ANAESTHESIA FOR SURGICAL FIXATION OF CLAVICLE FRACTURE AND INNERVATION OF CLAVICLE - A RETROSPECTIVE ANALYSIS

INTRODUCTION

Clavicle or collar bone is an organ of multiple and variable innervation. Being commonest fracture in childhood, it accounts for upto 10% if all fractures.^[1]

1. Clavicle is the only osseous link between the upper extremity and the trunk. The thinnest segment without any ligamentous attachments is the mid segment of clavicle which is henceforth frequently fractured.


2. Alman classification divides clavicular fracture into three classes:

Class 1 is midshaft, Class 2 is lateral 1/3, Class 3 is medial 1/3. Revised Neers classification distinguishes three subdivisions: Type 1 is undisplaced and fractures are lateral to coracoclavicular ligament and managed conservatively. Type 2 involves a separated medial fragment from coracoclavicular ligament. Type 3 is undisplaced fracture extending into acromioclavicular joint. Thus type 2 alone needs surgical intervention.

1. Crucial vessels and nerves are related to clavicle which are both advantageous and sometimes not. The structures serve easy identification but risky injury. The clavicle and the clavicular joints are innervated by subclavian, lateral pectoral and supraclavicular nerves. These nerves have wide anatomic variations in branching relations and levels. Knowledge of innervation of clavicle is needed for effective blockade of nerves for anaesthesia or analgesia. Though interscalene approach of brachial plexus block is a plan A block for shoulder surgeries, it has variable results for clavicular fractures.

This study examines the nerve supply of clavicle and reterospects the nerve blocks which have failed to come under Plan A block category and probes the need for elaboration in regional anaesthesia for fractures of clavicle.

AIMS AND OBJECTIVES

1. To analyse the effect of interscalene block in fractures of clavicle.


2. To examine variable innervation in different types of clavicle fractures.

MATERIALS AND METHODS

Study: Retrospective analysis.

Study Preparation: All patients who underwent surgical correction for clavicle fractures as recommended by Orthopedic surgeon.

Study Period: Jan 2024 to Jan 2025.

Study Place: DSMCH, Siruvachur, Perambalur.

Methods: All the patients are presented for surgical repair and fixation of clavicle, underwent surgery under ultrasound guided interscalene block followed by general anaesthesia. All procedures were uneventful and post-operative hemodynamics and pain relief were optimal and adequate for 8 hours in the post-operative period. The age, gender of the patients, the location and nature of the fractures of clavicle, the probable nerve supply of the fracture site and those needed for reduction of displaced fractures were all noted to support the need for general anaesthesia in all our cases of fracture clavicle, which were isolated fracture. Fractures of multiple bones or polytrauma were excluded from the case series.

RESULT

The case series consists of 23 patients with displaced isolated clavicular fracture. All of them underwent open reduction and internal fixation. Of 23 only 5 were females, most of them belonged to 30-35 years age group, 11 were fractures of left clavicle and 12 were that of right, 16 were fracture of middle third, 6 were lateral 1/3^rd of clavicle that was affected of the 23 two were communuted. The pull of muscles and strong ligaments namely trapezius, sternocleidomastoid, pectoralis major and lattismus dorsi and the sternoclavicular ligament all of different innervation necessitated general anaesthesia to reduce and fix the fracture of clavicle.

CONCLUSION

The interscalene approach to brachial plexus block resulted in reliable and predictable anaesthesia of shoulder, upper arm and clavicular region. The supraclavicular branches of cervical plexus supplying skin over the acromion and clavicle are also blocked due to proximal and superficial spread of local anesthetic. Considerations for superficial plexus block and infraclavicular approach to lateral and medial pectoral nerves and posteriorly the suprascapular block may contribute to toal nerve blockade if judiciously performed considering the type of fracture of clavicle. Thus analgesis serves useful where general anaesthesia would not be feasible in specific situations futher studies including cadaveric studies are needed to confirm the variable levels of innervation.