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VID1-003522-en-US | A | Distal Clavicle Fracture Reduction using Plate and Coracoid Fixation

Paul C. Brady

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Distal Clavicle Fracture Reduction using Plate and Coracoid Fixation

So on digital clavicle fractures, I'll fully expose the distal clavicle. Once again, I think a helpful technique is to really know where your AC joint is. I think it's real helpful to take a spinal needle and then to drop it down into your AC joint, and you can just leave it there. I mean, it'll drop nicely down into your AC joint that helps you expose the the fracture fragments fully with your elevator to really get to the distal extent of your, of your clavicle. Okay? Because you don't want your clavicle plate, your distal clavicle plate sitting here and really not encompassing the majority of the distal clavicle itself. So you want to take your plate not all the way to the edge, but pretty close to the edge of the distal clavicle. In order to maximize the amount of real estate that you're able to use with your distal clavicle locking screws. Okay, so there's two different distal clavicle plates. There's a one with five holes in the shaft, and there's one with eight holes in the shaft. So if you had a fracture that was primarily just your distal clavicle, I would probably choose the smaller plate because it fits nicely. It fits nicely to the bone. And and you don't have to do much contouring there. And it just fits nicely to the bone. And as long as you have three quarters, as long as you have three screw holes to drill proximally into the shaft of the clavicle, then you've got enough stability to take care of your fracture. But if your fracture extends more proximally, then you may have to go with a longer plate such as this. And this plate fits nicely as well. You can see it comes a little bit off the bone right here. So you may want to contour it just slightly in the axial plane so that it sits on the bone here. But but it really it will probably contour very nicely if you just put 1 or 2 screws in there. And we have this plate holding. Device, which will allow you to really hold that plate, keeps your hands in a safe zone so that you're not drilling through your fingers, and you can manipulate that plate exactly where you want it, and then you can provisionally fix it with a wire. So I'll go through one of these screw these drill holes. You can also use these tacks. And then let's do one of those a little more proximally to hold that plate in place. And that's nice. That's a good position for your plate. Once it's provisionally fixed you want to go ahead and secure it with screw fixation. Let's use a centering guide for a proximal screw. And we'll put it right here. And that measures a 12. So let's let's put it in a 12 millimeter non-locking screw. First, I like to get a non-locking screw in order to really compress the plate down to the bone. Good. Once that's there, we can remove this screw because it's really not adding anything to our to our construct. Next, let's secure this plate distally. There's a nice drill guide for these plates. There's a left and a right version of this. This is a left shoulder. So we're going to use the left drill guide. It will fit right over top of this guide pin that we inserted. And it'll sit right on the plate. And then it screws into that hole in the plate. If you if you look at this drill guide that we just attached to the plate, it's got holes which will recreate the trajectory that you need to drill your holes. Okay. And it will only allow you to drill in that trajectory. Okay. So that's a nice added feature to this system is that it will it will guide you as to the appropriate trajectory for your locking screws. You can drill one at a time or you can drill multiple. It's easier to drill multiple since you don't have to remove the drill guide. Now typically when you drill your distal clavicle holes, you're not going to get that dynamic, that dramatic bicortical bite that you do sometimes with your shaft drilling, because the bone of the distal clavicle is just a different consistency. And so sometimes it'll feel not quite right when you're going through that bone, but you can feel when you're in the bone and not in the bone. So next we'll use our depth gauge And one at a time. Find that trajectory once again. There's that trajectory on that one. So find our depth gauge. And that is a 12 millimeter. So these are 2.7mm locking screws. So we'll start with a 12 millimeter here. And I hold that I leave that depth gauge in place because I want to really reproduce that trajectory when I'm putting the screw in. So leave that depth gauge in place. And then at the last minute, remove the depth gauge and reproduce that angle with your screw. Once you get a couple bites, it should go itself. And then it should. It should fit nicely into the plate. Like it does a fine tune my trajectory. There's my trajectory. And that's that measures a 16. Basically, once you've got your plate secured and you know your and you've drilled your distal holes, it's it's once again just drill and fill. Follow the same technique. Find your angle. Reproduce your angle with your locking screw, and once it gets in the hole, it'll find its path and it'll lock down into the plate and continue until you've filled all the holes in the plate. So there are five locking holes in the plate. Sometimes the plate will be sitting slightly posterior or slightly anterior, and it really won't allow you to fill all of those holes. However, if you're able to get your plate right on the middle of the bone, I recommend filling every one of them if you have decent bone to fill it with. Now, if you have tremendous comminution in your distal clavicle, then some of the screws may not be obtaining any purchase whatsoever. And there's really no utility in putting a screw into thin air. And so in that case, you would use the small holes in the plate to cerclage, to use a cerclage suture to pass through or underneath the fragments and then attach it to the plate that way. So we can use a number two FiberWire suture. And we can use that to pass through the plate. And then use that to tie some of our fragments down. Okay. Okay. Now another another great option that that can be particularly useful for these difficult clavicle fractures is to obtain fixation of your clavicle plate to the underlying coracoid. This can be useful in multiple occasions. Number one is if you have tremendous comminution to your distal clavicle fracture, and you don't really have any great bite in any of those fragments, then you may want to get a secondary point of fixation to hold that plate down and to hold all those fractures in place. Number two is if you even if you do have decent bite, but you have disruption of your coracoclavicular ligaments or your joint capsule, and you have some, some dislocation of your AC joint, then you want to go ahead and secure that down to the clavicle as well to reestablish your coracoclavicular ligaments. So the way I do that is, as you typically have to extend your incision slightly. And then you want to start to dissect anterior and lateral to the clavicle. Okay. Right at this clavicle bend. If you go straight down you're going to hit the base of the coracoid. Okay. So you want to