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Umeda Y, Hagiwara K, Matsumoto S. Subclavian Artery Injury During Lung Tumor Resection. Cureus 2024; 16:e67846. [PMID: 39347204 PMCID: PMC11427703 DOI: 10.7759/cureus.67846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2024] [Indexed: 10/01/2024] Open
Abstract
An open penetrating injury of the subclavian artery is an extremely rare catastrophic situation in thoracic surgery. We experienced a 57-year-old case of iatrogenic subclavian artery injury during the resection of a lung tumor. The injury occurred during the dissection of the adhesion between the stapling site of the previous bullectomy and the chest wall. Systolic blood pressure dropped below 50 mmHg immediately after the injury. Following primary hemostasis achieved with suture closure, the site of injury was sufficiently exposed and successfully repaired.
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Affiliation(s)
- Yukio Umeda
- Cardiovascular and Thoracic Surgery, Gifu Prefectural General Medical Center, Gifu, JPN
| | - Kiyohiko Hagiwara
- Cardiovascular and Thoracic Surgery, Gifu Prefectural General Medical Center, Gifu, JPN
| | - Shinsuke Matsumoto
- Cardiovascular and Thoracic Surgery, Gifu Prefectural General Medical Center, Gifu, JPN
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Müller M, Bullinger Y, Pohlemann T, Orth M. [Clavicle fractures: practical approach in clinical routine]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:1045-1056. [PMID: 37702744 DOI: 10.1007/s00104-023-01958-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/14/2023]
Abstract
Fractures of the clavicle are among the most common fractures. They typically result from a fall onto the lateral shoulder or the extended arm and are often related to sports and bicycle accidents. Obtaining the exact trauma mechanism, proper clinical findings and adequate X‑rays usually lead to the correct diagnosis. Non-displacement fractures can be treated conservatively with good results. Unstable and displaced fractures should be treated operatively. Open fractures or looming penetration are emergencies und should be treated immediately. In addition to fracture classification and morphology, other factors such as additional injuries and patient-related factors need to be considered in order to make an individualized therapy decision. In operative treatment, angular stable plating is the therapy of choice, and in most cases early functional aftercare is possible.
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Affiliation(s)
- M Müller
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421, Homburg/Saar, Deutschland.
| | - Y Bullinger
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421, Homburg/Saar, Deutschland
| | - T Pohlemann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421, Homburg/Saar, Deutschland
| | - M Orth
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421, Homburg/Saar, Deutschland
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Chen W, Wang B, Liu Z. A fluoroscopic view for midshaft clavicular fracture reduction and internal fixation: posteroanterior 25° skyline projection. BMC Surg 2022; 22:371. [PMID: 36309726 PMCID: PMC9618203 DOI: 10.1186/s12893-022-01813-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Open reduction and internal fixation have been frequently applied for displaced midshaft clavicular fracture. Plate and screw fixation of clavicular fractures could provide rigid fixation and rotational control. Proper implant positioning in surgical fixation is critical to prevent iatrogenic complications. Fluoroscopy plays an important role in the intraoperative evaluation of implants. This study aimed to introduce a new fluoroscopic projection to evaluate the positioning of plates and screws. Methods Adult patients with a diagnosis of acute displaced midshaft clavicular fracture were included in this study. The slope angle of the midshaft clavicle was measured on sagittal reconstructions of preoperative computed tomography (CT) scans. The incidence of screw revision based on intraoperative standard posteroanterior (PA) and PA 25° cephalic skyline projections was compared. The interobserver agreement for the two projections was calculated. Results Twenty-nine patients with midshaft clavicular fractures were enrolled from January 2020 to June 2021. The PA 25° skyline projection could clearly display the tangential line of the plate and inferior border of the clavicle. The slope angle on the superior surface of the midshaft clavicle was 26.0 ± 5.8° (range: 18.5–38.3°). The incidence of screw revision using the PA projection (72.4%) was significantly different from that using the PA 25° skyline projection (34.5%) (P < 0.05). The concordance of the screw revision rate based on the standard PA and PA 25° skyline projections was strong, with kappa coefficients of 0.680 (95% CI: 0.394–0.968) and 0.776 (95% CI: 0.537–0.998). Conclusion The PA 25° skyline projection corresponds to the slope angle of the midshaft clavicle. It can provide more accurate information regarding the proper screw length and be applied as a routine method for intraoperative evaluation.
