indicated in FRACTURES OF THE CLAVICLE 27 recent cases. AYhen, however, operation is demanded a single loop of suture material will usually accomplish all that is required to hold the fragments in position; the Lane plate is almost never needed. The incision is best made a little below and parallel to the bone, rather than directly on it. If the incision is a little below the clavicle a short flap may be made, and the danger of infecting the wound from the cut skin edges will be lessened. Most surgeons prefer absorbable suture material (such as kanga- roo tendon) to wire, in securing the ends of the fragments. In operating on the inner end of the bone the surgeon should have in mind the relations of the important structures passing between the clavicle and the first rib. The subclavian vein lies directly behind, and in contact with, the clavicle and subclavius muscle, and just external to and behind the rhomboid ligament. A little external to the vein and separated from it by the scalenius anticus is the subclavian artery, which is also in relation with the clavicle and subclavius muscle. If the surgeon does not exercise great care either of these vessels may be injured, thus giving rise to serious and troublesome hemorrhage. External to the artery is the brachial plexus descending from the neck into the axilla. Fortunately however fracture of the clavicle in the region of these structures is rare. Operation is sometimes demanded in old cases because of injury 28 FRACTURES AND DISLOCATIONS to the brachial plexus with resultant paralyses. These injuries are usually due to pressure alone (without laceration of the nerves) and if the condition is not too old removal of pressure, by dividing the bone and raising the depressed fragment, will be all that is required. Following operation it will, as a rule, be wise to fix the parts with a Sayre's dressing to relieve the internal fixation of as much strain as possible.<Callout type="important" title="Important">Proper care during after-treatment can significantly impact recovery.</Callout> After-Treatment. — Sayre's dressing is the most secure known, yet it requires watching from day to day to correct slipping and to take up the slack as it develops. The fact that reduction is perfect and immobilization is secure after the dressing is in place should not lead the surgeon to assume that the same conditions will prevail a week later.* Most text-books advise the removal of the dressing at the end of a few days to inspect the skin for evidences of irritation and to see that reduction is maintained. This will seldom be needed if the dressing has been properly applied in the first place.<Callout type="tip" title="Tip">Regularly check the Sayre's dressing for signs of irritation or loosening.</Callout> Additional strips of adhesive following the course of the 'second strip,' as described in the application of Sayre's dressing, may be used as needed to raise the elbow and correct the downward slipping. The case should be carefully watched for signs of cutaneous irritation, strangulation of the circulation of the arm and for the partial recurrence of deformity.<Callout type="risk" title="Risk">Improper care can lead to complications such as skin irritation or reduced blood flow.</Callout> In the uncomplicated case in a child, union may be expected at the end of two and a half or three weeks, though the callus at this time is in no condition to withstand any considerable strain. In adults a month or a little more is necessary for the fragments to unite.<Callout type="important" title="Important">Children typically heal faster than adults.</Callout> The dressings may be removed at the end of three to five weeks, according to the age of the patient, and the arm carried in a sling for another week or ten days. During the after-treatment the dressing should be changed every ten days and the parts carefully inspected and cleansed.<Callout type="gear" title="Gear">A Sayre's dressing is essential for proper immobilization.</Callout> In removing the dressing the patient is best placed in the recumbent position so that the clavicle will not be subjected to strain during the change from the old dressing to the new. Care should be exercised not to pull the shoulder forward as the old dressing is being removed and the new one applied. With the upper extremity released it is well to fully extend the elbow and gently abduct the shoulder without disturbing the clavicle. This will aid in keeping these joints free, and will be followed by more rapid resumption of function when the dressings are permanently removed.<Callout type="warning" title="Warning">Avoid pulling on the shoulder during dressing changes.</Callout> If the dressings are replaced in the sitting position the surgeon should have an assistant to confine his entire attention to holding the shoulder upward, backward and outward while the dressings are being changed. Massage and passive motion should be instituted as soon as the dressings are permanently removed, but care should be exercised not to submit the clavicle to strain before the callus is well formed.<Callout type="important" title="Important">Early mobilization helps prevent stiffness.</Callout> These measures are of the greatest value in keeping up the tone of the muscles and in maintaining the integrity of the articular surfaces following operations on the nerves, pending the regeneration of these structures. Prognosis. — In the usual fracture of the clavicle complete resto- ration of function and strength should follow proper treatment. If the fragments have been allowed to unite in deformity there will be some loss of function, varying with the degree of deformity, and if the brachial plexus is impinged upon there may be a more or less complete paralysis of the upper extremity.<Callout type="risk" title="Risk">Damage to the brachial plexus can result in permanent paralysis.</Callout> If the disturb- ance in function is due simply to mechanical causes surprising improvement may take place as the years go by. The complication most often rendering the prognosis bad is injury to the brachial plexus. When this structure is damaged the outlook will depend on the nature and extent of the injury, and the length of time the paralysis has been established.<Callout type="warning" title="Warning">Early intervention for brachial plexus injuries can improve outcomes.</Callout> With paralysis existing a year or two there is little chance of improving the condition by operation, but even under these circumstances there is everything to gain and nothing to lose, and it is advisable, therefore, to expose the plexus and do what can be done by relieving pressure and suturing divided nerve ends. In recent cases the prognosis is not bad if operated early, although the process of regeneration may extend over months or even a year.<Callout type="important" title="Important">Early surgical intervention for brachial plexus injuries improves outcomes.</Callout> In the uncomplicated case of fracture of the clavicle the prog- nosis is good whether in child or adult, provided proper treatment is carried out.
Key Takeaways
- Use absorbable suture material for clavicle fracture repairs.
- Apply Sayre's dressing to ensure proper immobilization and reduce strain on the healing bone.
- Regularly check the patient for signs of skin irritation or circulation issues during recovery.
Practical Tips
- Use a Sayre's dressing to secure the clavicle, ensuring it remains in place without causing additional strain.
- Be cautious when changing dressings to avoid pulling on the shoulder and causing discomfort or injury.
- Instruct patients to perform gentle passive motions as soon as possible after removing the dressing.
Warnings & Risks
- Avoid applying excessive pressure during surgery, which could damage nearby blood vessels and nerves.
- Properly apply the Sayre's dressing to prevent skin irritation and ensure effective immobilization.
- Be aware that injury to the brachial plexus can result in permanent paralysis.
Modern Application
While the surgical techniques described here are historical, the principles of proper immobilization and early mobilization remain crucial for modern survival preparedness. Understanding these methods can help in providing immediate care until professional medical assistance is available.
Frequently Asked Questions
Q: What type of suture material should be used during clavicle fracture surgery?
Most surgeons prefer absorbable suture material, such as kangaroo tendon, over wire for securing the ends of the fragments.
Q: How long does it typically take for a child to recover from a clavicle fracture?
Children can expect union at the end of two and a half or three weeks, though the callus is not yet strong enough to withstand significant strain during this time.
Q: What are some signs that should be monitored after applying a Sayre's dressing for clavicle fracture treatment?
The case should be carefully watched for signs of cutaneous irritation, strangulation of the circulation of the arm, and partial recurrence of deformity.