start to dissect anteriorly. And you're just going to take a small sleeve of the deltoid anterior portion of the deltoid right off the bone. So it's not far down there until you hit the base of the coracoid. Let me get a freer. Got it. Make sure you're right down on the coracoid. And I like to dissect the coracoid out slightly. Typically, I'll use electrocautery in this area too in order to get right down on the bone, and I'll try to get slightly lateral as well. I try to stay away from that medial side of the coracoid because that's where danger can be located. But I'll try to go lateral or I won't try. I will go lateral to the coracoid and then I'll dissect underneath the coracoid. Okay. This is similar to a dissection for a ladder procedure. So if you have excellent visualization of the top of the coracoid, you can do this in a freehand manner. And I would just drill right like this through that hole and onto the top of the coracoid. However, if your visualization is not so good and actually I prefer to do this in most cases is you want to put your coracoid aiming device underneath the coracoid, and you can feel it underneath there with those nubbins. And then you want to place your drill guide through the drill, right through your oblong hole in the plate. So now once, once we have that aiming device in a good position and I feel like I'm underneath the coracoid, I'm going to go ahead and drill that the inner portion of this drill will come out and allow you to thread a nitinol wire right through the middle of this drill. So we're going to use that 2.4mm drill to pass through the clavicle and then through the coracoid. And if we're in a good position, we ought to feel for cortices as we go through. [00:10:46] One. Two, three. Four. Now I can feel the the metallic drill on my aiming device underneath. Here. Now I'll unscrew this. It has an inner trocar which can be unscrewed. And then that's going to allow you access to the inner Cannulation. We're going to pass a let me remove the drill sleeve now. And let's remove this portion of the we're going to pass that nitinol wire down through there. So we're going to pass that through there. It's going to be going underneath the we're going to pass it until it won't pass any further. When we drilled this the drill went right in between those two slots, right in that hole where exactly where it's supposed to go. And then when we pass the nitinol through there and we pulled this out, the nitinol came out with it so that that's an ideal situation. If that doesn't happen, then you have to take a curved hemostat and you have to retrieve relatively blindly or completely blindly retrieve that nitinol wire underneath the coracoid. And as long as you say right up against the underside of the coracoid, that is a safe zone. Okay. You do have the subscapularis underneath there protecting you from dangerous neurovascular structures. So that is a safe zone. When you're lateral to the coracoid and underneath the coracoid, you are in a safe zone. As long as you stay away from going too far inferior or too far medial. Okay. So once we have that night norm placed, I'll place a clip on that so we don't accidentally pull it out. And then I'll pull out our drill bit. Okay. So we'll pull that out just by hand. And now we have this nitinol going through the clavicle, through the coracoid and underneath the coracoid. Okay. The next step is to attach this this dog bone to a FiberTape. So let me show you how to do that. So the easy way to do that is to take the FiberTape fold it in half. Come up here to now. We want that dog bone to sit. It's got a convexity on one side and a concavity on one side. We want the concave side of the dog bone to sit underneath the coracoid. And so to do that we're going to clip this into place like this. Clip it there. Clip it there. And then we're going to pull the FiberTape portion up into the dog bone. And there's our dog bone construct okay. So I can remove the hemostat that's going to sit underneath our coracoid. It's going to go up through our coracoid through our clavicle. And then we're going to tie it through a specialized clavicle button that will fit nicely right into this plate. And I'll show you that in a second. So we'll take the FiberWire portion and go through our nitinol loop. And then we'll pull up. Pulling that into place. And then I like to just hold on to this with a little hemostat. Make sure we take the slack out of both sides. Hold on to that with the hemostat until you feel like it's underneath there. There. I feel like I'm underneath the coracoid. I'll let go with my hemostat. And now I'm secured underneath the coracoid with that dog bone button. Next I'm going to place the distal. I'm going to place these FiberTape sutures through the distal clavicle plate button. So this is an oblong button that's going to sit right into this hole. Okay. So we'll pass these FiberWire sutures. That then transition to the FiberTape. And then we'll let go with our. Hemostat. And that's going to sit down nicely. Right into that hole. Okay. So you can have an assistant at this point, you can have an assistant help you perform your reduction of your AC joint while you tie these FiberTape sutures. Go ahead and push down on that disk clavicle. So let's tie this. And I'm just going to use a surgeon's knot. Make sure that fits down now. Once you tie a single knot it's going to fit perfectly down into that plate okay. And then you'll secure that usually for throws with FiberTape is sufficient. Here. Okay. So that's your AC joint reconstruction. Now some people are concerned about this knot stack. If you are concerned about that knot stack then you can I haven't seen it to be a substantial problem. However if you have a relatively thin patient and you're a little concerned about that not stack, you can pass the FiberTape through the holes in the plate and that will help that not stack to sit down. And then you can tie that there just one one throw. And that will help that not stack to sit down. Another option would be to pass that those FiberTape limbs through the posterior periosteum. However, the hole in the plate works extremely well. That really lets that not stack sit down more flush against the bone. Still slightly prominent, but much more flush than if it's just sticking straight up. Obviously, you would fill the remainder of these holes with either non-locking or locking screws as you felt appropriate, and once again with your distal screws. If you're getting good bone purchase, then go ahead and fill them with with screws. If you're not getting that good of bone purchase, or if you've got a lot of comminution here, then use the Cerclage technique where you pass the FiberWire sutures through these small holes that are circumferentially found around the around the distal portion of the plate. So I really think this plate offers something that that hasn't been offered yet, which is a secondary method of fixation for your distal clavicle fractures. So when you have substantial comminution and you really can't rely on your fixation distally, then it's a good idea to augment that with coracoclavicular fixation, because that's going to take the stress off of off of the plate distally.

Distal Clavicle Fracture Reduction using Plate and Coracoid Fixation

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