Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail

Clinical effect of nice knot-assisted minimally invasive titanium elastic nail fixation to treat Robinson 2B midshaft clavicular fracture

BACKGROUND

The treatment of completely displaced midshaft clavicle fractures is still controversial, especially Robinson 2B fractures. Titanium elastic nail (TEN) fixation is a good option for simple fractures, but no reports exist on its use in complex fractures. This study aimed to present a surgical method using the Nice knot-assisted TEN fixation to treat Robinson 2B midshaft clavicular fractures.

METHODS

A retrospective analysis of 29 patients who underwent fixation with TEN and had a 1-year postoperative follow-up between 2016 and 2020 was performed. The fractures were classified as Robinson type 2B1 in 17 cases and type 2B2 in 12 cases. Length of the incision, postoperative shoulder function Disability of Arm Shoulder and Hand (DASH) score and Constant score, complications rate, and second surgical incision length were recorded.

RESULTS

The length of the incision was 2-6 cm (average 3.7 cm). All incisions healed by first intention, and no infection or nerve injury occurred. The Constant score was 92-100 (average 96) and the DASH score was 0-6.2 (mean, 2.64). TEN bending and hypertrophic nonunion occurred in one case (3.4%) and implant irritation occurred in four cases (13.8%) Fixation implants were removed at 12-26 months (mean, 14.6 months) after surgery, and the length of the second incision was 1-2.5 cm (average 1.3 cm).

CONCLUSIONS

Intramedullary fixation by TEN is approved as a suitable surgical technique in clavicular fracture treatment. Nice knot-assisted fixation provides multifragmentary fracture stabilization, contributing to good fracture healing. Surgeons should consider this technique in treating Robinson 2B midshaft clavicular fractures.

TRIAL REGISTRATION

Retrospectively registered. This study was approved by the Ethics Committee of Wuxi Ninth People's Hospital (LW20220021).

Simultaneous bilateral traumatic clavicle fractures: incidence, characteristics, and surgical outcomes

BACKGROUND

Although clavicle fractures are common injuries in adults, simultaneous bilateral clavicle fractures are rarely reported. The present report describes 13 patients with simultaneous bilateral traumatic clavicle fractures who were treated with surgical management and followed for more than 12 months postoperatively.

METHODS

This retrospective chart review involved skeletally mature patients with traumatic clavicle injuries. Patients with bilateral clavicle fractures who were followed up for at least 12 months after surgery were included. Data regarding the patients' demographics, injury characteristics, fracture classification, comorbidities, concomitant injuries, and treatment strategies were collected. Each displaced fracture was managed with open reduction and internal fixation. Postoperative follow-up included radiographs for assessment of bone union; calculation of the Constant-Murley score for shoulder function; administration of the Disability of the Arm, Shoulder, and Hand questionnaire for upper limb function; determination of the visual analogue scale score for pain; and assessment of complications.

RESULTS

From October 2013 to November 2021, 15 patients (10 men, 5 women) were diagnosed with bilateral clavicle fractures among 1542 patients with clavicle injuries (overall incidence of 1.0%). Of these 15 patients, this study included 13 patients (8 men, 5 women; mean age, 38.3 ± 15.3 years) who were followed up for more than 12 months postoperatively. Among the 13 patients, 10 (77.0%) had associated concomitant injuries, and 25 sides were fixed with internal plate fixation. After a follow-up period of 29.9 ± 28.5 months, all fractures achieved bone healing. Eleven patients attained excellent shoulder function on both sides and returned to their pre-injury daily activities, and the remaining two patients had unilateral shoulder dysfunction. No complications occurred.

CONCLUSIONS

Bilateral clavicle fractures are extremely rare and associated with polytrauma. Open reduction and internal fixation is recommended for such patients, especially those with severe chest injuries, because osteosynthesis of the clavicle can improve respiratory function and reduce the duration of functional disability.

