Augmentation of clavicular fractures by dual plating

Abstract

Introduction: The clavicle displays significant motion across all three anatomical planes, which poses challenges for achieving rigid internal fixation. While adding a second plate can increase construct stability, concerns exist about the potential compromise of the periosteal blood supply. This study evaluated the union rate, complications, reoperation rates, and functional outcomes of using an extra periosteal dual-plate fixation as an alternative to the conventional single-plate fixation for acute clavicle fractures at 1-year follow-up.

Methods: In this prospective study (May 2023-May 2024), 25 patients with acute clavicle fractures underwent open reduction and internal fixation within four weeks of injury. Dual orthogonal plating was performed in all cases meeting inclusion criteria (midshaft or lateral-third fractures) and also in patients requiring revision after failure of a primary single plate. All procedures were extraperiosteal to preserve blood supply. Patients were followed for a minimum of one year. Outcome measures included radiographic union (regular interval X-rays) and functional recovery assessed by the Constant-Murley shoulder score. Complications and any reoperations were recorded. Institutional ethical approval was obtained and informed consent was taken from all patients.

Results: A total of 25 patients (7 females, 18 males; mean age 39.7 ± 10.0 years) were treated and followed for an average of 11.3 ± 4.1 months. Of these, 23 patients (92%) underwent dual plating primarily (20 midshaft [80%] and 3 lateral-end [12%] fractures), and 2 patients (8%) had dual plating as a revision after failed single plating. By final follow-up, all 25 fractures achieved full bony union with no cases of nonunion or implant failure. The average time to union was ≤3 months in 15 patients and >3 months in 10 patients; all delayed unions had healed by one year without additional intervention. Shoulder function improved steadily, with mean Constant-Murley scores of 76.2 ± 6.1 at 6 weeks, 83.5 ± 3.5 at 3 months, and 92.2 ± 3.0 at 6 months post-surgery. According to Constant score categories, 20 patients (80%) had "very good" shoulder function and 5 patients (20%) had "good" function at final follow-up. Complications were infrequent: 2 patients (8%) developed superficial wound infections (resolved with antibiotics), and 6 patients (24%) experienced implant prominence/irritation. No hardware breakage, loosening, or refracture occurred, and no patient required reoperation for hardware-related problems within the follow-up period.

Conclusion: Dual-plate augmentation of acute clavicle fractures proved to be a reliable fixation strategy in this series, yielding a 100% union rate and a low incidence of complications. The application of a second plate in complex or highly unstable clavicle fractures did not adversely affect fracture healing or increase complication rates. In cases of failed single-plate fixation, revision with dual plating facilitated successful union and good functional outcomes. The primary drawback observed with dual plating was implant prominence in some patients, suggesting a need for further refinements to minimize hardware profile.

Keywords: Clavicle fracture; biomechanics; constant-murley score; dual plate augmentation; nonunion.

Figure 1

Radiographs of a 35 year old female sustaining right side clavicular fracture during a road traffic accident. A. Pre-operative radiograph showing a displaced mid shaft clavicular fracture. B. Post-operative radiograph showing augmentation by dual plating (anterior and superior plate). C. Follow-up radiographs at 3 months show some attempt of the union. D. The final follow-up radiograph at 6 months showed an uncomplicated union.

Figure 5

Shows the management of a 50-year-old male with comminuted mid-shaft clavicular fracture by dual plating augmentation. A. Pre-operative radiograph. B. Final follow-up radiograph at 1-year follow-up with complete callus formation and good Constant Murray scores.

Figure 4

Shows a fracture of the lateral end of the clavicle in a 30-year-old male sustaining an injury while he fell from a height. A. Pre-operative radiograph showing comminuted lateral end clavicle fracture AO type-15.3. B. Post-op radiograph shows an excellent reduction. C. Follow-up radiograph at 6 months with complete callus formation.

Figure 2

Radiographs of a 42-year-old male sustaining a right-side comminuted clavicular fracture during a fall from height. A. Pre-operative radiograph showing comminuted clavicular fracture. B. Post-operative radiograph showing fixation by single conventional plate. C. Follow-up radiographs at 3 months showed implant failure along with non-union at the fracture site.

Figure 3

Shows intra-op images of the patient with failed single conventional plating. A. Clinical picture showing impingement due to non-union and failure of implant. B. The incision was given to revise the surgery and remove the old plate. C. Picture showing removed clavicular plate. D. Post-operative radiograph showing revision surgery done by augmentation with dual plating. E. Final follow-up radiograph at 1 year showing good union without complications.