Osteosynthesis for clavicle fractures: How close are we to penetration of neurovascular structures?

Comparison of the clinical efficacy of three internal fixation methods in the treatment of Edinburgh type IB fractures of the proximal clavicle

Clavicle fractures are one of the most common fractures and usually occur in the medial third of the clavicle. The study explored the efficacy of three internal fixation methods to treat Edinburgh IB fractures of the proximal clavicle. 68 patients with Edinburgh IB fractures of the proximal clavicle were divided into T-shaped plate group, double-miniature steel plate group and memory alloy embracing device group. Postoperative complications, return time to work, and fracture healing time were recorded. The clinical efficacy was evaluated by Constant-Murley score of shoulder joint, Visual Analogue Scale (VAS) score of pain, and arm-shoulder-hand dysfunction score. The operative time of the memory alloy embracing device group was significantly better than T-shaped plate group and double-miniature steel plate group. The length of surgical incision in the double-miniature steel plate group was significantly shorter than that in the T-shaped plate group and the memory alloy embracing device group. The hospitalization cost and recovery time of the double-plate and memory alloy hug groups were lower than those of the T-plate group. The double-miniature steel plate group and the memory alloy embracing device group were significantly better than the T-shaped plate group at two weeks after operation. Satisfactory clinical results can be obtained by using T-shaped plate, double-miniature steel plate and memory alloy embracing device in the treatment of Edinburgh IB fracture of proximal clavicle. However, the double-miniature steel plate group has the advantages of small incision, low cost, and quick postoperative recovery, and has more early advantages.

Unicortical versus bicortical plate fixation for midshaft clavicular fractures

BACKGROUND

The aim of this study was to compare the functional and radiological outcomes of unicortical vs bicortical fixation in patients with midshaft clavicular fractures who were treated using pre-contoured locking plates.

METHODS

We performed a prospective multicenter study of 45 individuals who underwent open reduction and internal fixation of midshaft clavicular fractures with precontoured locking plates between March 2017 and December 2019. Twenty-five patients were treated with bicortical screws and 20 patients with unicortical screws. Functional outcomes were assessed at 6 months and 12 months after surgery using the Constant score, the 11-item version of the Disabilities of Arm, Shoulder and Hand (Quick- DASH) score and the Single Assessment Numeric Evaluation (SANE) score. Pain was evaluated using a visual analog scale (VAS). The rate of return to work and sports was also recorded. Radiologic evaluation was obtained in the immediate postoperative day, monthly until fracture consolidation, at 6 months and 12 months. All intraoperative and postoperative complications were documented.

RESULTS

At both 6 and 12 months, the follow-up rates were 100%, and the mean age was 28.5 years (range, 20 to 45 years). The mean postoperative Constant score, Quick DASH, and SANE score at 12 months were 93.5 (±6), 2.3 (±3), and 92% (±7), respectively. There were no significant differences in the functional scores between the groups neither at 6 months nor at 12 months. Of the 30 active workers, 97% were able to return to their previous working routine and from the 25 patients who practiced sports before the injury,92% returned to sports all at the same level. All the fractures healed in both groups. There were 6 complications (13%).

CONCLUSION

In young, active patients with displaced midshaft clavicular fractures, both unicortical and bicortical locked plates achieved 100% bone consolidation, with excellent functional outcomes and a low rate of complications without significant differences between the groups. Therefore, locked plates with unicortical fixation could be a very good alternative for the management of young patients with midshaft clavicular fractures, potentially avoiding severe neurovascular complications.

LEVEL OF EVIDENCE

Prospective comparative (Level II).

Usefulness of a drill stopper to prevent iatrogenic soft tissue injury in orthopedic surgery

Objective

This study introduces a novel technique utilizing a drill stopper to limit drill penetration depth and to prevent iatrogenic injuries, specifically neurovascular damage, in orthopedic surgeries. Orthopedic surgeries frequently involve the use of drills, which are essential tools for various procedures. However, improper handling of drills can lead to iatrogenic soft tissue injuries, causing severe consequences such as permanent disability or life-threatening complications. To address this issue, we propose the use of a drill stopper as a safeguard to prevent excessive drill penetration and reduce the risk of soft tissue damage during surgery.

Materials and Methods

The study involved 32 orthopedic surgeons, half of whom were experienced and the other half inexperienced. Synthetic femur bone models (Synbone) were used for drilling exercises, employing four configurations: a sharp drill bit without a stopper (SF, Sharp Free), a sharp drill bit with a stopper (SS, Sharp Stopper), a blunt drill bit without a stopper (BF, Blunt Free), and a blunt drill bit with a stopper (BS, Blunt Stopper). Each participant conducted three trials for each configuration, and the penetration depth was measured after each trial.

