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Open Reduction Internal Fixation of Distal Clavicle FractureWith Supplementary Button Coracoclavicular FixationAndrew Hanflik, M.D., Bryan T. Hanypsiak, M.D., Joshua Greenspoon, B.S., and

Darren J. Friedman, M.D.

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 stabi-lization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drillbit 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 constructis linked to the distal clavicle plate by heavy sutures using a second button that sits in the plate. The lateral locking holesare then filled to finalize fixation. This technique provides for a simplified way to achieve coracoclavicular stabilizationwhen using a plate for fixation of distal clavicle fractures.

lavicle fractures are a common injury, with

Croughly 20% occurring in the distal third of theclavicle.1 Neer2 classified distal-third clavicle fracturesbased on the location of the fracture line relative to thecoracoclavicular (CC) ligaments and acromioclavicular(AC) joint capsule. Both type I and type III fracturesoccur lateral to the CC ligaments, with type I fracturessparing the AC joint whereas type III extend into the ACjoint. These fractures are relatively stable and minimallydisplaced because the soft-tissue attachments are spared,and they typically heal without operative management.However, type II fractures involve disassociation of theproximal clavicle segment from the reduced distalsegment as the fracture line exits medial to the CC lig-aments and are thus unstable and often require surgicalmanagement for optimal outcome.Many surgical techniques are currently used, including

transacromial fixation with Kirschner wires, hook-plate

From the Department of Orthopaedic Surgery, Kingsbrook Jewish Medicalenter (A.H.), Brooklyn, New York; Arthrex (B.T.H.), Naples, Florida;niversity of Miami Miller School of Medicine (J.G.), Miami, Florida; andepartment of Orthopaedic Surgery, Weill Cornell Medical College (D.J.F.),ew York, New York, U.S.A.The authors report the following potential conflict of interest or source ofnding: B.H. receives support from Arthrex, Frantz Medical. D.J.F. receivespport from Arthrex, Allen Medical. Personal injury lawyer.Received January 30, 2014; accepted May 9, 2014.Address correspondence to Bryan T. Hanypsiak, M.D., 737 Park Avenue,

uite 1C, New York, NY 10021, U.S.A. E-mail: BH@glashowmd.com� 2014 by the Arthroscopy Association of North America2212-6287/1476/$36.00http://dx.doi.org/10.1016/j.eats.2014.05.012

Arthroscopy Techniques, Vol 3, No 5

fixation, locking-plate fixation, stabilization of theproximal fragment with CC screws or slings, tension-band wiring, and cerclage wiring of the fragments. Thesurgical technique detailed in this report provides analternative method to achieve fixation of unstabledistal-third clavicle fractures using CC stabilization witha button device placed through a superior clavicleplate. The CC augmentation aids in achieving fracturereduction while adding strength and stability to theconstruct.3

Surgical TechniqueThe patient is placed in the beach-chair position

(Video 1). A small rolled towel “bump” is placed cen-trally behind the patient between the scapulae to aid inclavicle reduction. The fluoroscopy unit with a large C-arm is positioned on the contralateral side to ensureappropriate radiographs before preparation (Table 1).The large C-arm allows for visualization of the entireclavicle and can be rotated to obtain anteroposteriorand apical oblique images. Bringing the C-arm from theopposite side simplifies intraoperative imaging becausethe surgical team does not need to step away from thesurgical field.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’sworking 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 theincision lateral enough for the AC joint to be visualized.

(October), 2014: pp e551-e554 e551

Table 1. Pearls, Key Points, and Indications

PearlsBringing 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 theoperative side, optimizing the surgeon’s working area whenplacing screws superior to inferior.

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

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

In distal-third clavicle fractures, the lateral bone stock is often poorin quality and quantity. Provisional lateral fixation should becompleted with K-wires or BB tacks through the 5 laterallocking holes.

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

It is important to angle roughly 30� from posterior to anterior toensure that the drill bit exits the base of the coracoid and notthrough the scapular body.

Key PointsOur 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 reductionby delivering an inferiorly directed force to the proximal segment.

