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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

posterior periosteum of the clavicle and the posterior joint cap- sule are intact, providing a protective layer between the bony injury and mediastinal structures.

Following exposure of the physeal fracture or sternoclavicular dislocation, a gentle reduction is performed utilizing the aid of a fracture reduction clamp. Once the clavicle is brought ante- riorly, it is important to converse with the anesthesiologist to ensure that the patient remained hemodynamically stable. An anatomic reduction is now performed ensuring that the clavic- ular head is anatomically seated in the clavicular notch of the sternum. Following anatomic reduction of either the fracture or dis- location, drill holes are made in the anterior metaphysis and epiphysis of the clavicle in cases of a fracture or the anterior epiphysis and sternum in cases of a dislocation. Placement of malleable retractors between the bone and posterior peri- osteum is helpful in preventing the drill from entering the mediastinum. Heavy nonabsorbable suture is then passed in a figure-of-eight fashion to provide the necessary stability (Fig. 19-22). The periosteum is then reapproximated with heavy suture to provide added stability, especially with a true dislocation as it provides indirect repair of the costo- clavicular and sternoclavicular ligaments. Stability is now assessed by ranging the ipsilateral shoulder and limb. Once stability is satisfactory, the wound is irrigated and closed in sequential layers.

Technique

✔ ✔ ORIF of Sternoclavicular Fracture–Dislocations: KEY SURGICAL STEPS ❑❑ Prep and drape the entire limb and hemithorax including contralateral sternoclavicular joint, chest, and upper abdomen ❑❑ Transverse skin incision in Langer lines from the diaphysis of the clavicle to the sternoclavicular joint ❑❑ Divide subcutaneous tissue and platysma in line with skin incision. Protect the supraclavicular nerves. ❑❑ Expose clavicle and sternum and incise periosteum working from lateral to medial on clavicle and from midline to lateral on sternum ❑❑ Evaluate the sternoclavicular joint to determine whether a true dislocation or physeal fracture occurred ❑❑ Reduce dislocation/fracture with aid of a fracture reduction clamp ❑❑ Converse with anesthesia to ensure hemodynamic stability of patient ❑❑ Place drill holes in anterior epiphysis and metaphysis for physeal fractures or anterior epiphysis and sternum for dislocations ❑❑ Pass heavy nonabsorbable suture in a figure-of-eight fashion and tie ❑❑ Reapproximate periosteum with heavy suture ❑❑ Irrigate and close wound in sequential layers ❑❑ Immobilize patient in sling and swathe or shoulder immobilizer

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Figure 19-22.  A: Drill holes created in the anterior medial clavicle and sternum in cases of true dislocations or anterior medial clavicular metaph- ysis and clavicular epiphysis in cases of physeal fracture. B: Heavy nonab- sorbable suture placed through the drill holes in a figure-of-eight fashion. C: Anatomic joint reduction following tying of the sutures. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

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