Open Reduction Internal Fixation of Distal Clavicle Fracture With Supplementary Button Coracoclavicular Fixation

Abstract

Distal clavicle fractures are common, and no standard treatment exists. Many different surgical modalities exist. This report describes an open reduction internal fixation technique that achieves both plate and coracoclavicular stabilization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drill bit is drilled across the clavicle and coracoid, passing through 4 cortices. The button is loaded onto an insertion device, passed across the 4 cortices, and captured on the undersurface of the coracoid under fluoroscopic guidance. This construct is linked to the distal clavicle plate by heavy sutures using a second button that sits in the plate. The lateral locking holes are then filled to finalize fixation. This technique provides for a simplified way to achieve coracoclavicular stabilization when using a plate for fixation of distal clavicle fractures.

Clavicle fractures are a common injury, with roughly 20% occurring in the distal third of the clavicle.¹ Neer² classified distal-third clavicle fractures based on the location of the fracture line relative to the coracoclavicular (CC) ligaments and acromioclavicular (AC) joint capsule. Both type I and type III fractures occur lateral to the CC ligaments, with type I fractures sparing the AC joint whereas type III extend into the AC joint. These fractures are relatively stable and minimally displaced because the soft-tissue attachments are spared, and they typically heal without operative management. However, type II fractures involve disassociation of the proximal clavicle segment from the reduced distal segment as the fracture line exits medial to the CC ligaments and are thus unstable and often require surgical management for optimal outcome.

Many surgical techniques are currently used, including transacromial fixation with Kirschner wires, hook-plate fixation, locking-plate fixation, stabilization of the proximal fragment with CC screws or slings, tension-band wiring, and cerclage wiring of the fragments. The surgical technique detailed in this report provides an alternative method to achieve fixation of unstable distal-third clavicle fractures using CC stabilization with a button device placed through a superior clavicle plate. The CC augmentation aids in achieving fracture reduction while adding strength and stability to the construct.³

Surgical Technique

The patient is placed in the beach-chair position (Video 1). A small rolled towel “bump” is placed centrally behind the patient between the scapulae to aid in clavicle reduction. The fluoroscopy unit with a large C-arm is positioned on the contralateral side to ensure appropriate radiographs before preparation (Table 1). The large C-arm allows for visualization of the entire clavicle and can be rotated to obtain anteroposterior and apical oblique images. Bringing the C-arm from the opposite side simplifies intraoperative imaging because the surgical team does not need to step away from the surgical field.

Table 1.

Pearls, Key Points, and Indications

Pearls

Bringing the C-arm from the opposite side simplifies intraoperative imaging.

A retractor may be placed under the clavicle while drilling to protect the underlying neurovascular structures.

A small rolled towel “bump” is placed centrally behind the patient between the scapulae to aid in clavicle reduction.

The entire clavicle and upper extremity are prepared and draped free. The head is gently tilted (roughly 30°) away from the operative side, optimizing the surgeon's working area when placing screws superior to inferior.

Reduction is maintained with 2.0-mm K-wires across the major fracture site placed outside the region in which the plate will sit.

A retractor may be placed under the clavicle while drilling to protect the underlying neurovascular structures.

In distal-third clavicle fractures, the lateral bone stock is often poor in quality and quantity. Provisional lateral fixation should be completed with K-wires or BB tacks through the 5 lateral locking holes.

An apical oblique image is obtained, with care taken to ensure that the x-ray beam is parallel to the long axis of the coracoid, producing a “perfect circle” (Fig 1A). This image can be obtained by rotating the C-arm to shoot from anterolateral to posteromedial.

It is important to angle roughly 30° from posterior to anterior to ensure that the drill bit exits the base of the coracoid and not through the scapular body.

Key Points

Our surgical technique provides an alternative method to achieve fixation of unstable distal-third clavicle fractures.

The addition of CC stabilization through a superior plate serves to add an additional point of fixation and aids in fracture reduction by delivering an inferiorly directed force to the proximal segment.

The technique avoids crossing the AC joint and eliminates the need for future removal of hardware.

Indications

Type II fractures involving disassociation of the proximal clavicle segment from the reduced distal segment as the fracture line exits medial to the CC ligaments

The entire clavicle and upper extremity are prepared and draped free. The head is gently tilted (roughly 30°) away from the operative side, optimizing the surgeon's working area when placing screws superior to inferior. The planned skin incision is drawn over the superior-lateral aspect of the clavicle. It is important to extend the incision lateral enough for the AC joint to be visualized.

An incision is made with anterior and posterior skin flaps developed superficial to the fascial layer. A Metzenbaum scissor is used for dissection medially in a direction perpendicular to the skin incision to help identify and protect the sensory supraclavicular nerve and its branches. The fascia overlying the clavicle is released in full-thickness fashion anteriorly and posteriorly. The fracture site is identified, and blunt Hohmann retractors are placed anterior and posterior to the clavicle. Soft-tissue attachments about the fracture site are preserved to maximize vascularity. Comminuted fragments are identified and reduced while interposed soft tissues are retracted. Comminuted fragments are keyed in and held reduced with small K-wires or pointed reduction clamps if necessary. Reduction is maintained with 2.0-mm K-wires across the major fracture site placed outside the region in which the plate will sit. Butterfly or comminuted fragments may be repaired to the major medial or lateral segment with screws outside of the plate.

An appropriately sized precontoured distal clavicle plate (Ar-2656dl; Arthrex, Naples, FL) is placed on the superior aspect of the clavicle. The plate is secured to the medial segment with a 3.5-mm bicortical nonlocking screw. A retractor may be placed under the clavicle while drilling to protect the underlying neurovascular structures. If there is good cortical contact between the major fracture segments, an eccentric nonlocking screw may be placed to create compression across the primary fracture site. A minimum of 3 bicortical screws should be placed medially. The hole overlying the base of the coracoid process should be left empty.

