What the Anesthesiologist Should Know before the Operative Procedure?
Fractures of the clavicle are very common, comprising 2.5% to 5% of all fractures. Mechanisms include sports injuries in young adults, motor vehicle accidents, and falls in the elderly. Only 9% suffer additional fractures, most commonly broken ribs.
Functional outcomes are generally good after nonoperative treatment of undisplaced clavicle fractures. However, displaced fractures have recently been associated with a higher rate of nonunion and functional deficits such as limited range of motion and pain in adults.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
There is some urgency (albeit small) to ORIF of the clavicle, because there is always risk of nonunion or malunion. However, most surgical candidates are young adults, and there is usually adequate time for preoperative studies and evaluation.
Emergent and urgent: Not applicable.
Elective: This surgery is elective, with timing only related to the risk of nonunion or malunion of the clavicle fracture. Although most patients are young adults (age 20 to 60), there usually is adequate time for thorough preoperative evaluation of comorbidities.
2. Preoperative evaluation
Physical examination of the upper extremity is performed to rule out brachial plexus or vascular injury. Chest radiograph can be obtained to rule out pneumothorax or hemothorax, which occurs in approximately 3% of clavicle fractures (when associated with multiple ipsilateral rib fractures). Further preoperative evaluation and studies are performed as otherwise indicated.
Posteriorly displaced clavicle fractures can cause injury to the subclavian vessels, although this is very uncommon. Associated trauma may warrant further evaluation.
3. What are the implications of co-existing disease on perioperative care?
Patients undergoing clavicle ORIF are generally healthy. If medical considerations of coexisting disease exist, one should consider nonoperative management (see comments below).
b. Cardiovascular system
Acute/unstable conditions: This may include blood loss from other injuries.
Preoperative chest radiography should be performed to rule out pneumothorax or hemothorax (as previously noted above). If these conditions are detected chest tube placement may be indicated. Associated rib fractures may lead to intubation or thoracic epidural placement for management. If serious, acute or unstable conditions are present, ORIF of the clavicle is generally delayed for evaluation or not performed.
Baseline coronary artery disease or cardiac dysfunction: Patients should be assessed with the standard AHA/ACC guidelines.
If active symptoms of coronary artery disease are present, then ORIF of the clavicle is generally delayed for evaluation or not performed.
A history of moderate to severe reactive airway disease would favor a technique that did not involve general anesthesia.
A thorough history and physical examination will be the best evaluation for severity of disease (admission to the hospital, oxygen requirements at home, or steroid use). Pulmonary function tests and arterial blood gas may also be helpful in evaluating the patient’s disease state.
Perioperative risk reduction
Continuing the patient’s home medication on the day of surgery and avoiding instrumentation of the airway will reduce the likelihood of postoperative pulmonary complication.
Reactive airway disease (Asthma)
Like COPD, a thorough history and physical will identify the severity of the patient’s disease (number of hospitalizations, active wheezing, steroid use).
Perioperative risk reduction
Like COPD, an anesthetic technique that avoids general anesthesia would be the preferred method.
Patients with sleep apnea should have the severity of the disease assessed, and appropriate strategies developed to reduce the potential for postoperative exacerbation of their disease by opioid-induced respiratory depression. They should continue the use of their CPAP therapy in the perioperative period.
A history of severe gastroesophageal reflux (GERD) may mandate an endotracheal intubation if general anesthesia is chosen.
Acute onset of new neurological deficits should be assessed prior to the procedure, requiring a full history and physical examination. Neurology consultation may be warranted and deferring the elective procedure until such time as these issues can be evaluated and/or stabilized is absolutely indicated.
Perioperative risk reduction
Again, as total knee arthroplasty is an elective procedure, any acute neurologic changes should be fully investigated before proceeding to surgery.
As part of the complete history and physical examination, recent exacerbations of disease states or chronic neuropathies should be evaluated.
Perioperative risk reduction
Chronic medications should be continued on the day of surgery. Also, dependent on the chronic neuropathy, both neuraxial and perineural anesthesia should be evaluated as suitable for the patient.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient’s medications and how should they be managed in the perioperative period?
Most patients are taking oral analgesics. Preoperative pain scores, responses to these oral pain medications, and any side effects should be noted in the preoperative evaluation of the patient.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
Cardiac: Continue cardiac medications as indicated, though this patient population is rarely on them.
Pulmonary: Use bronchodilators if asthma is present.
