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(A) The longitudinal incision for open reduction and internal fixation of the clavicle crosses the Langer lines in a more perpendicular manner versus the (B) necklace-type incision, which is oriented more parallel to the Langer lines. (C) Clinical photo of a healed necklace incision.
Source publication
Background
Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons.
Purpose
To compare patient satisfaction and subjective outcomes betwe...
Contexts in source publication
Context 1
... total of 45 patients consented to the study and com- pleted the online survey. Nine patients did not meet the inclusion criteria, leaving 36 participants included in the final analysis. These 36 patients were divided into 2 groups based on incision type: necklace versus longitudinal. A lon- gitudinal incision was defined as one that was made along the length of the subcutaneous border (long axis) of the clavicle ( Figure 1A), while the necklace-type incision was defined as one that was performed along the Langer lines, more perpendicular to the clavicle ( Figure 1B). The operat- ing surgeon's preference for surgical approach as corrobo- rated in the operative note determined the assignment of patients into a specific ...
Context 2
... total of 45 patients consented to the study and com- pleted the online survey. Nine patients did not meet the inclusion criteria, leaving 36 participants included in the final analysis. These 36 patients were divided into 2 groups based on incision type: necklace versus longitudinal. A lon- gitudinal incision was defined as one that was made along the length of the subcutaneous border (long axis) of the clavicle ( Figure 1A), while the necklace-type incision was defined as one that was performed along the Langer lines, more perpendicular to the clavicle ( Figure 1B). The operat- ing surgeon's preference for surgical approach as corrobo- rated in the operative note determined the assignment of patients into a specific ...
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Background
Surgical management of unstable distal clavicle fractures (DCFs) remains controversial. Traditional open techniques result in acceptable union rates but are fraught with complications. In response to these limitations, arthroscopic techniques have been developed; however, clinical outcome data are limited.
Purpose
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The rate of operative fixation of acute midshaft clavicle fractures has exponentially increased in recent years; however, the rate of reoperation for symptomatic hardware removal remains high and the optimal fixation strategy unknown. This systematic review aimed to summarize available evidence for dual plating of acute displaced midshaf...
Background:
Early definitive fixation of clavicular fractures is rising in popularity when compared with conservative management. Despite this, the relative risk of subsequent hardware removal or revision surgery is relatively undocumented in the literature. The aim of this study was to review all clavicle fractures treated operatively in a single...
Citations
... Vertical incisions have been hypothesized to lead to a lower rate of numbness compared with horizontal incisions, but the results have been inconsistent. One study indicated a lowered rate of numbness [12], but two other studies showed no significant difference between horizontal and vertical incisions [13,14]. At our institute, we routinely use the horizontal incision due to the extensile exposure and ease of enlargement when necessary. ...
Background
The branches of the supraclavicular nerve are often sacrificed during open reduction and internal fixation (ORIF) for clavicle fracture. No consensus exists on whether the supraclavicular nerve should be routinely identified and protected during ORIF.
Methods
We developed a simple method to make nerve sparing easier; Wide-Awake Local Anesthesia No Tourniquet (WALANT) solution is locally injected prior to the surgical incision being made. This retrospective study enrolled 340 patients and divided them into supraclavicular-nerve-sparing (n = 45) and supraclavicular-nerve-sacrifice (n = 295) groups. Surgical outcomes—including operative time, estimated blood loss, postoperative pain, union rate, time to union, functional score, paresthesia, complications, implant removal rate, and complication rate—were recorded.
Results
Incisional or anterior chest wall numbness and intraoperative blood loss were significantly less (p < 0.001) in the nerve-sparing group. The operative time was similar in the two groups. No significant differences were discovered in QuickDASH score, postoperative pain score, union rate, time to union, implant removal rate, complication rate, or revision rate.
Conclusions
Our study demonstrated that the outcomes of supraclavicular nerve sparing during ORIF with WALANT can reduce postoperative incisional and anterior chest wall numbness and intraoperative blood loss without increasing the operative time or complication rate.
... 11,12 Se llevó a cabo una investigación bibliográfica de estudios que compararon el abordaje longitudinal con el oblicuo o vertical. 3,5 El abordaje vertical u oblicuo evita el compromiso de las ramas sensitivas del nervio supraclavicular; no obstante, puede generar más incomodidad para el cirujano, menor exposición de la fractura clavicular y sus resultados funcionales a largo plazo son similares a los del abordaje longitudinal. Según los estudios publicados, no hay una diferencia estadísticamente significativa de las complicaciones en ambos grupos de pacientes. ...