Results

For experienced surgeons, the average penetration depths were 3.83 (±1.826)mm for SF, 11.02 (±3.461)mm for BF, 2.88 (±0.334)mm for SS, and 2.75 (±0.601)mm for BS. In contrast, inexperienced surgeons had average depths of 8.52 (±4.608)mm for SF, 18.75 (±4.305)mm for BF, 2.96 (±0.683)mm for SS, and 2.83 (±0.724)mm for BS.

Conclusion

The use of a drill stopper was highly effective in controlling drill penetration depth and preventing iatrogenic injuries during orthopedic surgeries. We recommend its incorporation, particularly when using a blunt drill bit or when an inexperienced surgeon operates in an anatomically unfamiliar area. Using the drill stopper, the risk of severe injuries from excessive drill penetration can be minimized, leading to improved patient safety and better surgical outcomes.

Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures

Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.

Power-Tool Use in Orthopaedic Surgery: Iatrogenic Injury, Its Detection, and Technological Advances: A Systematic Review

Power tools are an integral part of orthopaedic surgery but have the capacity to cause iatrogenic injury. With this systematic review, we aimed to investigate the prevalence of iatrogenic injury due to the use of power tools in orthopaedic surgery and to discuss the current methods that can be used to reduce injury.

Plunging Dangerously: A Quantitative Assessment of Drilling the Clavicle

Bicortical drilling of the clavicle is associated with risk of iatrogenic damage from plunging given the close proximity of neurovascular structures. This study determined plunge depth during superior-to-inferior clavicle drilling using a standard drill vs drill-sensing technology. Two orthopedic surgeons drilled 10 holes in a fresh cadaveric clavicle with drill-sensing technology in freehand mode (functions as standard orthopedic drill) and another 10 holes with drill-sensing technology in bicortical mode (drill motor stops when the second cortex is breached and depth is measured in real time). The drill-measured depths were compared with computed tomography-measured depths. Distances to the neurovascular structures were also measured. The surgeons' plunge depths were compared using an independent t test. With freehand (standard) drilling, the mean plunge depth was 8.8 mm. For surgeon 1, the range was 5.6 to 15.8 mm (mean, 10.9 mm). For surgeon 2, the range was 3.3 to 11.0 mm (mean, 6.4 mm). The surgeons' plunge depths were significantly different. In bicortical mode, the drill motor stopped when the second cortex was penetrated. Drill-measured depths were verified by computed tomography scan, with a mean difference of 0.8 mm. Mean distances from the clavicle to the neurovascular structures were 15.5 mm for the subclavian vein, 18.0 mm for the subclavian artery, and 8.0 mm for the brachial plexus. Plunge depths differed between surgeons. However, both surgeons' plunge depths were greater than distances to the neurovascular structures, indicating a risk of injury due to plunging. Although a nonspinning drill bit may still cause soft tissue damage, drill-sensing technology may decrease the risk of penetrating soft tissue structures due to plunging. [Orthopedics. 2021;44(1):e36-e42.].

Open Reduction and Long Locking Plate Fixation of Complex Proximal Humeral Metadiaphyseal Fractures

BACKGROUND

A minority of proximal humeral fractures extend into the diaphysis and their optimal treatment remains controversial. We evaluated the outcomes and risk of complications in patients with these injuries, treated by a protocol of open reduction and long locking plate fixation (LPF).

METHODS

Between 2007 and 2014, all locally resident patients with a proximal humeral fracture extending into the diaphysis were referred to a specialist shoulder clinic. Operative treatment using a protocol of open reduction and LPF was offered to medically fit patients. Those with 2-year radiographic follow-up were included in the study, and standardized assessments of clinical and radiographic outcomes were performed during the first 2 years postoperatively. At a mean of 8.8 years (range, 5 to 12 years) after LPF, the functional outcomes and satisfaction of surviving, cognitively intact patients were assessed with a questionnaire study.

RESULTS

One hundred and two patients met the inclusion criteria; the majority were older women who had incurred the injury during a simple fall. Fractures were divided into 2 types depending on the pattern of diaphyseal extension. The pain levels, functional scores, and satisfaction with treatment were satisfactory both at the 2-year follow-up and at the longer-term follow-up at a mean of 8.8 years postsurgery. Complications were predominantly due to postsurgical stiffness (in 7 patients, with 3 undergoing additional surgery) and nonunion or fixation failure (in 7 patients, with 6 undergoing additional surgery).