Neurologic: Continue antiseizure medication if needed.
Antiplatelet: Because of interference with clotting, medications may be held and surgery may be delayed a week to allow return of normal function. This includes herbal medications and fish oil, too.
j. How To modify care for patients with known allergies –
Avoid drugs to which the patient is allergic.
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Remove all latex products from operating room and ensure all staff are aware of allergy.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
If allergic to penicillin or cephalosporins, substitute vancomycin or clindamycin.
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:
Proposed general anesthetic plan
Ensure MH cart is available that includes MHAUS protocol
Family history or risk factors for MH
Local anesthetics/ muscle relaxants
Allergic reactions to local anesthetics most commonly occur in the ester class of local anesthetics and are associated with the release of para-aminobenzoic acid (PABA) as a metabolic product. Allergies to the amide class of local anesthetics are exceedingly rare. Often, patients report allergies that, on questioning, are related to epinephrine absorption and palpitations.
5. What laboratory tests should be obtained and has everything been reviewed?
Most clinicians obtain routine labs prior to this procedure.
Hemoglobin levels: May be indicated if there was blood loss with other injuries
Coagulation panel: NA unless patient was receiving anticoagulants
Imaging: Chest radiograph to evaluate for pneumothorax
Other tests: Only if clinically indicated
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The surgery can be performed in supine or beach-chair (head-up) position. Recently, adverse neurologic events have been reported after general anesthesia and surgery in head-up position. However, if adequate cerebral perfusion is maintained (for example, with NeoSynephrine infusion, and not deliberately inducing hypotension to reduce blood loss), these adverse events can likely be avoided. Furthermore, patients undergoing clavicular ORIF are unlikely to have risk factors for these adverse neurologic events (advanced age, diabetes, hypertension, history of stroke, etc.).
a. Regional anesthesia
Brachial plexus blocks and cervical plexus blocks are often performed as described below. In most cases ultrasound guidance is used to place these blocks and a long acting local anesthetic agent is used (bupivacaine or ropivacaine). It is important to block the supraclavicular nerves of the superficial cervical plexus for adequate postoperative pain relief. In addition, peripheral nerves derived from the C5 and C6 ventral ramus also contribute to sensory innervation of this region (nerve to the subclavius muscle, suprascapular nerve, and the lateral pectoral nerve). The innervation of the clavicle includes:
Cervical Plexus Contributions from the Supraclavicular Nerves (C4):
Lateral Pectoral Nerve (C5, C6, C7) Acromioclavicular Joint
Skin Overlying the Clavicle
The Clavicle Itself (Intraosseous)
Nerve to the Subclavius Muscle (C5, C6) The Clavicle Itself (Intraosseous)
Suprascapular Nerve (C5, C6) Acromioclavicular Joint
Local infiltration may also be a good alternative for analgesia. However, we are still lacking evidence comparing different analgesic techniques following clavicle ORIF. One would presume that the more lateral the clavicle fracture the more important the brachial plexus contributions would be for postoperative analgesia (or conversely, the more medial the clavicle fracture the more important the cervical plexus contributions).
Neuraxial: Not applicable
Peripheral nerve block
Benefits include good pain relief postoperatively. Drawbacks are that it may not include all areas, depending on the location of the fracture.
b. General Anesthesia
Benefits include better airway control. Drawbacks include potential for greater hypotension in beach-chair position, more postoperative nausea and vomiting. Airway concerns—an LMA is usually adequate unless there is concern about significant GERD.
c. Monitored Anesthesia Care
Not usually applicable for this procedure
6. What is the author’s preferred method of anesthesia technique and why?
Because of the positioning and anatomic location of the surgery, the author prefers to use general endotracheal anesthesia for this procedure. Placement of a laryngeal mask airway also is a reasonable option if the surgery can be performed in an expeditious fashion in supine position. Postoperative pain relief is a significant concern, and therefore a combined anesthetic technique is often utilized. The sensory innervation of the clavicle, overlying skin and adjacent tissue is complex, involving nerves of the brachial plexus (nerve to the subclavius, suprascapular nerve, and lateral pectoral nerve) and the superficial cervical plexus (supraclavicular nerves). Therefore, interscalene block of the brachial plexus with additional superficial cervical plexus block is performed before induction of general anesthesia and surgery.