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Liu P, Xiao JX, Zhao C, Li X, Sun G, Yang F, Wang X. Factors Associated With the Accuracy of Depth Gauge Measurements. Front Surg 2022; 8:774682. [PMID: 35096957 PMCID: PMC8793061 DOI: 10.3389/fsurg.2021.774682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: It is important to select appropriate screws in orthopedic surgeries, as excessively long or too short a screw may results failure of the surgeries. This study explored factors that affect the accuracy of measurements in terms of the experience of the surgeons, passage of drilled holes and different depth gauges.Methods: Holes were drilled into fresh porcine femurs with skin in three passages, straight drilling through the metaphysis, straight drilling through the diaphysis, and angled drilling through the diaphysis. Surgeons with different surgical experiences measured the holes with the same depth gauge and using a vernier caliper as gold standard. The length of selected screws, and the time each surgeon spent were recorded. The measurement accuracy was compared based on the experiences of the surgeons and the passage of drilled holes. Further, parameters of depth gauges and 12-mm cortical bone screws from five different manufacturers were measured.Results: A total of 13 surgeons participated in 585 measurements in this study, and each surgeon completed 45 measurements. For the surgeons in the senior, intermediate, and junior groups, the average time spent in measurements was 689, 833, and 785 s with an accuracy of 57.0, 42.2, and 31.5%, respectively. The accuracy and measurement efficiency were significantly different among the groups of surgeons (P < 0.001). The accuracy of measurements was 45.1% for straight metaphyseal drilling, 43.6% for straight diaphyseal drilling, and 33.3% for angled diaphyseal drilling (P = 0.036). Parameters of depth gauges and screws varied among different manufacturers.Conclusion: Both observer factor and objective factors could affect the accuracy of depth gauge measurement. Increased surgeon's experience was associated with improvements in the accuracy rate and measurement efficiency of drilled holes based on the depth gauge. The accuracy rate varied with hole passages, being the lowest for angled drilled holes.
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Affiliation(s)
- Pengcheng Liu
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Joanna Xi Xiao
- School of Clinical Medicine, The National University of Ireland Galway, Galway, Ireland
| | - Chen Zhao
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaodong Li
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guantong Sun
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei Yang
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoqing Wang
- Shanghai Key Laboratory of Orthopedic Implant, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xiaoqing Wang
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Fozzato S, Petrucci QA, Passeri A, Bianco Prevot L, Accetta R, Basile G. Brachial plexus paralysis in a patient with clavicular fracture, medico-legal implications. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022285. [PMID: 36043954 PMCID: PMC9534230 DOI: 10.23750/abm.v93i4.13435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/08/2022] [Indexed: 11/23/2022]
Abstract
Clavicular fractures make up 2.6-4% of all fractures in adults. The most frequent mechanism of injury is a fall with direct trauma to the shoulder during sports or road accidents. These fractures can have acute complications such as vascular lesions, nerve injuries, pneumothorax, and musculoskeletal injury. Primary brachial plexus injuries are rare events, both in the adult and paediatric population, have an incidence of less than 1% and are usually caused by direct compression of the fragments. We describe a case of midshaft clavicular fracture treated conservatively with a figure-eight bandage, associated with acute brachial plexus injury, and possible medico-legal repercussions thereof. It is important to recognize the progression of neurological deficits early on, in order for appropriate treatment to be undertaken promptly. Patients must be monitored and re-evaluated within few days after the injury to check the correct positioning of the brace, its degree of tolerability, and the possible onset of neurological deficits, because some clavicular fractures can be associated with compression of the brachial plexus.