Does cerclage wiring interfere with fracture healing of osteosynthesis in comminuted midshaft clavicle fractures? A multicenter study

INTRODUCTION

Historically, cerclage wires were not used in the treatment of clavicle fractures because of their invasiveness. The purpose of this study was to evaluate the radiologic results and the incidence of complications following cerclage wire application and plate fixation in the treatment of comminuted mid-shaft clavicle fractures.

MATERIALS AND METHODS

A total of 116 patients with comminuted mid-shaft clavicle fractures who underwent open reduction and internal fixation were reviewed. We analyzed the postoperative length ratio and bone union period according to the fracture classification, patient age, the number of fragments and the number of applied wires. The thickness of the fracture site was compared with the normal contralateral clavicle shaft.

RESULTS

Bone union was confirmed in all enrolled patients at an average of 14.9±4.67 weeks. There are no significant differences in the length ratio or bone union period among the subgroups (including the fracture types, age, number of fragments and applied wires). The diameter at the occupied area was not significantly from that on the normal side (p=.505).

CONCLUSIONS

The application of a single cerclage or multiple cerclage wires around the fracture site did not hamper the clavicle shaft fracture healing. This result suggests that cerclage wires should not be avoided, but can be used as a viable treatment option for clavicle shaft fractures.

LEVEL OF EVIDENCE

IV.

Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications

BACKGROUND

The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns.

METHODS

A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification.

RESULTS

Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05).

CONCLUSION

Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.

Lateral approach for intramedullary nailing of displaced midshaft clavicle fractures; a retrospective cohort study

PURPOSE

Midshaft clavicle fractures represent about 4% of all fractures in the emergency department. Non-operative treatment of displaced midshaft clavicle fractures (DMCF) can result in a relatively high non-union rate. Several operative techniques, including intramedullary fixation (IMF) using elastic stable intramedullary nailing (ESIN), have therefore been established. IMF through the medial approach is less suitable for fractures of the lateral diaphysis. IMF of DMCF of the lateral diaphysis through a lateral approach can be an alternative approach for these fractures. The aim of this study is to describe the technique of IMF from the lateral side and to present the functional outcome and complications.

METHODS

A retrospective cohort study was performed. All patients with a traumatic DMCF treated with IMF using ESIN through a lateral approach between 2014 and 2019 were included. Endpoints were the functional outcome (QuickDASH, Subjective Shoulder Value (SSV)), pain (numeric rating scale (NRS)), daily impairment (activities of daily living (ADL)), complications and implant removal.

RESULTS

Forty out of 43 patients were available for follow-up. Mean follow-up was 37 months. Mean age was 24 years (range 13-70). The median QuickDASH score was 0 (IQR 0.0-0.0) and the median SSV was 100 (95-100). The median ADL score was 1 (1-4) and the median NRS was 0 (0-0). No non-union occurred. Implant related irritation occurred in 11 patients (27.5%). Implants were removed in a total of 38 (95%) patients; in 10 cases due to irritation, in 28 cases routinely or on patient's request.

CONCLUSION

IMF of DMCF of the lateral diaphysis through a lateral approach leads to excellent functional results and seems to be a suitable option for internal fixation. However, as with IMF from the medial side, it is not without complications and implant-related irritation.

Management of clavicle shaft fractures with intramedullary devices: a narrative review

INTRODUCTION

Displaced and shortened clavicle fractures are frequently treated surgically. Although extramedullary fixation using a plate and screws is most commonly used, intramedullary nailing has become increasingly popular over the last decade. Traditional intramedullary nailing is usually associated with a high risk of hardware migration as well as hardware irritation at its entry point. Newer devices, however, seem to mitigate these problems. The aim of this narrative review is to provide an overview of clavicle shaft fractures and treatment with intramedullary nails, in particular the newer, locked devices.

AREAS COVERED

In general, this review covers current literature related to clavicle shaft fractures with a specific focus on the treatment of displaced and shortened fractures with intramedullary nails.

EXPERT OPINION

Clavicle shaft fractures can be effectively treated with an intramedullary nail. The risk of hardware migration when employing the newer, improved designs appears to be minimal. The advantages of using intramedullary fixation include smaller incision sizes as well as the avoidance of routine procedures generally associated with the removal of prominent subcutaneous hardware as per extramedullary fixation.