A long-acting local anesthetic drug (bupivacaine 0.375%, 10 to 20 mL) is used to provide postoperative pain relief for these ambulatory surgery patients. Ultrasound guidance can be used to identify the brachial plexus between the anterior and middle scalene muscles for online guidance of the injection. In some patients direct ultrasound imaging of the supraclavicular nerves of the superficial cervical plexus is possible for online block. These nerves lie superficial to the brachial plexus at the posterolateral edge of the sternocleidomastoid muscle.
What prophylactic antibiotics should be administered?
Cephalosporin 1-2 g is usually indicated; if allergy present, vancomycin 1 gram or clindamycin is an acceptable substitute.
What do I need to know about the surgical technique to optimize my anesthetic care?
See comments above about positioning.
What can I do intraoperatively to assist the surgeon and optimize patient care?
Cell Saver and transfusion are not usually required.
What are the most common intraoperative complications and how can they be avoided/treated?
Complications are rare, but pneumothorax is possible with complex fractures and manipulation. Hypotension in the sitting position is more common.
Cardiac complications are rare. Pneumothorax is possible, and respiratory distress can occur with an interscalene block if used.
Patients are at risk for injury to the supraclavicular nerves from the surgery, which can result in a small patch of numbness over the clavicle and chest. The rate of incisional and chest wall numbness ranges from 10% to 29% after operative fixation of the clavicle. The supraclavicular nerves cross over the central portion of the clavicular shaft, with only the ends of the clavicle near the acromioclavicular and sternoclavicular joints designated as safe zones.
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
What analgesic modalities can I implement?
A block is ideal, with oral opioids an alternative.
What level bed acuity is appropriate?
With an effective block, the patient can be discharged home with their arm in a sling and oral analgesics. Routine post-block instructions are given.
What are common postoperative complications, and ways to prevent and treat them?
The most common postoperative complications are pain and/or nausea, which can be reduced by use of multimodal analgesics to reduce opioid consumption, or a block.
What’s the Evidence?
Choi, DS, Atchabahian, A, Brown, AR. “Cervical plexus block provides postoperative analgesia after clavicle surgery”. Anesth Analg. vol. 100. 2005 May. pp. 1542-3.
Mehta, A, Birch, R. “Supraclavicular nerve injury: the neglected nerve”. Injury. vol. 28. 1997. pp. 491-2.
Aszmann, OC, Dellon, AL, Birely, BT, McFarland, EG. “Innervation of the human shoulder joint and its implications for surgery”. Clin Orthop Relat Res. 1996 Sep. pp. 202-7.
Lanz, E, Theiss, D, Jankovic, D. “The extent of blockade following various techniques of brachial plexus block”. Anesth Analg. vol. 62. 1983 Jan. pp. 55-8.
Havet, E, Duparc, F, Tobenas-Dujardin, AC, Muller, JM, Frééger, P. “Morphometric study of the shoulder and subclavicular innervation by the intermediate and lateral branches of supraclavicular nerves”. Surg Radiol Anat. vol. 29. 2007 Dec. pp. 605-10.
Nathe, T, Tseng, S, Yoo, B. “The anatomy of the supraclavicular nerve during surgical approach to the clavicular shaft”. Clin Orthop Relat Res. vol. 469. 2011 Mar. pp. 890-4.
Natsis, K, Totlis, T, Chorti, A, Karanassos, M, Didagelos, M, Lazaridis, N. “Tunnels and grooves for supraclavicular nerves within the clavicle: review of the literature and clinical impact”. Surg Radiol Anat. vol. 38. 2016 Aug. pp. 687-91.
Valdéés-Vilches, LF, Sáánchez-del ÁÁguila, MJ. “Anesthesia for clavicular fracture: selective supraclavicular nerve block is the key”. Reg Anesth Pain Med. vol. 39. 2014 May-Jun. pp. 258-9.
Navarro, RA, Gelber, JD, Harrast, JJ, Seiler, JG, Jackson, KR, Garcia, IA. “Frequency and complications after operative fixation of clavicular fractures”. J Shoulder Elbow Surg. vol. 25. 2016 May. pp. e125-9.
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- What the Anesthesiologist Should Know before the Operative Procedure?
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient’s medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author’s preferred method of anesthesia technique and why?
- What prophylactic antibiotics should be administered?
- What do I need to know about the surgical technique to optimize my anesthetic care?
- What can I do intraoperatively to assist the surgeon and optimize patient care?
- What are the most common intraoperative complications and how can they be avoided/treated?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management