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

IndicationsType II fractures involving disassociation of the proximal clavicle

segment from the reduced distal segment as the fracture lineexits medial to the CC ligaments

e552 A. HANFLIK ET AL.

An incision is made with anterior and posterior skinflaps developed superficial to the fascial layer. A Met-zenbaum scissor is used for dissection medially in adirection perpendicular to the skin incision to help

Fig 1. (A) Before coracoid drilling, an apical oblique radiograph ibeam parallel to the long axis of the coracoid (right shoulder in bbit (Arthrex) is centered over the empty hole in the plate directlythen confirmed radiographically. (B) The 4 cortices are drilled, undand to ensure appropriate trajectory (right shoulder in beach-cha

identify and protect the sensory supraclavicular nerveand its branches. The fascia overlying the clavicle isreleased in full-thickness fashion anteriorly and poste-riorly. The fracture site is identified, and blunt Hoh-mann retractors are placed anterior and posterior to theclavicle. Soft-tissue attachments about the fracture siteare preserved to maximize vascularity. Comminutedfragments are identified and reduced while interposedsoft tissues are retracted. Comminuted fragments arekeyed in and held reduced with small K-wires orpointed reduction clamps if necessary. Reduction ismaintained with 2.0-mm K-wires across the majorfracture site placed outside the region in which theplate will sit. Butterfly or comminuted fragments maybe repaired to the major medial or lateral segment withscrews outside of the plate.An appropriately sized precontoured distal clavicle

plate (Ar-2656dl; Arthrex, Naples, FL) is placed on thesuperior aspect of the clavicle. The plate is secured tothe medial segment with a 3.5-mm bicortical non-locking screw. A retractor may be placed under theclavicle while drilling to protect the underlying neuro-vascular structures. If there is good cortical contact be-tween the major fracture segments, an eccentricnonlocking screw may be placed to create compressionacross the primary fracture site. A minimum of 3bicortical screws should be placed medially. The holeoverlying the base of the coracoid process should be leftempty.In distal-third clavicle fractures, the lateral bone stock

is often poor in quality and quantity. Provisional lateralfixation should be completed with K-wires through the5 lateral locking holes. Fluoroscopy should be used toensure 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 axisof the coracoid, producing a “perfect circle” (Fig 1A).

s obtained, showing a circular coracoid process with the x-rayeach-chair position, Zanca view). A 3.7-mm spade-tipped drillabove the base of the coracoid. The position of the drill bit iser fluoroscopy, with care to avoid over-penetration of the drillir position, Zanca view).

Fig 2. (A) A pectoralis button isscrewed onto the cannulated insertiondevice. The button attaches to a threa-ded central pin, thus minimizing therisk of disassociation of the buttonduring passage. (B) FiberTape and No.5 FiberWire are threaded back andforth through the button eyelet in thesame direction. This button will capturethe undersurface of the coracoid, andthe sutures will be secured to the plateplaced superiorly on the clavicle.

DISTAL CLAVICLE FRACTURE e553

This image can be obtained by rotating the C-arm toshoot from anterolateral to posteromedial. Centeredover the empty hole in the plate, a 3.7-mm spade-tipped drill bit (Ar-2272; Arthrex) is oriented directlyabove the base of the coracoid. Once the position isconfirmed radiographically, the drill bit is driven acrossall 4 cortices (clavicle and coracoid). It is important toangle roughly 30� from posterior to anterior to ensurethat the drill bit exits the base of the coracoid and notthrough the scapular body. Fluoroscopy must be usedto 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 devicethrough a threaded central pin, thus minimizing risk ofdisassociation of the button during passage. The buttonis preloaded with FiberTape (Arthrex) and No. 5FiberWire suture (Arthrex), with the surgeon makingsure to thread both sutures in the same direction (Fig2B). By use of fluoroscopic guidance, the button ispassed across all 4 cortices. A mallet may be used togently tap on the top of the insertion device to aid inpassage. The insertion device is released from the but-ton and removed, capturing the button on the under-surface of the coracoid (Fig 3A). Superior tension isdelivered to the sutures, and the FiberTape and No. 5FiberWire 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 thenfilled, with care taken to avoid penetrating the AC joint.