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Affiliation(s)
- Stefania Fozzato
- Department of Trauma Surgery IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - Quirino Alessandro Petrucci
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, “Sapienza” University of Rome, Rome, Italy
| | | | - Luca Bianco Prevot
- Department of Trauma Surgery IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - Riccardo Accetta
- Department of Trauma Surgery IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - Giuseppe Basile
- Department of Trauma Surgery IRCCS Orthopedic Institute Galeazzi, Milan, Italy
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Firoozabadi R, Wilkerson J, Hemingway J, Tran N. Axillary Artery Pseudoaneurysm After Revision Plate Osteosynthesis of a Midshaft Clavicle Fracture Nonunion: A Case Report. JBJS Case Connect 2020; 10:e19.00591. [PMID: 37475452 DOI: 10.2106/jbjs.cc.19.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
CASE A patient with history of nonunion repair of traumatic midshaft clavicle fracture was referred to our orthopaedic trauma clinic for new-onset shoulder pain and paresthesias involving the ipsilateral arm. Computed tomography angiography revealed an axillary artery pseudoaneurysm adjacent to the instrumentation and recurrent nonunion of the fracture site. The patient underwent coil embolization of the pseudoaneurysm and nonunion repair. CONCLUSION This case demonstrates that iatrogenic neurovascular injury during clavicle fracture nonunion repairs can present in a delayed fashion requiring more thorough clinical and imaging evaluation to achieve successful treatment.
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Affiliation(s)
- Reza Firoozabadi
- Department of Orthopaedics & Sports Medicine, University of Washington, Seattle, Washington
| | - Jacob Wilkerson
- Department of Orthopaedics & Sports Medicine, University of Washington, Seattle, Washington
| | - Jake Hemingway
- Department of Vascular Surgery, University of Washington, Seattle, Washington
| | - Nam Tran
- Department of Vascular Surgery, University of Washington, Seattle, Washington
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Müller SA, Müller-Lebschi JA, Müller AM. Komplikationsmanagement in der operativen Versorgung der Klavikulafraktur. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00341-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Parry JA, Chambers LR, Koval KJ, Langford JR. Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:227-230. [PMID: 31502012 DOI: 10.1007/s00590-019-02546-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. METHODS A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. RESULTS None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. CONCLUSIONS None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Joshua A Parry
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
| | - Lori R Chambers
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
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Zeng J, Ye J, Xie Y, Chen C, Lin Z. [Effectiveness analysis of distal radius microplate locking plate for treatment of displaced fracture of medial clavicle]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:527-530. [PMID: 31090342 PMCID: PMC8337208 DOI: 10.7507/1002-1892.201808113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 04/02/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate and evaluate the effectiveness of the distal radius microplate locking plate for the treatment of displaced fracture of medial clavicle. METHODS Between January 2013 and June 2017, 18 cases of obvious displaced fracture of medial clavicle were treated with distal radius microlocking plate. There were 10 males and 8 females, with an average age of 51.4 years (range, 18-88 years). Causes of injury included traffic accident injury in 15 cases, heavy object injury in 3 cases; all of them were closed injury. According to Edinburgh classification, 15 cases were ⅠB1 type and 3 cases were ⅠB2 type. Fracture displacement was 12-21 mm (mean, 16.3 mm). The time from injury to operation was 3-7 days (mean, 4.3 days). After operation, the clinical healing and complications of fracture were observed, and shoulder function was evaluated according to Rockwood's scoring criteria. RESULTS No incisional infection, neurovascular injury, or other early complications occurred. All 18 patients were followed up 8-15 months (mean, 12 months). All fractures reached clinical osseous union, and the healing time was 8-24 weeks (mean, 16.6 weeks). Postoperative plate loosening occurred in 1 case, which was removed surgically, while other patients did not suffer from complications such as bone nonunion, displacement, internal fixator loosening, and loss of reduction. At last follow-up, according to Rockwood's scoring criteria, the results were excellent in 12 cases and good in 6 cases. CONCLUSION The distal radius microplate locking plate is effective for the treatment of displaced medial clavicle fracture, which has few complications, and is feasible for early functional exercise, and is helpful for the recovery of shoulder joint function.
