Ergonomically Optimized Setup for Superior Plating of Clavicle Open Reduction and Internal Fixation

Abstract

The clavicle, characterized by its S-shaped structure, is anatomically divided into 3 sections: proximal, midshaft, and distal. Clavicle fractures are very common, particularly among children and young adults, especially with certain activities, including mountain biking, skiing, and snowboarding. Approximately 80% of these fractures are located in the middle third, with nearly half of them being displaced. Treatment for these fractures can be either operative or conservative. Although several options exist for treatment, superior plating for displaced fractures is commonly performed. This Technical Note describes an ergonomically optimized setup and preparation in the beach-chair position for superior plating of midshaft clavicle fractures.

Clavicle fractures are common injuries in both adults and children, comprising 2.6% to 4% of adult fractures and 35% of shoulder girdle fractures.¹ In adults, over two-thirds of clavicle injuries occur at the midshaft, while in children, up to 90% of fractures occur at the midshaft.² These fractures can be managed either surgically or nonsurgically. Traditionally, nonsurgical treatment has been preferred initially due to relatively high union rates with conservative treatment.² However, a meta-analysis by Guerra et al. demonstrated that surgical intervention for midshaft clavicle fractures significantly reduces nonunion rates and accelerates union compared to nonsurgical approaches.³

Numerous techniques for open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but there is a paucity of literature describing a modern, optimized setup for treatment of these injuries. In this Technical Note and associated video (Video 1), we describe the setup of the beach-chair position for the superior plating of midshaft clavicle fractures.

Surgical Technique

Indications and Preoperative Planning

Absolute indications for clavicle fracture treatments include open injuries, skin tenting, or concomitant lower extremity or distal extremity injuries. Relative indications for ORIF of midshaft clavicle fractures include displaced fractures with shortening, comminuted fractures, and need for early mobilization. Preoperative workup includes anteroposterior and various axial tilt radiographs (Fig 1). The advantages and disadvantages of this setup are shown in Table 1.

Fig 1.

Radiograph of the right shoulder. Anteroposterior view of the shoulder with the green arrow indicating the fracture of the clavicle.

Table 1.

Advantages and Disadvantages

Advantages	Disadvantages
Improved surgical site visualization	Risk of hypotension
Improved ergonomics	Labor-intensive setup
Easy visualization of intraoperative fluoroscopic images	Decrease in cerebral perfusion
Comfort for surgeons who perform shoulder arthroscopy in the beach-chair position

Preoperative Anesthesia

Patients are given the option for general anesthesia with regional anesthesia for intraoperative and postoperative analgesia. Regional anesthesia options include a single-shot interscalene block with or without a superficial cervical plexus block both using liposomal bupivacaine. If the patient opts out of regional anesthesia, they are treated with subcutaneous liposomal bupivacaine mixed 1:1 with 0.25% bupivacaine.

Patient Positioning

After administration of general endotracheal anesthesia, the endotracheal tube is positioned and taped to exit the contralateral side of the face to facilitate exposure and access to the surgical site. The patient’s head is carefully secured in the head positioner, ensuring proper airway management. Straps support the head, neck, and torso in a neutral position to prevent cervical stress. Padded head straps are applied for stability (Fig 2A). Underneath the patient’s legs, a wedge pillow is placed to maintain positioning and to prevent the patient from sliding down the table intraoperatively (Fig 2B). The contralateral arm is placed in a padded arm holder to maintain wrist neutrality and avoid ulnar nerve compression. Finally, 2 well-padded kidney posts are secured to the table to stabilize the patient (Fig 2B). Next, the bed is rotated 90° to optimize exposure to the surgical site, to facilitate exposure to the airway for anesthesia, and to allow for easy positioning to the fluoroscopy machine. Importantly, the monitor is positioned near the anesthesia machine facing the surgeon to allow for easy intraoperative viewing without having to turn or look away from the surgical field (Fig 3). Prior to prepping and draping, a provisional fluoroscopy image is taken to ensure complete, unobstructed views of the entire clavicle. The fluoroscopy machine is positioned parallel to the table to allow for ease of sliding in and out (back toward the contralateral shoulder) of the surgical field. The pearls and pitfalls for this setup are described in Table 2

Fig 2.

Patient positioning. (A) The patient is placed in the beach-chair position demonstrating securement of the head and neck with a foam mask. (B) Underneath the patient’s legs, a wedge pillow is placed to maintain positioning and to prevent the patient from sliding down the table intraoperatively, and 2 well-padded kidney posts are secured to the table to stabilize the patient.