Fig 3. (A) The insertion device isreleased from the button and removed,leaving the final implant position withthe button resting on the undersurfaceof the coracoid (right shoulder inbeach-chair position, Zanca view). (B)Final plate appearance showing CCsutures tied over clavicle plate button.The sutures have been tied over thedistal clavicle button, which now sitsflush in the screw hole. The 5 laterallocking holes have been filled.

The fascia is closed in full-thickness fashion over theclaviclewithmultipleNo.1absorbable sutures.Meticulousfascial closure is critical to restore deltoid and trapeziusfunction, aswell as toprovide soft-tissue coverage over thehardware. The dermis is closed with a No. 2-0 absorbablestitch, and the skin is closed with a running No. 3-0absorbable monofilament subcuticular stitch. A standardsling is applied.Elbow range-of-motion exercises in the supine position

are begun on postoperative day 1. The sling is dis-continued after 4 weeks, and full passive, active-assisted,and active exercises are started. Radiographs are obtainedat 2 weeks’, 6 weeks’, 3 months’, 6 months’, and12 months’ follow-up. Resistance and strengthening ac-tivities are started when there is radiographic evidence ofhealing, usually around 6 weeks. Return to competitivesporting activities is allowed once there is radiographicevidence of healing, full range of motion has been ach-ieved, and strength is 90% of the contralateral extremity.

DiscussionHistorically, distal clavicle fractures have had a poor

prognosis, with nonunion rates of up to 44% afternonoperative treatment.1,4-6 With modern operativetechniques, the healing rates are improved; however,multiple surgical techniques exist (K-wire fixation,clavicular hook-plate fixation, modified tension-bandfixation, Bosworth-type screw fixation), each associ-ated with its own set of complications either as a resultof the fixation itself or due to spanning the AC joint and

e554 A. HANFLIK ET AL.

thus limiting its natural micromotion.4-8 Currently,there is no consensus regarding the most reliable sur-gical treatment for the treatment of these injuries.The addition of CC stabilization through a superior

plate serves to add an additional point of fixation andaids in fracture reduction by delivering an inferiorlydirected force to the proximal segment. The CC fixationalso increases the strength and stability of the constructin relation to plate fixation alone. A recent in vitrostudy showed that the addition of CC suture supple-mentation doubled the load to failure in plate fixationof type IIB fractures.3 This technique also avoidscrossing the AC joint and eliminates the need for futureremoval of hardware. The described technique has beenused in 5 patients with encouraging early clinical andradiographic results.

References1. Robinson CM. Fractures of the clavicle in the adult.

Epidemiology and classification. J Bone Joint Surg Br1998;80:476-484.

2. Neer CS II. Fractures of the distal third of the clavicle. ClinOrthop Relat Res 1968;58:43-50.

3. Madsen W, Yaseen Z, LaFrance R, et al. Addition of a su-ture anchor for coracoclavicular fixation to a superiorlocking plate improves stability of type IIB distal claviclefractures. Arthroscopy 2013;29:998-1004.

4. Levy O. Simple, minimally invasive surgical technique fortreatment of type 2 fractures of the distal clavicle. J ShoulderElbow Surg 2003;12:24-28.

5. Rieser GR, Edwards K, Gould GC, Markert RJ, Goswami T,Rubino LJ. Distal-third clavicle fracture fixation: A biome-chanical evaluation of fixation. J Shoulder Elbow Surg2013;22:848-855.

6. Stegeman SA, Nacak H, Huvenaars KH, Stijnen T,Krijnen P, Schipper IB. Surgical treatment of Neer type-IIfractures of the distal clavicle: A meta-analysis. Acta Orthop2013;84:184-190.

7. Chun JM, Kim SY. Modified tension band fixation forunstable distal clavicle fractures. J Trauma 2011;70:E88-E92.

8. Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment ofdistal clavicle fracture: A systematic review of treatmentmodalities in 425 fractures. Arch Orthop Trauma Surg2011;131:525-533.