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WORST CASE SCENARIO

Air Embolus During Clavicle Internal Fixation
Table 2. Management of suspected vascular injury

with a Plate Air Emboli
Anaesthetist
Aggressive fluid resuscitation
Risk factors for air emboli involve any event that increases
Position patient trendelenburg and left side
the pressure gradient between the surgical site (atmospheric down
pressure) and venous system (right atrial pressure). This
includes negative intrathoracic pressure, hypovolemia, and Orthopaedic High index of suspicion
Surgeon
Early referral to a vascular surgeon if injury is
positioning where the operative site is higher than the right suspected
atrium. The subclavian vein retains its patency even in Flood wound with saline

hypovolemia due to its soft tissue attachments, allowing large Control haemorrhage
volumes of air to enter if injured.
Acknowledgements
Measures to prevent air emboli include, maintaining
We extend our condolences to the family. Acknowledgement
normovolemia, avoiding venous injury, strict haemostasis and to the Queensland Coroner’s Office for providing information
positive pressure ventilation. Conversely, positive pressure
and to the operating surgeon who supporting this review and
ventilation may cause venous engorgement resulting in an for this information being made available. The authors have no
enlarged subclavian vein, increasing the risk of iatrogenic
conflict of interest in this paper.
injury.

If venous injury is suspected the wound should be immersed
in saline to prevent air entry. The patient should be immediately
placed into a trendelenberg position with the left side down,

and the vessel controlled. A right atrial catheter can aspirate
air and reduce bubble size. The author’s current approach to

minimise risk is outlined in table 1 and 2.

Table 1. Recommendations to prevent vascular injury with
fixation of clavicle fractures
Appl
y for an ISAKOS

Pre-operative Assess risk factors such as a small clavicle,

Teaching Center
assessment
medial fracture, osteoporosis, comminution,
non-union, take down of malunion, previous
surgery or infection.
Scholarship!
Perform a 3D CT angiogram in high risk
patients.

ISAKOS is pleased to offer a Teaching Advise the anaesthetist of the risk of vessel
penetration and air embolus prior to the case
Center Scholarship as part of the ISAKOS
Global Connection Campaign. The and just prior to drilling the clavicle.

scholarship is designed to give ISAKOS Measure clavicle dimensions in complex
Members an opportunity to visit an ISAKOS cases.

Teaching Center to expand their education Anaesthetic
Advise the anaesthetist of risk pre-operatively
and just prior to drilling.
in the specialties of Arthroscopy, Knee
Surgery and Orthopaedic Sports Medicine. Positive pressure ventilation

Please visit the ISAKOS website to view Surgical Subperiosteal dissection of the clavicle, so
eligibility requirements.
exposure
that the position of the drill and screws at time
of perforation of the second cortex can be
visualised.
Apply
Application Deadline: Do not breach the posterior periostium, (as the
October 1, 2013
Today
vessels may be adherent) as it acts as a layer

between the instruments and vessels.

Fixation
Medial clavicle – Superior plate
Mid clavicle – Unicortical screws
Lateral clavicle – Anterior plate

Drilling of Superior to inferior on medial clavicle
clavicle
Anterior to posterior on lateral clavicle
Use a new, or sharp drill bit for each case.

The drill is advanced slowly, with attention
being paid to the change in pitch as the drill is

www.isakos.com/teaching
almost through the second cortex.

36 ISAKOS NEWSLETTER 2013: Volume II