CONCLUSIONS

Proximal humeral fractures with diaphyseal extension are rare. The results of our study support the use of LPF in medically stable patients in centers with the expertise to perform these procedures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Morphometric analyses of clavicle's nutrient foramen

PURPOSE

Fractures of the clavicle, which has an important location and function in the upper extremity and shoulder joint, compose 10% of all fracture cases. During the osteosynthesis of clavicle fractures and in the post-operative period of patients, considering the detailed morphometric and topographic properties of the nutrient foramen of clavicle is important to avoid the disruption of arterial nutrition of the clavicle and prevent unexpected injuries. The aim of this study was to investigate the morphometric properties of the nutrient foramen of clavicle in more detail using computedtomography images.

METHODS

Computed tomography images of 116 healthy individuals (56 women/60 men) who had no pathology history were included in the presented study. Computed tomography images were reconstructed three-dimensionally using free-licensed Horos v3.3.3 software. Then, distances from clavicle's nutrient foramen to sternal end, anterior and posterior edges of the clavicle were measured. Statistical analyses were completed using SPSS v21 software.

RESULTS

Our results demonstrated that the nutrient foramen of clavicle was located closer to the sternal end of the clavicle. The shortest distance to the sternal edge of clavicle was measured as 3.3 cm. Analyses of gender differences indicated that statistically significant differences were in favor of men. However, topographic properties of the clavicle's nutrient foramen were not affected by age.

CONCLUSION

Nutrient foramen is mostly located closer to the sternal end of clavicle. Especially during osteosynthesis of clavicle fractures at the sternal end, maintaining the arterial supply of clavicle is of great importance for increasing the post-operative life quality of patients.

The Anatomy of the Clavicle and Its In Vivo Relationship to the Vascular Structures: A 2D and 3D Reconstructive Study Using CT Scans

OBJECTIVES

To describe in detail both the proximity and location of the subclavian vessels relative to both the right and left clavicle. This will give surgeons a more precise knowledge of safe and dangerous areas for screw placement during operative stabilization of clavicle fractures.

METHODS

A radiology storage database was reviewed to obtain a total sample of 103 clavicles with no evidence of periclavicular pathology. Each clavicle was divided along its length into 13 specific points of measurement. At each point, the distance and angular position between the clavicle and each subclavian vessel were measured.

RESULTS

The mean distance of the subclavian artery was greater than 10 mm at all positions. At the most medial point of the clavicle, the right subclavian artery was on average 1 cm closer to the clavicle than on the left. From medial to lateral, in the sagittal plane, the position of the subclavian artery transitions obliquely across the clavicle from a 2 to 6 o'clock position. The mean distance to the subclavian vein is less than 10 mm along the medial half of the clavicle on both sides of the body. In these areas, the position of the subclavian vein to the clavicle transitions from the 3 to 5 o'clock positions from medial to the mid-point of the clavicle.

CONCLUSIONS

The subclavian vein is the vascular structure at highest risk during clavicle fracture fixation. The major area of danger in our study is the medial clavicle with distance being less than 1 centimeter over the entire medial half of the clavicle on both right and left. In this danger area, the subclavian vein courses from 3 to 5 o'clock positions. The subclavian artery is more distant and relatively safer but is closer at the right medial clavicle than the left.

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures

INTRODUCTION

Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels.

METHODS

A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk.

RESULTS

None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up.

CONCLUSIONS

None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique.

LEVEL OF EVIDENCE

Level IV, case series.

Real-Time Monitoring with a Controlled Advancement Drill May Decrease Plunge Depth

BACKGROUND

Although drill use is fundamental to orthopaedic surgery, the risk of plunging past the far cortex and potentially damaging the surrounding soft tissues remains unavoidable with conventional drilling methods. A dual motor drill may decrease that risk by providing controlled drill-bit advancement and real-time monitoring of depth and energy expenditure. We hypothesized that using the dual motor drill would decrease plunge depth regardless of the user's level of experience.

METHODS

Sixty-six subjects of varying operative experience (20 attending orthopaedic surgeons, 20 orthopaedic surgery residents, and 26 senior medical students) drilled 3 holes with a conventional drill and 3 holes with a dual motor drill in a bicortical Sawbones block set in ballistic gel. The depth of drill penetration into the ballistic gel was measured for each hole using a digital caliper.