... Se ha llegado a la conclusión de que los pacientes se sintieron más conformes con los resultados estéticos del abordaje longitudinal. 5 Los neuromas iatrogénicos son una complicación poco frecuente en las fracturas de clavícula. La lesión de las ramas cutáneas del nervio supraclavicular o su compresión con el material de osteosíntesis o el callo de fractura pueden generar dolor e hiperestesia en la región de la cicatriz y sus alrededores. ...
Introducción: Las fracturas de clavícula representan el 4% de las fracturas del adulto; el 80% son mediodiafisarias. Se ha demostrado que el tratamiento quirúrgico disminuye el riesgo de seudoartrosis, consolidación viciosa y dolor residual, aunque no está exento de complicaciones, como la hipoestesia regional (12-29%), entre otras. Objetivo: Evaluar la incidencia de hipoestesia subclavicular luego de una reducción abierta y fijación interna para una fractura de clavícula, si afecta la calidad de vida del paciente y cómo la afecta. Materiales y Métodos: Se realizó un estudio transversal analítico prospectivo de pacientes con una fractura mediodiafisaria desplazada de clavícula tratados con reducción abierta y fijación interna entre 2018 y 2021. Se utilizó un cuestionario elaborado por el equipo, que consistió en 6 preguntas para responder de forma anónima. Se evaluó la presencia de hipoestesia subclavicular, dolor regional y afectación de la vida cotidiana. Resultados: Se evaluó a 29 pacientes con un seguimiento posoperatorio mínimo de un año, operados mediante un abordaje longitudinal. Veintidós (76%) tenían alteración de la sensibilidad y siete (24%) negaron este síntoma. La hipoestesia subclavicular afectó la calidad de vida de manera leve o nula del 97% de los pacientes. Conclusión: Es importante advertirle al paciente antes de la cirugía sobre la posibilidad de hipoestesia cutánea como complicación posoperatoria, debido a su alta frecuencia, aunque es poco probable que dicha complicación afecte la calidad de vida.
... Indications for surgical fixation include open fractures, neurovascular compromise, severe angulation or displacement with a risk of cutaneous perforation, or symptomatic non-union. [67][68][69][70][71]. Either a longitudinal incision along the subcutaneous border of the clavicle or a vertical (necklace) incision along the Langer lines may be used for osteosynthesis using pre-contoured plates, although smaller skin incisions may be used in a minimally invasive approach with plate osteosynthesis or intramedullary fixation devices [72][73][74][75]. Unstable distal fractures may further require coracoclavicular repair, tension-band wiring, reconstruction, hook plating, or transacromial pinning [75]. ...
Objective. Clavicle fractures are common injuries potentially associated with significant perioperative pain. However, this region’s complex sensory innervation poses a challenge for regional anesthetic or analgesic (RA) techniques. We conducted this scoping review to summarize the current literature, particularly with regards to motor-sparing techniques. Methods. A scoping review was carried out in accordance with the Joanna Briggs Institute’s framework. All articles describing the use of RA for clavicle fractures or surgery were included. PubMed®, Ovid MEDLINE®, EMBASE®, Scopus®, CINAHL®, and the Cochrane database were searched without language restrictions. Results. Database searches identified 845 articles, 44 of which were included in this review, with a combined patient total of 3161. We included all peer-reviewed publications containing clinical data and summarized the findings. Conclusions. Current evidence of RA techniques in clavicle surgery is heterogeneous, with different approaches used to overcome the overlapping sensory innervation. The literature largely comprises case reports/series, with several randomized controlled trials. Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block. Cervical plexus block can provide motor-sparing analgesia following clavicle surgery. Promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique. Further studies are required to determine the efficacy and safety of various techniques.
... A transverse skin incision was made along the superior border of the clavicle from the SC joint to the AC joint. This incision was in line with a surgical approach used in open reduction and internal fixation (ORIF) of the clavicle [14]. Subsequently, meticulous dissection of the soft tissue was performed to identify the SCN branches as they coursed perpendicularly over the clavicle. ...
