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TRAUMA

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OFFICIAL JOURNAL OF

Orthopaedic Trauma Association

Belgian Orthopaedic Trauma Association

Canadian Orthopaedic Trauma Society

Foundation for Orthopedic Trauma

International Society for Fracture Repair

The Japanese Society for Fracture Repair

Special Case Report Series

CASE REPORTS

Precontoured Plate Fixation With Interfragmentary Lag ScrewUse in a Middle Third Clavicle Fracture Fixation

Alireza Naderipour, MD and Michael D. McKee, MD, FRCS(C)

Summary: Middle third clavicle fractures are common injuriesthat need surgical fixation in a certain subset of patients. The useof precontoured clavicle plates facilitates intraoperative fixationand can reduce soft tissue irritation and hardware removal rates.Lag screw fixation is a well-established technique for thetreatment of oblique fractures. Empirical application of thismethod in clavicle fracture fixation and clavicle nonuniontreatment has been reported previously. A recent biomechanicalstudy supports the use of a lag screw technique in clavicle fracturefixation when possible. We report a 46-year-old patient witha mid-shaft right clavicle fracture who was treated with thistechnique, which resulted in an excellent clinical outcome.

Key Words: clavicle, lag screw, precontoured plate

INTRODUCTIONClavicle fractures are one of the most common upper limb

fractures. The annual incidence of this fracture is 29 per 100,000withyoung activemen of younger than 20 years of age having the highestincidence.1 Themost common location of fracture is themiddle thirdof clavicle in 80%of cases.1,2 The usualmechanismof injury is directtrauma to the shoulder or fall on tip of the shoulder.1,2 Typically, the

distal fragment is displaced inferiorly, anteriorly, andmedially. Clas-sically, this injury was believed to be a benign, uneventful fracturewith minimal long-term disability.3,4 However, multiple recent stud-ies have shown a high rate of complications after conservative man-agement of this injury. The rate of nonunion (15%) and patientdissatisfaction (31%) has been found to be significantly higher thanthat reported in older studies.5,6 Recent high-quality randomizedclinical trials, demonstrating superior functional outcome in the sur-gical group, have revived the interest in surgical fixation of thisfracture in a certain group of patients. In addition to classic indica-tions for fracture surgery (ie, open fractures), shortening of .2 cm,displacement of.2 cm, and significant comminution are now con-sidered relative indications for surgical fixation of a closed, isolatedclavicle fracture.7 The current trend for surgical management ofacute clavicle fractures favors application of a precontoured 3.5-mm plate with 3 bicortical screws in each fragment. This tech-nique decreases the need for intraoperative plate contouring andhas a high union rate, low incidence of complications, anda reduced rate of hardware removal.5,8

CASE REPORTA 46-year-old male patient presented with right shoulder pain

and limited range of motion. He had sustained a closedmiddle thirdright clavicle fracture 10 weeks before presentation, after a directfall on his right shoulder. This fracture was initially managedconservatively with a sling. The patient complained of ongoingpain and visible deformity of his shoulder. Clinically, the deformityof his right shoulder was quite obvious with overriding of thefracture fragments and also shortening and protraction of theshoulder. The fracture site was still tender and mobile. Range ofmotion of the right shoulder was moderately restricted in alldirections, especially in flexion and abduction, mainly because ofpain. His medical history was significant for hypothyroidism,treated medically with a daily dose of thyroid hormone replace-ment. Hewas a right hand dominant nonsmoker individual workingin an office job. Radiographs showed a long oblique middle third

Accepted for publication July 17, 2015.

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Stryker Trauma & Extremities.

From the Division of Orthopaedics, Department of Surgery, St. Michael’sHospital, and the University of Toronto, Toronto, ON, Canada.

M. D. McKee is a consultant for Zimmer, Acumed, and Stryker. Hereceives royalties from Stryker, LWW, and Springer. A. Naderipourdeclares no conflict of interest.

Reprints: Michael D. McKee, MD, FRCS(C), Division of Orthopaedics,Department of Surgery, St. Michael’s Hospital, and the University ofToronto, Toronto, ON, Canada (e-mail: mckeem@smh.ca).

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clavicle fracture with 100% displacement, 3 cm of shortening,and minimal evidence of healing at 10 weeks (Figs. 1 and 2).

Considering the amount of deformity, ongoing disability, andthe delayed healing response, we elected to manage this casesurgically. Our method of choice for the surgical fixation of a mid-shaft clavicle fracture is an anterosuperior surgical approach in thebeach-chair position with fixation of the reduced fracture usinga precontoured superior clavicle plate. In this case, the long obliquenature of the fracture presented an opportunity for lag screwfixation. After debridement of the fracture ends and anatomicreduction, we used a 2.7-mm anteroposterior lag screw to hold thereduction and achieve interfragmentary compression before apply-ing the plate. Then, a 3.5-mm precontoured 6-hole clavicle platewas fixed on superior aspect of clavicle with 3 bicortical screwsdistally and 2 bicortical screws proximally (Fig. 3). The arm waskept in a sling for a week after surgery; then, active range of motionexercises was initiated. At 6 weeks, resisted activities and strength-ening were allowed, followed by unrestricted activities and sportsat 12-week postoperatively. At 1-year postoperatively, the patientwas asymptomatic, had minimal hardware irritation, and had re-turned to full function.

