PREOPERATIVE DIAGNOSIS: Comminuted right closed mid shaft clavicle fracture, unstable.
POSTOPERATIVE DIAGNOSIS: Comminuted right closed mid shaft clavicle fracture, unstable.
PROCEDURE: Open reduction internal fixation right clavicle.
DESCRIPTION OF PROCEDURE: After obtaining informed consent Levi was brought to the operating room where upon smooth induction of general anesthesia was performed the patient was positioned in a beach chair position on the operating room table and all bony prominences were well padded. A bump was placed under the proximal thoracic spine to allow the scapula and shoulder to retract on the right. The right upper extremity was prepped and draped in the standard sterile fashion from the neck to the midline of the chest to the fingertips. An alcohol pre-prep was used. The clavicle fracture was readily palpable about the mid shaft. A longitudinal incision overlying the subcutaneous border of the clavicle centered on the deformity was made and length was approximately 10 cm. The skin and subcutaneous tissue were carefully dissected sharply down to the level of the periosteum overlying the clavicle. Hemostasis was carefully obtained using Bovie cautery. The clavicle fracture was dissected free of early soft callus in a subperiosteal fashion superiorly and anteriorly. The medial and lateral fragments were identified. The central comminution was noted to be severe with at least 3 fragments making up the central area in addition to the larger medial and lateral fragments. The fracture margins were carefully cleaned using suction, a small rongeur, and a small curet. Following this a careful anatomic reduction was obtained manually and held using multiple bony reduction clamps. Care was taken throughout the operation to protect the subclavian vessels about the inferior surface of the clavicle.
Once the provisional reduction had been achieved and was maintained with bone clamps 2 interfragmentary lag screws from the Acumed precontoured clavicle plate set (titanium) were used to hold the provisional reduction and this was successful. A 8-hold right-sided precontoured clavicle titanium plate was then removed from the set and placed over the fracture. The right-sided plate was the least bend was found to fit well. However, it fit better in a reverse position with the intended medial end facing laterally. This was because the fracture encompassed more of the more lateral bend of the clavicle as opposed to the medial bend. The plate required some contouring medially and this was done with plate benders. The plate was then solidly fixed to the bone in a noncompression fashion using 3.5 mm fully threaded cortical titanium screws from the set. All 8 holes were filled. Three lateral screws and 2 medial screws were fully in the lateral and medial fragments respectively. The 3 central screws were attached to portions of the lateral and medial fragments as well as the intervening comminution. Screw length was checked by direct palpations and intraoperatively using a flat plate x-ray. The reduction of the fracture and position of the hardware was confirmed and the wound was copiously irrigated with normal saline. It was then closed in layers using 0 Vicryl suture in a simple interrupted fashion for the deep fascia. The subcutaneous tissue was closed using interrupted 3-0 Monocryl suture in a simple buried fashion. A subcuticular 4-0 Prolene suture was then used to close skin. Steri-Strips and a sterile compressive dressing were applied and the patient was placed in a right upper extremity sling. He was awakened from anesthesia and taken to the recovery room in stable condition. Estimated blood loss was 250 mL. There were no intraoperative complications. Postoperatively he will be strictly non-weightbearing on the right upper extremity with use of a sling. He will have p.o. pain medicine for pain control. If he requires admission for pain control I expect this to be less than 24 hours.