Objectives The supraclavicular nerve (SCN) supplies the skin over the clavicle and proximal chest. The unpredictable branching pattern of the SCN within the posterior triangle of the neck makes it susceptible to damage during open fixation of clavicle fractures. Resultant iatrogenic injuries can lead to paraesthesia and neuroma over the clavicle. The position of the SCN branches in relation to clinically appreciable landmarks has not hitherto been described. The aim of this study was to identify the precise location of the SCN branches in relation to the acromioclavicular (AC) and sternoclavicular (SC) joints. Methods Ten soft-embalmed cadavers, donated under the Human Tissue Act (2004), were carefully dissected along the superior border of both clavicles to identify the SCN branches. The distance from each branch of the SCN to the SC and AC joints was measured. Results The SCN was found to comprise either 2 branches (8/20), or 3 branches (12/20). No branches were found within 2.6 cm and 2.9 cm of the SC and AC joint, respectively. Between these two “safe zones”, the locations of the branches varied significantly. Conclusions No safe zone was identified in the mid-clavicular region. Hence, meticulous dissection is required here to preserve the SCN branches.
... There is a general acceptance in the surgical community that an incision following Langer's lines gives cosmetically pleasing surgical results [8]. Evidence suggests that the appearance of such an incision is more pleasing to patients [9]. The theory proposed here is that a skin incision along Langer's lines is under reduced tension, and therefore, less likely to result in complications. ...
... The benefit of this study is its comparatively large sample size. Chechik et al. and Shukla et al. both compared skin incision for clavicle fixation with 38 and 36 patients, respectively [6,9]. Our findings mirror both studies with no difference in complications between the two groups. ...
Introduction
Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer’s lines, as opposed to a traditional transverse incision, reduces complications.
Methods
We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer’s lines or a transverse incision was used according to surgeon’s preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher’s exact tests.
Results
Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified.
Conclusion
Based on our data, an incision following Langer’s lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.
... The supraclavicular nerve is at risk of injury during clavicle fixation. It pierces through the platysma crossing the clavicle 97% of the time, most commonly over the lateral two thirds, to provide sensation to the anteromedial shoulder and upper chest wall [19][20][21]. ...
... Incidence varies widely from 6 to 90% (Appendix I). There is a consistent trend of improvement over time, though without full resolution for all patients [11,19,[23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Previous groups have demonstrated good outcomes despite high prevalence of numbness leading them to refute correlation between numbness and patient satisfaction [19,23,31]; whereas You et al. [29] concluded that conventional approaches led to discomfort in 74.3% of their patients. ...
... There is a consistent trend of improvement over time, though without full resolution for all patients [11,19,[23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Previous groups have demonstrated good outcomes despite high prevalence of numbness leading them to refute correlation between numbness and patient satisfaction [19,23,31]; whereas You et al. [29] concluded that conventional approaches led to discomfort in 74.3% of their patients. The impact of sensory disturbances on patients' outcomes has not been well elucidated. ...
Background
Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures.
Methods
Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction.
Results
Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall.
Conclusions
Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively.
... 19 Several authors attempted to use a necklace incision with a transverse incision to reveal the supraclavicular nerve and avoid iatrogenic supraclavicular nerve injury. 5,17 The line running between the condyle tip and the midpoint of the sternocleidomastoid muscle is located on the lateral side of the lateral branch of the supraclavicular nerve middle group. We used this anatomic feature to design a new type of incision that is located where the line joining the lateral border of the condylar process apex and the posterior border of the sternocleidomastoid muscle intersects with the clavicle. ...
Background:
Iatrogenic supraclavicular nerve injury is frequent during surgical repair of clavicle fractures through a transverse incision. The use of an oblique incision may be a potential approach to avoiding this complication. This study compared the clinical effectiveness of oblique and transverse incisions in the treatment of fractures in the middle and outer thirds of the clavicle.
Methods:
This prospective observational study included patients with fracture of the mid-to-outer third of the clavicle between August 2011 and August 2016. We allocated the patients into 2 groups based on their choice of treatment: oblique incision (n = 62) and transverse incision (n = 64). We compared the following parameters between the 2 groups: operative time, intraoperative blood loss, postoperative fracture healing time, incision size, clinical complications, postoperative subjective satisfaction, and shoulder function.
Results:
Operative time, postoperative fracture healing time, postoperative shoulder function (Constant-Murley and disabilities of the arm, shoulder and hand [DASH] scores), and clinical complications did not differ significantly between groups (all P > .05). The oblique incision group had less intraoperative blood loss (41.4 ± 16.4 vs. 65.3 ± 10.4 mL, P < .001) and smaller surgical incisions (3.6 ± 1.6 vs. 10.3 ± 2.6 cm, P < .001). The oblique incision group showed better outcomes for postoperative satisfaction (85.5% vs. 64.1%, P = .015), absence of shoulder numbness at the last follow-up (89.3% vs. 70.3%, P = .010), and satisfaction with the scar (90.3% vs. 3.1%, P < .001).
