Surgical Approach to Injuries of the Cervical Plexus and Its Peripheral Nerve Branches :

Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures. We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures. In a multicenter, prospective clinical trial, 132 patients with a displaced midshaft fracture of the clavicle were randomized (by sealed envelope) to either operative treatment with plate fixation (sixty-seven patients) or nonoperative treatment with a sling (sixty-five patients). Outcome analysis included standard clinical follow-up and the Constant shoulder score, the Disability of the Arm, Shoulder and Hand (DASH) score, and plain radiographs. One hundred and eleven patients (sixty-two managed operatively and forty-nine managed nonoperatively) completed one year of follow-up. There were no differences between the two groups with respect to patient demographics, mechanism of injury, associated injuries, Injury Severity Score, or fracture pattern. Constant shoulder scores and DASH scores were significantly improved in the operative fixation group at all time-points (p = 0.001 and p < 0.01, respectively). The mean time to radiographic union was 28.4 weeks in the non-operative group compared with 16.4 weeks in the operative group (p = 0.001). There were two nonunions in the operative group compared with seven in the nonoperative group (p = 0.042). Symptomatic malunion developed in nine patients in the nonoperative group and in none in the operative group (p = 0.001). Most complications in the operative group were hardware-related (five patients had local irritation and/or prominence of the hardware, three had a wound infection, and one had mechanical failure). At one year after the injury, the patients in the operative group were more likely to be satisfied with the appearance of the shoulder (p = 0.001) and with the shoulder in general (p = 0.002) than were those in the nonoperative group. Operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at one year of follow-up. Hardware removal remains the most common reason for repeat intervention in the operative group. This study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.

The anatomy of the greater and lesser occipital nerves has come under increased scrutiny with the increased appreciation of their role in the causation of chronic occipital headaches. Classic anatomical descriptions of their paths have differed from some recent published reports. Measurements of the courses of the greater and lesser occipital nerves were conducted bilaterally in 125 individuals, consisting of 112 live intraoperative measurements and 13 cadaver specimens. In addition to nerve width and trajectory in the occiput, measurements of the distance of the nerves from the occipital protuberance were performed. The greater occipital nerve had a diameter of 3.8 +/- 1.6 mm, and emerged from the semispinalis capitis muscle 14.9 +/- 4.5 mm lateral to the midline and 30.2 +/- 5.1 mm inferior to the occipital protuberance. The nerve almost always (98.5 percent) pierces the body of the semispinalis capitis muscle, and in 6.1 percent of individuals it is split by fibers of this muscle or in the trapezial tunnel. The nerve then travels in a superolateral course. In 43.9 percent of patients, the nerves were asymmetric on the two sides. The lesser occipital nerve had a diameter of 1.2 +/- 1.6 mm and was often located along the posterior border of the sternocleidomastoid muscle. The course of these two nerves differs in several critical aspects from that described in classic anatomical reports. These findings have direct implications for application of nerve blocks and surgical decompression of these nerves.

From 1992-1994, we operated on 251 fresh completely displaced mid-third clavicle fractures in adults; 232 were followed up. The fractures were plated with a Mizuho C-type plate or an AO/ASIF 3.5 mm reconstruction plate. Comminuted fragments were reduced and wired (133 cases). There were 150 men and 82 women; the median age was 37.3 years (range 18-79). The mean follow-up was 4.4 years (range 3.0-5.9). The mean time to radiographic union was 10 weeks. Seven patients (3%) developed nonunion. Healing with angulation occurred in 14 patients. Deep infection developed in one patient, and superficial infection in four cases; 21 patients reported soreness with changes in the weather and activity; 28 patients had residual skin numbness caudal to the incision. No patient had shoulder droop, and none had impairment of range of motion or shoulder strength. None developed new or late neurovascular impairment; 171 patients eventually had the hardware removed at an average 401 days post operatively. Overall, 94% were satisfied with the procedure. For completely displaced clavicle fractures in adults, plating is a reliable procedure.