In distal-third clavicle fractures, the lateral bone stock is often poor in quality and quantity. Provisional lateral fixation should be completed with K-wires through the 5 lateral locking holes. Fluoroscopy should be used to ensure appropriate reduction and hardware placement. Attention is then turned to the CC fixation.

An apical oblique image is obtained, with care taken to ensure that the x-ray beam is parallel to the long axis of the coracoid, producing a “perfect circle” (Fig 1A). This image can be obtained by rotating the C-arm to shoot from anterolateral to posteromedial. Centered over the empty hole in the plate, a 3.7-mm spade-tipped drill bit (Ar-2272; Arthrex) is oriented directly above the base of the coracoid. Once the position is confirmed radiographically, the drill bit is driven across all 4 cortices (clavicle and coracoid). It is important to angle roughly 30° from posterior to anterior to ensure that the drill bit exits the base of the coracoid and not through the scapular body. Fluoroscopy must be used to ensure appropriate trajectory and to avoid over-penetration (Fig 1B). A Pectoralis Button (Ar-2267; Arthrex) is loaded onto a cannulated insertion device (Fig 2A). The button attaches to the insertion device through a threaded central pin, thus minimizing risk of disassociation of the button during passage. The button is preloaded with FiberTape (Arthrex) and No. 5 FiberWire suture (Arthrex), with the surgeon making sure to thread both sutures in the same direction (Fig 2B). By use of fluoroscopic guidance, the button is passed across all 4 cortices. A mallet may be used to gently tap on the top of the insertion device to aid in passage. The insertion device is released from the button and removed, capturing the button on the undersurface of the coracoid (Fig 3A). Superior tension is delivered to the sutures, and the FiberTape and No. 5 FiberWire are tied over a Distal Clavicle Plate Button (Arthrex), which sits flush in a screw hole in the plate (Fig 3B). The 5 lateral 2.7-mm locking holes are then filled, with care taken to avoid penetrating the AC joint.

Fig 1.

(A) Before coracoid drilling, an apical oblique radiograph is obtained, showing a circular coracoid process with the x-ray beam parallel to the long axis of the coracoid (right shoulder in beach-chair position, Zanca view). A 3.7-mm spade-tipped drill bit (Arthrex) is centered over the empty hole in the plate directly above the base of the coracoid. The position of the drill bit is then confirmed radiographically. (B) The 4 cortices are drilled, under fluoroscopy, with care to avoid over-penetration of the drill and to ensure appropriate trajectory (right shoulder in beach-chair position, Zanca view).

Fig 2.

(A) A pectoralis button is screwed onto the cannulated insertion device. The button attaches to a threaded central pin, thus minimizing the risk of disassociation of the button during passage. (B) FiberTape and No. 5 FiberWire are threaded back and forth through the button eyelet in the same direction. This button will capture the undersurface of the coracoid, and the sutures will be secured to the plate placed superiorly on the clavicle.

Fig 3.

(A) The insertion device is released from the button and removed, leaving the final implant position with the button resting on the undersurface of the coracoid (right shoulder in beach-chair position, Zanca view). (B) Final plate appearance showing CC sutures tied over clavicle plate button. The sutures have been tied over the distal clavicle button, which now sits flush in the screw hole. The 5 lateral locking holes have been filled.

The fascia is closed in full-thickness fashion over the clavicle with multiple No. 1 absorbable sutures. Meticulous fascial closure is critical to restore deltoid and trapezius function, as well as to provide soft-tissue coverage over the hardware. The dermis is closed with a No. 2-0 absorbable stitch, and the skin is closed with a running No. 3-0 absorbable monofilament subcuticular stitch. A standard sling is applied.

Elbow range-of-motion exercises in the supine position are begun on postoperative day 1. The sling is discontinued after 4 weeks, and full passive, active-assisted, and active exercises are started. Radiographs are obtained at 2 weeks', 6 weeks', 3 months', 6 months', and 12 months' follow-up. Resistance and strengthening activities are started when there is radiographic evidence of healing, usually around 6 weeks. Return to competitive sporting activities is allowed once there is radiographic evidence of healing, full range of motion has been achieved, and strength is 90% of the contralateral extremity.

Discussion

Historically, distal clavicle fractures have had a poor prognosis, with nonunion rates of up to 44% after nonoperative treatment.^1,4-6 With modern operative techniques, the healing rates are improved; however, multiple surgical techniques exist (K-wire fixation, clavicular hook-plate fixation, modified tension-band fixation, Bosworth-type screw fixation), each associated with its own set of complications either as a result of the fixation itself or due to spanning the AC joint and thus limiting its natural micromotion.^4-8 Currently, there is no consensus regarding the most reliable surgical treatment for the treatment of these injuries.

The addition of CC stabilization through a superior plate serves to add an additional point of fixation and aids in fracture reduction by delivering an inferiorly directed force to the proximal segment. The CC fixation also increases the strength and stability of the construct in relation to plate fixation alone. A recent in vitro study showed that the addition of CC suture supplementation doubled the load to failure in plate fixation of type IIB fractures.³ This technique also avoids crossing the AC joint and eliminates the need for future removal of hardware. The described technique has been used in 5 patients with encouraging early clinical and radiographic results.

Supplementary Data

Video 1

Technique for augmentation of distal clavicle fractures treated with a plate using a button device. This technique provides for a simplified way to achieve CC stabilization when using a plate for fixation of distal clavicle fractures.