Conclusion:
Oblique incisions have several advantages over transverse incisions: less bleeding, smaller incisions, less iatrogenic injury to supraclavicular nerves, and higher patient satisfaction. These 2 approaches have equivalent effects on recovery of shoulder joint function.
Background
Clavicle fractures, frequently associated with sports and trauma, are prevalent injuries in the upper extremity. Surgical repair, a common intervention, aims to restore skeletal stability and facilitate functional recovery. The role of neural protection, particularly concerning the supraclavicular nerve, in clavicle fracture surgery remains an area of interest. The purpose of this study was to compare operative time, bleeding, postoperative hospitalization, postoperative pain, numbness, and upper extremity function between clavicle plastic surgery patients using supraclavicular nerve preservation and supraclavicular nerve sacrifice techniques.
Methods
A retrospective cohort study spanning January 2021 to January 2023 involved patients with midshaft clavicle fractures treated with dynamic compression plates or locking plates at Xi'an People's Hospital (Xi'an Fourth Hospital). Patient data were extracted, and surgical outcomes were meticulously recorded. Parameters such as operative time, estimated blood loss, post-operative hospitalization duration, Visual Analog Scale (VAS) scores, Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score, and the occurrence of numbness were among the comprehensive outcomes analyzed.
Results
Among the 241 eligible patients, the study categorized them into Supraclavicular Nerve Preservation (SNP) and Supraclavicular Nerve Sacrificing (SNS) groups. Baseline analysis revealed comparable demographic and injury-related characteristics. Surgical outcomes analysis demonstrated no significant difference in operative time between the SNP and SNS groups (64.28 ± 16.07 vs. 67.50 ± 17.53, p = 0.19). Strikingly, the SNP group exhibited significantly lower blood loss during surgery compared to the SNS group (28.43 ± 13.35 vs. 36.51 ± 16.54, p < 0.01). No substantial difference in post-operative hospitalization duration was noted between the two groups (3.07 ± 1.07 vs. 3.23 ± 41.06, p = 0.32). Evaluation of postoperative numbness consistently favored the SNP group at 1 month (94.1% vs. 8.1%, p < 0.01), 3 months (95.6% vs. 10.4%, p < 0.01), 6 months (98.5% vs. 11.6%, p < 0.01), and 1 year postoperatively (98.5% vs. 13.3%, p < 0.01).
Conclusion
This study suggests that the Supraclavicular Nerve Preservation approach, while equivalent in operative efficiency, offers advantages in reducing blood loss (p < 0.01) and minimizing postoperative numbness (all p < 0.01). These findings contribute valuable evidence to the discourse on optimal clavicle fracture management, emphasizing the importance of nerve preservation in surgical interventions. Further research is warranted to validate and extend these findings for broader clinical implications.
Introduction: Supraclavicular nerve injury is one of the common complications after clavicle open reduction internal fixation (ORIF) affecting up to 55% of patients. There is debate about whether sparing supraclavicular nerves improves functional outcomes and patient satisfaction. The purpose of this study was to compare numbness, patient-reported outcomes and surgical time in patients undergoing clavicle ORIF using supraclavicular nerve sparing and supraclavicular nerve sacrificing techniques.
Patients and Methods: We conducted a retrospective cohort study with prospective survey of 108 patients with clavicular fractures treated with ORIF at a level 1 trauma centre. Patients were divided into two groups: 1) ORIF with supraclavicular nerve sparing techniques and 2) ORIF with supraclavicular nerve sacrificing techniques. Questionnaires were conducted and subjective numbness around supraclavicular nerve distribution was our primary outcome measure. Secondary outcome measures included the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score, a numeric rating scale for pain and satisfaction with treatment and surgical time.
Results: An overall response rate of 92% was achieved with an average follow-up of 16 months. There were 20 patients in the supraclavicular nerve sparing group and 79 patients in the supraclavicular nerve sacrificing group. 76% of all patients experienced numbness post-operatively and 91% of these patients experienced persistent numbness at final follow-up. There was no significant difference between the groups for age, gender, time to follow-up and mechanism of injury. Patients in the supraclavicular nerve sparing group had significantly less numbness at final follow-up (35% vs 86%, P < 0.001; OR=0.21 95%CI 0.11-0.40). There was no significant difference in the QuickDASH score nor the NRS for pain and function. Sparing supraclavicular nerves did not result in a significantly longer operation.
Conclusions: Our study demonstrates that identification and protection of the supraclavicular nerves result in significantly less numbness following clavicle ORIF but does not affect patient reported functional outcomes.
Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.
Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.
However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.
The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.
Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033