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Affiliation(s)
- Jinyuan Zeng
- Department of Orthopedic Trauma, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Junjian Ye
- Department of Orthopedic Trauma, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005,
| | - Yun Xie
- Department of Orthopedic Trauma, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Chunyong Chen
- Department of Orthopedic Trauma, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Zhangxiong Lin
- Department of Orthopedic Trauma, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
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Trans-Metaphyseal Screws Placed in Children: An Argument for Monitoring and Potentially Removing the Implants. J Pediatr Orthop 2019; 39:e28-e31. [PMID: 30379707 DOI: 10.1097/bpo.0000000000001280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons frequently use trans-metaphyseal screws in children to achieve osteosynthesis after fractures or stability after reconstructive osteotomies. Screws that were initially inserted below the cortex of bone can become prominent and symptomatic due to the process of funnelization that narrows the wide metaphysis to the diameter of the thinner diaphysis. METHODS Case series presentation of 11 children who presented with screw prominence after the cutback process range in age from 19 to 169 months. We used the screws as radiographic markers to quantitate the amount of bone "cutback" or lost during the process of funnelization. RESULTS The average length of screw protrusion beyond the edge of the bone when symptomatic was 8.7 mm (range, 3.3 to 14.3 mm). Time from implantation to the last radiograph averaged 40 months (range, 19 to 84 mo). The average loss of bone width at the time of presentation was 21% (range, 7% to 36%). CONCLUSIONS These cases suggest that orthopaedic surgeons should consider monitoring children after implantation of trans-metaphyseal screws and informing parents and patients about the possibility of screw prominence necessitating removal due to the process of metaphyseal funnelization. LEVEL OF EVIDENCE Level IV.
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Conant SH, Hickerson LE. Arteriovenous Fistula Development After Nonoperative Treatment of a Clavicular Fracture: A Case Report. JBJS Case Connect 2018; 8:e65. [PMID: 30134262 DOI: 10.2106/jbjs.cc.18.00016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a case of prominent venous dilation in the supraclavicular area with an underlying arteriovenous fistula following nonoperative management of a fracture in the medial third of the clavicle in an adult. The venous dilation indicated elevated venous pressures, likely caused by hypertrophic callus formation and/or fistula development. CONCLUSION Arteriovenous fistula and prominent venous dilation are possible sequelae of nonoperative treatment of clavicular fractures. Surgeons should be aware of their possibility when planning either operative or nonoperative treatment. More information is needed to guide management of these issues when they occur.
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Affiliation(s)
- Scott H Conant
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lindsay E Hickerson
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Downey C, O'Neill D, Lee M, Donnelly M, Mullett H. Chylous-Related Complications Following Surgical Management of Clavicular Fractures: A Report of Two Cases. JBJS Case Connect 2018; 8:e61. [PMID: 30095470 DOI: 10.2106/jbjs.cc.17.00260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We treated 2 patients with chylous-related complications following open reduction and internal fixation (ORIF) of the clavicle. These complications were of unknown etiology; 1 was treated with percutaneous injection of a sclerosing agent, while the other was treated with ligation of the thoracic duct. CONCLUSION A chyle leak is more commonly seen with upper gastrointestinal, thoracic, and head and neck surgery. This complication potentially carries a substantial rate of morbidity. We report the successful management of 2 patients with difficult postoperative chylous-related complications following ORIF of the clavicle.