Fig 3.

Views from the surgeon’s perspective. (A, B) The monitor is positioned near the anesthesia machine facing the surgeon to allow for easy intraoperative viewing without having to turn or look away from the surgical field.

Table 2.

Pearls and Pitfalls

Pearls	Pitfalls
Position the fluoroscopy monitor in direct view from the surgical field to minimize surgeon head movement intraoperatively.	Check a fluoroscopy image prior to draping to ensure no obstructions to view are present.
Position the fluoroscopy machine parallel to the surgical table to allow for easy sliding in and out of the field.	Ensure the drapes are positioned onto the patient’s ipsilateral neck and to the sternum to allow for complete access to the clavicle.
Cover the armpit with 3M Ioban 2 to reduce the risk of Cutibacterium acnes contamination.	Request that anesthesia position the endotracheal tube away from the surgical field to prevent being impeded intraoperatively.

Preoperative Skin Preparation

Skin decontamination consists of clipping any patient hair from the surgical site, including the armpit. A nonsterile 1000 drape is then applied, which creates exposure of the patient’s ipsilateral neck and sternum to provide an adequate surgical field. Finally, this is followed by 2 stages of skin preparation. The first stage consists of a 70% isopropyl alcohol wash using gauze, followed by a standard chlorohexidine skin prep. After a 2-minute dry time, the remainder of the surgical draping continues.

Surgical Draping

First, a ¾ down sheet is placed to cover the patient’s chest, abdomen, and legs (Fig 4A). Next, the image intensifier is rotated into the field and carefully draped with a cover. Next, 2 sets of U-drapes are placed, again onto the patient’s neck and medial to the level of the sternum (Fig 4B). 3M Ioban 2 (3M) is then cut into 5-cm strips, which are used to outline the periphery of the surgical field as well as to completely cover the armpit (Fig 4D). Finally, an impervious stockinette is used to cover the hand and elbow, which is then overwrapped with 3M Coban (3M) (Fig 4C).

Fig 4.

Surgical draping. (A) A ¾ down sheet is placed to cover the patient’s chest, abdomen, and legs. (B) Next, 2 sets of U-drapes are placed, again onto the patient’s neck and medial to the level of the sternum. (C) The hand and elbow are then overwrapped with 3M Coban (3M). (D) A 3M Ioban 2 (3M) is cut into 5-cm strips, which are used to to completely cover the armpit.

Open Reduction and Internal Fixation of the Fracture

Surgical technique involves an approximately 8-cm straight incision centered over the apex of the fracture. Sharp dissection continues through the clavipectoral fascia and platysma with care to preserve any crossing branches of the supraclavicular nerves. The fracture site is identified and debrided. In most cases, 2 butterfly fragments exist, which are fixated to the major medial and lateral fragments using 2.0-mm fully threaded lag screws in a lag-by-technique fashion. Once 2 effective fracture fragments are created, these are reduced, sometimes held with another 2.0 lag screw if not stable, and then fixed with a 2.7-mm precontoured superior plate (Synthes). This plate is fixed with a combination of 2.7 mm cortical and/or locking screws with at least 6 cortices of fixation on each side of the fracture (Fig 5).

Fig 5.

Superior plating of the clavicular fracture. An anteroposterior radiograph (A) and axial radiograph (B) demonstrating the fixation of the fracture.

Closure

Prior to closure, meticulous hemostasis is achieved, followed by copious irrigation with normal saline. Next, 1 g vancomycin powder is placed into the wound. A 2-0 absorbable braid is used to close the clavipectoral fascia and again used to close the platysma fascia, followed by a 2-0 absorbable monofilament for the deep dermal layer and a running subcuticular 3-0 absorbable monofilament for the skin. Dermabond is placed over the incision, and a silver-impregnated dressing that is impervious to water is placed overtop. The patient is placed into a simple sling.

Rehabilitation

Postoperative rehabilitation commences immediately following resumption of motor and sensory function after the nerve block wears off and includes full, unrestricted range of motion of the hand, wrist, elbow, and shoulder with a 5-lb weightbearing limit for 6 weeks.

