaft fractures
with 2A including cortical alignment fractures
and 2B displaced fractures
displaced shortened comminuted fractures are considered 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 with intramedullary fixation by hurst and millet
at the AAOSM meeting in 2009
the indications for fixing clavicle fractures
as published by mckee's group in 2008 include healthy active
patients between the ages of 16 to 60
with complete displacement
and two or more centimeters of shortening
for midshaft clavicle fractures
severe displacement with skin tenting or imminent skin breakthrough as well as
open fractures
concomitant near vascular injuries
floating shoulders with displaced fractures
and obvious deformities are indications for surgery
contraindications for surgery are active infections in the surgical field
prior irradiation burns
debilitating medical conditions
high risk of non-compliance and elderly patients with sedentary lifestyles
possible complications of surgical treatment include hardware failure or
prominent hardware requiring revision procedures or hardware removal
also fractures after or before hardware removal
and your neurovascular injuries can be seen
rarely infections pneumothorax or air embolism do occur
in 2009
hurst and colleagues showed in a series of 61 patients with intramedullary fixation
midshaft clavicle fractures an overall complication rate
of 30 percent and a nonunion rate of 9.8 percent
in 2007 the canadian orthopedic trauma society under mckee
published an the overall complication rate of 37 percent
and a nonunion rate of 3.2 percent
with plate fixation of midshaft clavice fractures in a similar number
of patients
later in 2010
hurst and colleagues published outcome data on a series of 53 patients
with 100 percent
displaced midshaft clavicle fractures
here 27 were treated non operatively and 26 underwent
intramedullary fixation
in the non operative group
26 percent had to go on to further surgery
whereas only 7.7 percent of the intramedullary fixation group
had to be revised
overall
the intramedullary group was more satisfied and had better overall DASH
and ASES scores although no statistical differences were present
the following case shows a surgical technique of intramedullary fixation
of the clavicle pin
this is a minimally invasive technique for midshaft clavicle fractures
in this case a seventy-year-old highly active gentlemen injured himself while
skiing
he broke his right clavicle tore his trapezius and subclavius muscles on the
right side acutely extended a chronic rotator cuff tear
dislocated the long head of the biceps tendon out of its grove and tore his
labral all on the right shoulder
the pre-op x-ray show a complete displaced shortened and comminuted fracture
of the right clavicle
it was decided to fix this fracture with an intramedullary clavicle pin
the operation is performed in the V chair position with a C Arm draped into the
field this is needed for intraoperative radiographic assessment
the fracture side is prepped draped and marked in routine fashion
prior to incision the appropriate pin size is determined by holding up the various
sized tabs and viewing them with fluoroscopy
approximately 90 percent of the time we use a three millimeter diameter pin
a curvilinear skin incision is made over the fracture in line with longer
lines
subcutaneous flaps are developed supraclavicular nerves are protected if they are
seen
next the trapezius and subclavius muscles are split in line with their
fibers
first the medial fragment is tapped with the predetermined sized blunt tap
sometimes a drill can be useful before tapping
but care should be taken not to penetrate the intramedular
fragment
tap placement is checked under fluoroscopy
next the lateral fragment is drilled
again care should be taken to have the right angle
before drilling out of the lateral posterior cortex correct placement is confirmed
with fluoroscopy
it is important to tap the lateral fragment to 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 the power drill so that the sharp lateral
end of the pin can be drilled out of the lateral posterior cortex of the lateral
fragment
the skin is incised just above where the pin exits and the pin is driven out
care should be taken so that the pin exits superior to the spine of the scapula

next the drill is changed to the lateral part of the pin
the pin is backed up the fracture is reduced and the pin is driven into the
medial fragment
drill the pin far enough to reduce the fracture and then assemble the locking
mechanism laterally
for this procedure is to estimate how far the pin needs to travel into
the medial fragment
to reduce a fracture and then to cold weld the nuts in the appropriate place
outside of the skin
the pin is cut flesh and any sharp edges are removed with a tool before
burying it under the skin
then the lateral wrench is used to drive the pin completely into the medial fragment
reducing the fracture
number 5 poly sutures are passed around the clavicle to shuttle double
number 2 absorbable sutures
as many sutures as needed are passed around in the same fashion
the number 2 sutures are then tied with the racking half hitch knot to
the communite fragments back into place
to complete the reduction
the construct is then backed up with a number of half hitches
the reduction is checked once more and the pin is driven in with a lateral wrench
until the nuts come to rest at the posterior lateral cortex of the clavicle
fluoroscopy from different angles is used to confirm reduction
muscular layers are closed in a routine fashion
in this case we proceed with routine arthroscopic 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 fixed bone and compare to the unaffected
side
for stable fractures our standard rehabilitation protocol includes full
active and passive render motion from day one after operation
strengthening from week four and return to full activities at week six when
the fracture is clinically and radiographically stable
for unstable fractures only full passive range of motion in the supine position
is allowed for the first two weeks
active range of motion should be delayed to week two or three
strengthening is started at week four and full activities can be resumed after
clincial and radiographically proof of stability after six weeks
removal of clavicler pin
the pin is routinely removed after three 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 removal procedure
healing has been confirmed clinically and radiographically
the removal procedure is performed in V chair position with mild sedation
local anesthetic is injected under the skin over the posterior lateral tip of the clavicle
or the nuts that were buried
the skin is carefully incised and the soft tissues around the nuts are carefully
dissected
next a medial wrench is taken and placed on the nuts
a few turns are made by hand before a power driver is attached
the pin is carefully removed the incision is irrigated and the complete
hardware removed as well as stability is confirmed under fluoroscopy
our standard rehabilitation protocol after pin removal is full active and
passive range of motion immediately but no heavy lifting or loading for four
weeks
at four weeks post removal stability is confirmed clinically and radiographically
and after that the patient is cleared for return to full actvities