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Affiliation(s)
- Colum Downey
- Departments of Orthopaedics (C.D., M.D., and H.M.), and Radiology (D.O'N. and M.L.), Beaumont Hospital, Dublin, Ireland
| | - Damien O'Neill
- Departments of Orthopaedics (C.D., M.D., and H.M.), and Radiology (D.O'N. and M.L.), Beaumont Hospital, Dublin, Ireland
| | - Michael Lee
- Departments of Orthopaedics (C.D., M.D., and H.M.), and Radiology (D.O'N. and M.L.), Beaumont Hospital, Dublin, Ireland
| | - Michael Donnelly
- Departments of Orthopaedics (C.D., M.D., and H.M.), and Radiology (D.O'N. and M.L.), Beaumont Hospital, Dublin, Ireland
| | - Hannan Mullett
- Departments of Orthopaedics (C.D., M.D., and H.M.), and Radiology (D.O'N. and M.L.), Beaumont Hospital, Dublin, Ireland
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Nair A, Dolan J, Tanner KE, Kerr CM, Jones B, Pollock PJ, Kellett CF. Ultrasound-guided adductor canal block: a cadaver study investigating the effect of a thigh tourniquet. Br J Anaesth 2018; 121:890-898. [PMID: 30236251 DOI: 10.1016/j.bja.2018.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/08/2018] [Accepted: 05/16/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Placement of local anaesthetic within the adductor canal using ultrasonography is an alternative to femoral nerve blocks for postoperative pain relief after knee joint replacement surgery. However, the effect of an inflated thigh tourniquet on the distribution of local anaesthetic within the adductor canal is unknown. The aim of this cadaveric study was to compare the distribution of radio-opaque dye within the adductor canal in the presence or absence of an inflated thigh tourniquet. METHODS Bilateral ultrasound-guided adductor canal blocks were performed on the thawed lower limbs of five fresh frozen human cadavers. The left and right lower cadaver limbs were randomised to receive or not receive a thigh tourniquet inflated to 300 mm Hg for 1 h. X-rays with iohexol radio-opaque dye were obtained in four views, and fiducial markers inserted as reference points. Virtual editing technology was used to recreate outlines representing the distribution of the radio-opaque dye and superimpose these on anatomical images. RESULTS Radio-opaque dye was distributed on the medial aspect of the thighs with entire and well circumscribed margins. The majority of the radio-opaque dye was confined within the adductor canal. Superior-inferior dye distribution was 315 mm [95% confidence intervals (CI) 289-342] and 264 mm (95% CI 239-289) in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -80.46 to -22.22, P=0.0081). Image analysis using the recreated radio-opaque outlines suggested that the most proximal point of the radio-opaque dye was 100 mm (95% CI 82-117) or 117 mm (95% CI 62-171) below the inguinal ligament in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -38 to 72, P=0.456). CONCLUSIONS Application and inflation of thigh tourniquets significantly increased the combined superior-inferior dye distribution within the adductor canal of cadaveric limbs. There was insufficient evidence to suggest significant proximal spread of 25 ml of local anaesthetic to involve the motor branches of the femoral nerve. In some patients, the local anaesthetic may reach the popliteal fossa in close approximation to the sciatic nerve.
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Affiliation(s)
- A Nair
- School of Medicine, Glasgow, UK
| | - J Dolan
- Department of Anaesthesia, Glasgow, UK.
| | | | - C M Kerr
- School of Engineering, Glasgow, UK
| | - B Jones
- Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - P J Pollock
- School of Veterinary Medicine, University of Glasgow, Glasgow, UK
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Looft JM, Corrêa L, Patel M, Rawlings M, Ackland DC. Unicortical and bicortical plating in the fixation of comminuted fractures of the clavicle: a biomechanical study. ANZ J Surg 2017; 87:915-920. [PMID: 28922701 DOI: 10.1111/ans.14139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/01/2017] [Accepted: 06/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative neurovascular complications with clavicle fracture fixation are often due to far cortex penetration by drills and screws, but could be avoided using a unicortical construct. The objective of this study was to compare the bending and torsional strength of a unicortical locking screw plate construct and a hybrid (with central locked and outer non-locked long oblique screws) unicortical plate construct for clavicle fracture fixation with that of a conventional bicortical locking screw construct of plate fixation. METHODS Twenty-four human clavicle specimens were harvested and fractured in a comminuted mid-shaft butterfly configuration. Clavicles were randomly allocated to three surgical fixation groups: unicortical locking screw, bicortical locking screw and hybrid unicortical screw fixation. Clavicles were tested in torsion and cantilever bending. Construct bending and torsional stiffness were measured, as well as ultimate strength in bending. RESULTS There were no significant differences in bending stiffness or ultimate bending moment between all three plating techniques. The unicortical locked construct had similar torsional stiffness compared with the bicortical locked construct; however, the hybrid technique was found to have significantly lower torsional stiffness to that of the bicortical locking screw construct (mean difference: 87.5 Nmm/degree, P = 0.028). CONCLUSIONS Unicortical locked screw plate fixation and hybrid unicortical plating fixation with centrally locked screws and outer long, oblique screws may alleviate far cortex penetration, protecting nearby anatomical structures, and may ease implant removal and conversion to bicortical fixation for revision surgery; however, use of long oblique screws may increase the risk of early loosening under torsion.