RESULTS

Overall, subjects plunged less with the dual motor drill (0.9 mm) than with the conventional drill (4.2 mm) (p < 0.001). This finding was consistent within each group: attending surgeons (0.9 compared with 3.2 mm; p = 0.02), residents (1.0 compared with 3.0 mm; p < 0.001), and students (0.7 compared with 6.0 mm; p < 0.001). Plunge depths were also stratified into 3 categories: 0 to <2 mm, 2 to 5 mm, and >5 mm. Using the dual motor drill, subjects were more likely to plunge <2 mm (97% plunged, on average, 0 to <2 mm and 3% plunged, on average, 2 to 5 mm), whereas subjects were more likely to plunge deeper with the conventional drill (27% plunged, on average, 0 to <2 mm, 45% plunged, on average, 2 to 5 mm, and 27% plunged, on average, >5 mm). Notably, no subject plunged ≥2 mm on the third attempt with the dual motor drill. Attending surgeons (p = 0.02) and residents (p = 0.01) plunged less than students with the conventional drill. There was no significant difference between attending surgeons and residents with the conventional drill (p = 0.96). There was no significant difference in plunge depth between groups using the dual motor drill.

CONCLUSIONS

The dual motor drill significantly decreased plunge depth for both surgically experienced and inexperienced subjects. Although inexperienced subjects performed worse with the conventional drill than those with experience, there was no difference in their performance with the dual motor drill.

CLINICAL RELEVANCE

Use of a controlled advancement drill may decrease the chance of plunge-related neurovascular injury during in vivo drilling.

[Effectiveness analysis of distal radius microplate locking plate for treatment of displaced fracture of medial clavicle]

OBJECTIVE

To investigate and evaluate the effectiveness of the distal radius microplate locking plate for the treatment of displaced fracture of medial clavicle.

METHODS

Between January 2013 and June 2017, 18 cases of obvious displaced fracture of medial clavicle were treated with distal radius microlocking plate. There were 10 males and 8 females, with an average age of 51.4 years (range, 18-88 years). Causes of injury included traffic accident injury in 15 cases, heavy object injury in 3 cases; all of them were closed injury. According to Edinburgh classification, 15 cases were ⅠB1 type and 3 cases were ⅠB2 type. Fracture displacement was 12-21 mm (mean, 16.3 mm). The time from injury to operation was 3-7 days (mean, 4.3 days). After operation, the clinical healing and complications of fracture were observed, and shoulder function was evaluated according to Rockwood's scoring criteria.

RESULTS

No incisional infection, neurovascular injury, or other early complications occurred. All 18 patients were followed up 8-15 months (mean, 12 months). All fractures reached clinical osseous union, and the healing time was 8-24 weeks (mean, 16.6 weeks). Postoperative plate loosening occurred in 1 case, which was removed surgically, while other patients did not suffer from complications such as bone nonunion, displacement, internal fixator loosening, and loss of reduction. At last follow-up, according to Rockwood's scoring criteria, the results were excellent in 12 cases and good in 6 cases.

CONCLUSION

The distal radius microplate locking plate is effective for the treatment of displaced medial clavicle fracture, which has few complications, and is feasible for early functional exercise, and is helpful for the recovery of shoulder joint function.

Dynamic Compression of the Subclavian Artery Secondary to Clavicle Nonunion: A Report of 2 Cases

CASE

We describe 2 patients with nonunion of the clavicle and dynamic compression of the subclavian artery. In both patients, no structural abnormality of the subclavian vessels was evident at rest; however, with the arm in hyperabduction, arterial occlusion occurred because of the mobility of the fracture and a prominent callus.

CONCLUSION

This small case series demonstrates an important and, to our knowledge, unreported clinical complication of clavicle fracture nonunion. We believe that this complication is worth considering as a rare but important cause of pain in patients with delayed union or nonunion of the clavicle.

The distributed pattern of the neurovascular structures around clavicle to minimize structural injury in clinical field: anatomical study

INTRODUCTION

The aim of this study was to determine the location and distribution pattern of neurovascular structures superior and inferior to the clavicle by detailed dissection.

METHODS

Fifteen adult non-embalmed cadavers with a mean age of 71.5 years were studied. For measurements, the most prominent point of the sternal end of the clavicle (SEC) on anterior view and the most prominent point of the acromial end of the clavicle (AEC) were identified and divided five equal sections before dissection. A line connecting the SEC and AEC was used as a reference line. The surrounding neurovascular structures were investigated.

RESULTS

The supraclavicular nerve was mainly distributed in the second and the third sections (distribution frequency: 41.30% and 30.43%, respectively) from AEC. Branches of the thoracoacromial artery were mainly distributed in the second, third, and fourth sections (distribution frequency: 21.15%, 26.92%, and 28.85%, respectively). Branches of the subclavian vein were mainly distributed in the third and fourth sections (distribution frequency: 23.26 and 30.23%, respectively). Distribution frequency of subclavian vein, subclavian artery, and brachial plexus ranged from 31.3 to 57.5%.

DISCUSSION

When the clavicle was divided into five sections, there was relatively little distribution of neurovascular damage in the first section or the fifth section. This study reveals the average location of subclavian vein with artery and brachial plexus. Results of this study could be used as reference during surgery.