DISCUSSIONRecent studies have shown benefits of surgical fixation of mid-

shaft clavicle fracture in selected patient groups.7 Surgical inter-vention for isolated, closed mid-shaft clavicle fractures is bestreserved for relatively healthy, young patients who have

significant shortening and displacement. These patients have a highchance of developing nonunion, mal-union, and unsatisfactoryresults after nonoperative care.5,6 The use of a precontoured3.5-mm plate on the superior aspect of the clavicle is a well-established technique for acute and delayed fixation of claviclefractures and nonunions.9,10

Interfragmentary lag screw is a common technique for fixationof oblique noncomminuted fractures. A lag screw providesmechanically stable fixation with the added benefit of compressingthe fracture ends together.11–13 Lag screw utilization and anteroin-ferior plate fixation have been described for treatment of claviclenonunions.9,14–16 A recent biomechanical finite model study hasshown the significant mechanical advantage of using a lag screwin clavicle fracture fixation.17 This added strength was enhancedwhen used with clavicle-specific plates.17

This finding encourages the use of interfragmentary compres-sion technique in clavicle fracture surgery, especially in non-comminuted, oblique fractures. The added lag screw not only helpswith maintenance of reduction but also adds to overall strength andstability of the construct and provides fracture site compression aswell. Considering the size of the clavicle, we typically use 2.7-mmlag screws to avoid potential splitting of the fragments.

CONCLUSIONSThis case report supports the use of a lag screw in clavicle

fracture fixation, whenever feasible, as advocated in recent bio-mechanical studies. It also emphasizes the importance of early

FIGURE 1. Standing anteroposterior (AP) view of theright clavicle. Note complete displacement andsignificant shortening of the shoulder.

FIGURE 2. Standing upshot view of right clavicle.This view reveals more details, including minorcomminution not visible on anteroposterior (AP)view.

Naderipour and McKee

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recognition of patients who would benefit from surgical interven-tion: this can prevent an unnecessary delay in treatment and shortenthe overall period of morbidity.

REFERENCES1. Robinson CM. Fractures of the clavicle in the adult. J Bone Joint Surg Br.1998;80B:476–484.

2. Stanley D, Trowbridge EA. The mechanism of clavicular fracture. A clin-ical and biochemical analysis. J Bone Joint Surg Br. 1988;70B:461–464.

3. Neviaser JS. The treatment of fractures of the clavicle. Surg Clin NorthAm. 1963;43:1555–1563.

4. Neer CS. Nonunion of the clavicle. JAMA. 1960;172:1006–1011.5. Zlowodzki M, Zelle BA, et al. Treatment of midshaft clavicle fractures:systemic review of 2144 fractures. J Orthop Trauma. 2005;19:504–507.

6. Hill JM, McGuire MH. Closed treatment of displaced middle-third frac-tures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79B:537–539.

7. McKee MD. Optimal Treatment of Displaced Midshaft Fractures of theClavicle. Philidelphia, PA: Saunders; 2009:126–132.

8. Celestre P, Robertson C. Biomechanical evaluation of clavicle fractureplating techniques: does a locking plate provide improved stability?J Orthop Trauma. 2008;22:241–247.

9. Boyer MI, Axelrod TS. Atrophic nonunion of the clavicle: treatment bycompression plate, lag-screw fixation and bone graft. J Bone Joint Surg Br.1997;79:301–303.

10. Canadian Orthopaedic Trauma Society (MD McKee, principal inves-tigator). Plate fixation versus nonoperative care for acute, displaced

midshaft fractures of the clavicle. J Bone Joint Surg Br. 2007;89A:1–11.

11. Perren SM. Force measurements in screw fixation. J Biomech. 1976;9:669–675.

12. Perren SM, Frigg R, et al. Lag screw. In: Ruedi TP, Murphy WM, eds.AO Principles of Fracture Management. Stuttgart, Germany: Thieme;2000.

13. Schatzker J, Sanderson R. The holding power of orthopedic screwsin vivo. Clin Orthop Relat Res. 1975;108:115–126.

14. Kloen P, Werner CM. Anteroinferior plating of midshaft clavicle nonun-ions and fractures. Oper Orthop Traumatol. 2009;21:170–179.

15. Collinge C, Devinney S. Anterior-inferior plate fixation of middle-thirdfractures and nonunions of the clavicle. J Orthop Trauma. 2006;20:680–686.

16. Kloen P, Sorkin AT. Anteroinferior plating of midshaft clavicular nonun-ions. J Orthop Trauma. 2002;16:425–430.

17. Marie C. Strength analysis of clavicle fracture fixation devices and fixationtechniques using finite element analysis with musculoskeletal force input.Med Biol Eng Comput. 2015. [epub ahead of print].

FIGURE 3. Standing anteroposterior (AP) view 6months after surgery shows anatomical fixation withrestoration of length.

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Precontoured Plate Fixation

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