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Affiliation(s)
- John M Looft
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lincoln Corrêa
- Department of Orthopaedic Surgery, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Minoo Patel
- Department of Orthopaedic Surgery, Epworth Healthcare, Melbourne, Victoria, Australia.,Centre for Limb Reconstruction, The Epworth Centre, Melbourne, Victoria, Australia.,Department of Surgery, Southern Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mathew Rawlings
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - David C Ackland
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
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Stillwell A, Ioannou C, Daniele L, Tan SLE. Osteosynthesis for clavicle fractures: How close are we to penetration of neurovascular structures? Injury 2017; 48:460-463. [PMID: 27839796 DOI: 10.1016/j.injury.2016.10.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/25/2016] [Accepted: 10/30/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Risks associated with drill plunging are well recognised in clavicle osteosynthesis. To date no studies have described plunge depth associated with clavicle osteosynthesis. PRIMARY AIM To determine whether plunge depth associated with clavicle osteosynthesis is great enough to penetrate neurovascular structures and whether surgical experience reduces the risk of neurovascular injury METHOD: Cadaveric clavicles were pressed into spongy phenolic foam to allow measurement of drill bit penetration beyond the far cortex (plunge depth). 15 surgeons grouped according to experience were asked to drill a single hole in the medial, middle and lateral clavicle in 2 specimens each. Each surgeon used fully a charged standard Stryker drill with a new 2.6mm drill bit and guide. Plunge depths were measured in 0.5mm increments. Depth measurements were compared amongst groups and to previously documented distances to neurovascular structures as outlined by Robinson et al. Kruskal-Wallis test was used for overall comparison and Mann-Whitney U test was used for comparing the groups individually. RESULTS Mean plunge depth across all groups was 3.4mm, (0.5-6.5), 4.0mm (1mm-8.5mm) and 4.0mm (0.5mm-15mm) in the medial, middle and lateral clavicle. Plunge depths were greater than previously documented distances to the subclavian vein at the medial clavicle on nine occasions. Plunge depths in the middle and lateral clavicle were well within the previously documented distances from neurovascular structures. There was no correlation between level of experience and median plunge depth (p=0.18). However, inexperienced surgeons plunged 1mm greater than intermediate and experienced surgeons (p=0.026). There was one significant outlier; a 15mm plunge depth by an inexperienced surgeon in the lateral clavicle. CONCLUSION Clavicle osteosynthesis has a relatively high risk of neurovascular injury. Plunge depths through the clavicle often exceed the distance of neurovascular structures, especially in the medial clavicle. A thorough understanding of the anatomy of these neurovascular structures and methods to prevent excessive plunging is important prior to undertaking clavicle osteosynthesis.
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Affiliation(s)
- A Stillwell
- Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - C Ioannou
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - L Daniele
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - S L E Tan
- Gold Coast University Hospital, Gold Coast, QLD, Australia; Griffith University, Gold Coast, QLD, Australia
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Kenyon RM, Morrissey DI, Molony DC, Quinlan JF. Locking plate external fixation and negative pressure wound therapy for treatment of a primary infection in a closed clavicle fracture. BMJ Case Rep 2016; 2016:bcr-2016-218241. [PMID: 27895083 DOI: 10.1136/bcr-2016-218241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Infection in a clavicle fracture is uncommon, but remains a challenging problem. A paucity of soft tissue coverage often combined with significant displacement and interfragmentary movement add complexity to an already difficult situation for effective infection treatment. External fixation in principle offers a means of achieving fracture stability, while the infection is being eradicated. We present the case of a closed clavicle fracture, initially treated conservatively, that presented 5 weeks later with infection. The fracture was definitively treated with external fixation using a locking plate positioned superficially to the skin, plus negative pressure wound therapy and subsequent secondary closure and antibiotic therapy. This case illustrates a novel method of treatment in this unusual presentation that was well tolerated by the patient and resulted in a good clinical outcome.
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Affiliation(s)
| | | | | | - John Francis Quinlan
- Department of Trauma and Orthopaedics, The Adelaide and Meath Hospital Incorporating the National Childrens Hospital, Dublin, Ireland
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