Functional outcomes and complications of intramedullary fixation devices for Midshaft clavicle fractures: a systematic review and meta-analysis

Background

An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device.

Methods

A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group.

Results

Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93–95) and 94.0 (95%CI 92–95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14–26) and 12% (95%CI 8–18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13–35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2–17) of cases (GRADE Very low).

Conclusion

Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient.

Level of Evidence

IV

Functional outcomes, union rate, and complications of the Anser Clavicle Pin at 1 year: a novel intramedullary device in managing midshaft clavicle fractures

Background

Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up.

Methods

A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction.

Results

There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up.

Conclusion

Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non-device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.

Bilaterally Threaded, Minimal Invasive, Elastic Locking Intramedullary Nailing (ELIN) for the Treatment of Clavicle Fractures

Objective

To evaluate and present the effectiveness of this innovatively designed, elastic locking intramedullary nail (ELIN) in fixation of clavicle fractures.

Methods

The study included 38 patients from July 2014 to July 2017. All of them received intramedullary fixation treated with ELIN, 22 were males and 16 females. The mean age of the patients was 54 years. There were twenty right‐side and 18 left‐side clavicular fractures. Radiographs were taken to assess the fracture type: 21 were type A, 16 type B, and one type C. General anesthesia or cervical block was given to all patients. A small incision of 3–5 cm was given only to those who needed mini‐open reduction. The administration of ELIN and reduction of the fracture was made sure with a C arm machine. After a follow‐up of 8 to 33 months, the clinical outcomes were assessed and evaluated. The constant scores and disabilities of the arm, shoulder and hand questionnaire (DASH) were used to determine the outcomes and functional status of the patients. The study was done accordingly to the guidelines provided by the ethics committee.

Results

Mean operation time was 25.63 min. Mean follow‐up time was 16.5 months. The rate of closed reduction and open reduction was 84% and 16% respectively. There was no shortening of the clavicle. There was no breakage of the nail, though bending of the nail occurred in one patient. Superficial skin infection occurred in three patients at insertion points or the nail tip which was embedded subcutaneously. Skin erosion with nail exposure occurred in a patient with no significant infection. All the other patients had excellent shoulder function. A mini scar was observed in seven patients all the other patients had no scar. Asymmetry was observed in three patients. The mean Constant score was 98.47 and the mean DASH score was 1.55 at the last follow‐up. The implant was removed in all the patients.

Conclusion

Clavicular fractures treated with ELIN is minimally invasive, which presents a safe and novel surgical technique with less complications and a high success rate, excellent aesthetic and quick recovery after surgery. ELIN restores the micro‐dynamic stress at the fracture ends and promotes fracture healing, keeps intact the fracture hematoma and maintains the blood supply, accelerates healing and thus leads to faster osseous healing and better restoration of clavicle length.

Biomechanical performance of an intramedullary Echidna pin for fixation of comminuted mid-shaft clavicle fractures

BACKGROUND

Surgical fixation of comminuted mid-shaft clavicle fractures commonly employs intramedullary devices; however, pins with smooth surfaces are prone to migration, whilst threaded pins can be challenging to remove post-operatively. The aim of this study was to evaluate the biomechanical performance of fractured clavicles repaired using a novel intramedullary Echidna pin device and a non-threaded Knowles pin. The Echidna pin features retractable spines that engage with the bone to minimize migration and facilitate ease of device removal.

METHODS

A total of 28 cadaveric clavicle specimens were harvested and a mid-shaft wedge-shaped osteotomy was performed to simulate a comminuted butterfly fragment. Specimens were allocated randomly to either the Echidna pin or Knowles pin fracture repair groups. Following surgery, eight specimens in each group underwent 200 cycles of four-point bending, whilst six specimens in each group underwent torsional testing and pull-out. Cyclic construct bending stiffness, torsional stiffness and ultimate strength were recorded.

