title: Osteosynthesis for clavicle fractures: How close are we to penetration of neurovascular structures?
abstract: BACKGROUND
  Risks associated with drill plunging are well recognised in clavicle osteosynthesis. To date no studies have described plunge depth associated with clavicle osteosynthesis.
  
  
  OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Gold Coast University Hospital, Gold Coast, QLD, Australia. Electronic address: andrew.stillwell1@gmail.com.
authors.forename: A
authors.initials: A
authors.lastname: Stillwell
authors.affiliation: Gold Coast University Hospital, Gold Coast, QLD, Australia.
authors.forename: C
authors.initials: C
authors.lastname: Ioannou
authors.affiliation: Gold Coast University Hospital, Gold Coast, QLD, Australia.
authors.forename: L
authors.initials: L
authors.lastname: Daniele
authors.affiliation: Gold Coast University Hospital, Gold Coast, QLD, Australia; Griffith University, Gold Coast, QLD, Australia.
authors.forename: S L E
authors.initials: SL
authors.lastname: Tan
mesh_terms: D002102:Cadaver; D002968:Clavicle / Q000033:anatomy & histology* / Q000293:injuries / Q000473:pathology; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000473:pathology* / Q000601:surgery; D006801:Humans; D013348:Subclavian Artery / Q000033:anatomy & histology; D013350:Subclavian Vein / Q000033:anatomy & histology; D057772:Vascular System Injuries / Q000517:prevention & control*
keywords: Clavicle fracture; Clavicle osteosynthesis; Internal fixation; Neurovascular injury; Plating; Plunge depth; Surgical complication; Surgical experience; Trauma