Biomechanical Comparison of Superior Versus Anterior Plate Position for Fixation of Distal Clavicular Fractures: A New Model.

OBJECTIVES: Although most clavicular fractures are amenable to nonoperative management, metadiaphyseal fractures are considerably more complex, with rates of suboptimal healing as high as 75% when treated nonoperatively. The poor results are ascribed to the deforming forces on the distal clavicle from the surrounding muscles and the weight of the arm. It recently has been noted that some operative fixations of these fractures are also failing when a standard superiorly placed plate is used. We hypothesized that anterior plating, when compared with superior plating, improves the strength and durability of the construct by redirecting the axis of the major deforming force across rather than in line with the screws of the construct.

METHODS: Six pairs of fresh-frozen human cadaveric clavicles with the scapula attached by the coracoclavicular ligaments were osteotomized just medial to the ligaments and plated with a standard 3.5-mm limited-contact dynamic compression plate. Specimens were potted and mounted on a materials testing system machine, preserving the anatomic relationship of the clavicle and scapula. They were then loaded through the coracoclavicular ligaments to mimic the weight of the arm pulling inferiorly. Each specimen was loaded with 375 N at 1 Hz for 2000 cycles. Sequential loading was then applied at 25-N intervals until failure. Statistical analysis was performed using a Wilcoxon signed-rank test.

RESULTS: The superiorly plated specimens failed after fewer cycles and with lower force than the anteriorly plated specimens. The median number of cycles to failure was 2082 for anterior plated specimens and 50 for superiorly plated (P = 0.028). The median load to failure was 587.5 N in the anterior group and 375 N in the superior group (P = 0.035). The median stiffness was 46.13 N/mm for anterior and 40.45 N/mm for superior (P = 0.375) plates.

CONCLUSIONS: Anteriorly plated distal third clavicular fractures have superior strength and durability compared with fractures plated superiorly when using a physician-contoured, 3.5-mm, limited-contact, dynamic compression plate in this cadaver model.