RESULTS

Echidna pin intramedullary repair constructs showed significantly greater bending stiffness (mean difference 0.55 N.m/°, 95% confidence interval -0.96, -0.14, P = 0.01) and pull-out strength (mean difference 146.03 N, 95% confidence interval 29.14, 262.92, P = 0.019) in comparison to Knowles pin constructs. There was no significant difference in torsional stiffness between Echidna pin and Knowles pin repair constructs (P > 0.05).

CONCLUSION

The intramedullary Echidna pin device, which exhibits greater bending strength and pull-out strength than that of the Knowles pin, may produce a more stable clavicle fracture reduction compared to that of commercially available threadless intramedullary pins.

The Effectiveness of a Flexible Locked Intramedullary Nail and an Anatomically Contoured Locked Plate to Treat Clavicular Shaft Fractures: A 1-Year Randomized Control Trial

BACKGROUND

Displaced and shortened clavicular shaft fractures can be treated operatively with intramedullary or extramedullary fixation. The aim of the present study was to compare the union rates and functional outcomes of displaced and/or shortened clavicular shaft fractures treated with a flexible locked intramedullary nail or with an anatomically contoured locked plate.

METHODS

Seventy-two patients with acute displaced and/or shortened clavicular shaft fractures underwent randomly assigned management with either an intramedullary locked nail or an anatomically contoured locked plate. The same surgeon performed all surgical procedures, and all patients underwent identical postoperative treatment regimens. Incision length, surgical time, and union rate were recorded, and the functional outcome of the shoulder was assessed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant Shoulder (CS) scores. Data were analyzed with use of traditional statistical methods as well as Cohen effect sizes, which were based on the minimal clinical important differences.

RESULTS

Thirty-seven patients were managed with an anatomically contoured locked plate, and 35 patients were managed with a Sonoma CRx intramedullary flexible locked nail. There were no differences in general patient characteristics, fracture type, or displacement between treatment groups. The nailing group had significantly better outcomes (p < 0.001) than the locked plating group for surgical time (mean and standard deviation [SD], 45 ± 12 compared with 65 ± 21 minutes, respectively) and incision size (mean and SD, 37 ± 9 compared with 116 ± 18 mm). A union rate of 100% was observed in both groups. DASH scores were similar between groups at 1.5, 3, and 6 months, whereas the nailing group had significantly better DASH scores at 12 months (p = 0.022); however, this difference had only a moderate effect size. Overall, individual variation in DASH and CS scores was substantially higher in the plating group compared with the nailing group.

CONCLUSIONS

Both the precontoured locked plate and the flexible locked intramedullary nail effectively treated displaced and/or shortened clavicular shaft fractures. Similar outcomes were achieved at 1.5, 3, and 6 months after surgical intervention, and better DASH scores were found in the nailing group at 12 months. Cohen effect sizes suggested that slightly better outcomes were potentially achieved in the nailing group.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Distal clavicle fracture treated with a titanium elastic nail (TEN)

It is generally known to use internal fixation using a hook plate or Kirschner wire as an operative treatment for distal clavicle fracture. TEN is a surgical technique that is mainly used in clavicle mid-shaft fracture, and there is no reported case for distal clavicle. We report a case of distal clavicle fracture treated with TEN. A 19-year-old man came to the emergency department with right shoulder pain after bicycle accident. The radiographs showed a distal clavicle fracture without apparent disruption of the acromioclavicular joint (AC-joint) and classification with a Neer type IIA fracture pattern. One day after trauma the patient was treated with closed reduction and internal fixation using a titanium elastic nail (TEN). At 6 months postoperatively, there was no complication and radiograph showed good distal clavicle union. Therefore we performed removal of a TEN.

Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults

Background:

Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients.

Methods:

At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal.

Results:

The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF.

Conclusions:

The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF.

Level of Evidence:

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Midshaft clavicle fractures: Current concepts

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033

[Analysis of the accuracy of fit of five anatomically precontoured clavicle plate systems]

BACKGROUND

A common method in surgical treatment of midshaft clavicular fractures is the clavicle plating system. In addition to traditional osteosynthetic devices, anatomically preformed plate systems also exist. Advantages are described in greater accuracy of fit and less irritation of surrounding soft tissues. The purpose of this study was to compare the anatomical fit of five different precontoured clavicle plating systems.