Discussion

In this Technical Note, we describe the beach-chair setup for the superior plating of midshaft clavicle fractures. Most important, the technique describes important nuances, which include helpful ergonomic positioning pearls, important draping techniques for improved exposure, and adjuvants to decrease infection risk. The supine and beach-chair positions are commonly employed based on the surgeon’s preference. However, it is essential to exercise caution while placing fixation plate screws during clavicular fracture repairs, as they pose risks to neurovascular structures. Notably, complications, including air embolism in the subclavian vein, pseudoaneurysm or thrombosis in the subclavian artery, and thoracic outlet syndrome, have been documented following such procedures.⁴ Proper patient positioning is crucial for limiting postoperative complications and achieving successful outcomes after surgery.

Previous studies on the ORIF of clavicular fractures with a plate only examined the proximity of the tips of the screws and the neurovascular structures when patients were positioned supine. These studies generally advocated for anteroinferior plating in the treatment of clavicular fractures.5, 6, 7 This recommendation stems from the observation that in the supine position, the placement of screws tends to be further from critical neurovascular structures. However, Chuaychoosakoon et al.⁸ found the beach-chair position to be safer when using a superior clavicular plate. They hypothesized that in the beach-chair position, gravity helps shift important neurovascular structures inferiorly, thus reducing the risk of damage during surgery.⁸

Limited evidence exists on the beach-chair setup for the ORIF of clavicular fractures with a plate. However, it is important to note that about two-thirds of shoulder surgeries are performed in the beach-chair position. This preference is attributed to several advantages, including simplified setup, enhanced visualization, orientation within the joint, and reduced risk of brachial traction injuries.⁹ Despite these advantages, the beach-chair position is usually associated with complications such as compromised cerebral perfusion. While this Technical Note advocates for the use of the beach-chair position for ORIF involving superior plating of clavicular fractures, further research is required to confirm the safety and efficacy of this positioning within the specific context of ORIF of clavicular fractures.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.J.R. is a consultant or advisor for Smith and Nephew. All other authors (E.K.A., O.M.J., T.M.A., C.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

A step-by-step video illustration describing the beach-chair setup for superior plating of clavicle open reduction and internal fixation. This is a 22-year-old man who fell onto his right shoulder while snowboarding. He immediately heard a cracking sensation. On examination, he had severe pain over his right shoulder and crepitus at the right midshaft clavicle. X-rays show a comminuted, shortened midshaft clavicle fracture. Patients are given the option of general anesthesia with regional anesthesia for intraoperative and postoperative analgesia. In this case, general anesthesia was administered. After administration of general endotracheal anesthesia, the patient’s head is carefully secured in the head positioner, ensuring proper airway management. Straps support the head, neck, and torso in a neutral position to prevent cervical stress. Padded head straps are applied for stability. Underneath the patient’s legs, a wedge pillow is placed to maintain positioning and to prevent the patient from sliding down the table intraoperatively. The contralateral arm is placed in a padded arm holder to maintain wrist neutrality and avoid ulnar nerve compression. Finally, 2 well-padded kidney posts are secured to the table to stabilize the patient. Next, the bed is rotated 90° to optimize exposure to the surgical site, to facilitate exposure to the airway for anesthesia, and to allow for easy positioning to the fluoroscopy machine. First, a ¾ down sheet is placed to cover the patient’s chest, abdomen, and legs. Next, the image intensifier is rotated into the field and carefully draped with a cover. Two sets of U-drapes are placed, again onto the patient’s neck and medial to the level of the sternum. The first layer of sterile U-drapes is placed, one below and one above. Then, the second layer of U-drapes is placed in the same fashion. While the U-drapes are being placed, the c-arm is translated toward anesthesia to facilitate safer draping. An impervious stockinette is used to cover the hand and elbow, which is then overwrapped with 3M Coban (3M). A 3M Ioban 2 (3M) is then cut into 5-cm strips, which are used to outline the periphery of the surgical field as well as to completely cover the armpit to reduce the risk of Cutibacterium acnes infection. An approximately 8-cm straight incision is made over the center of the apex of the fracture, and we proceed to the superior plating with open reduction and internal fixation of the midshaft fracture. The radiograph shows the completed construct of superior plating with 2.0-mm lag screws and a superior neutralization plate. Finally, postoperative rehabilitation commences immediately once the patient regains motor and sensory function after the nerve block. Rehabilitation includes full, unrestricted range of motion of the hand, wrist, elbow, and shoulder with a 5-lb weightbearing limit for 6 weeks.