MATERIAL AND METHODS

The anatomical fit of five different types of anatomical precontoured clavicle plates, 3 times VariaxSystem® (Stryker, Kalamazoo, MI), Meves® Plate (Ulrich medical Ulm, Germany) and LCP clavicle plate (Synthes, Bettlach, Switzerland) were investigated in 20 embalmed human cadaveric clavicles. An imprint of the space between the well-positioned plate and the clavicle was obtained using a silicone mass and the silicone imprint was digitally measured. Additionally, the anatomical fit was evaluated by three investigators following a standardized protocol (+2 to -2 points at lateral, midshaft and medial clavicle portions).

RESULTS

The first three ranks went to the Stryker Variax-plates. They showed the least distance (Stryker 628027: 7‑hole 1.44 mm, low curvature 0.93 mm-2.36 mm, 2. Stryker 628028: 8‑hole low curvature 1.68 mm, 1.03 mm-2.4 mm and 3. Stryker 628128: 8‑hole high curvature 1.87 mm, range 1.09 mm-3.1 mm) The evaluation of the anatomical fit by the investigators was in agreement with the measurement results.

CONCLUSION

Although there was no complete congruency between the plates and the clavicle, all clavicle plates investigated in this study presented a reasonable anatomical shape. The 7‑hole VariAx Stryker plate with slight curvature showed the best anatomical fit. A low profile and optimized anatomical precontouring can minimize irritation of the surrounding soft tissues and should be considered in plate design and implant choice.

An intramedullary Echidna pin for fixation of comminuted clavicle fractures: a biomechanical study

Background

Intramedullary fixation of comminuted mid-shaft clavicle fractures has traditionally been employed with satisfactory clinical outcomes; however, pins with smooth surfaces may protrude from the bone and are prone to migration, while some threaded pins are difficult to remove post-operatively. The aim of this proof-of-concept study was to develop and evaluate the biomechanical strength of a novel intramedullary Echidna pin device designed to maintain fracture reduction, resist migration and facilitate ease of post-operative removal.

Methods

Thirty human clavicle specimens were harvested and fractured in a comminuted mid-shaft butterfly configuration. Each specimen was randomly allocated to three surgical repair groups including intramedullary fixation using the Echidna pin and Herbert Cannulated Bone Screw System, as well as plate fixation using bi-cortical locking screws. Using a biomechanical testing apparatus, construct bending and torsional stiffness were measured, as well as ultimate bending strength.

Results

There was no significant difference in torsional stiffness and ultimate bending moment between the Echidna pin and Herbert screw repair constructs (p > 0.05); however, the Echidna pin construct demonstrated a significantly greater bending stiffness compared to that of the Herbert screw construct (mean difference 0.55 Nm/deg., p = 0.001). The plate construct demonstrated significantly greater torsional stiffness, bending stiffness and ultimate bending moment compared to those of the Herbert screw and Echidna pin (p < 0.05).

Conclusions

An intramedullary Echidna pin device was designed to stabilize comminuted fractures of the clavicle, maintain fracture compression and provide ease of removal post-operatively. Since the results suggest equivalent or superior torsional and bending stability in the Echidna pin compared to that of the Herbert screw, the Echidna pin concept may represent an alternative fixation device to conventional intramedullary screws, nails and pins; however, superior plating using bi-cortical locking screws provides substantially higher construct structural rigidity than intramedullary devices, and may therefore be useful in cases of osteoporotic bone, or where high fracture stability is required.

A retrospective study of titanium elastic stable intramedullary nailing in displaced mid-shaft clavicle fractures

OBJECTIVE

The aim of this study is to analyze the functional outcome following titanium elastic stable intra-medullary nailing (ESIN) for displaced mid-shaft clavicular fractures (DMCF).

METHODS

A retrospective study of 60 patients between March 2009 and March 2015 was conducted. Patients were selected based on the inclusion criteria. Six patients were lost during follow up. Out of the remaining 54 patients, there were 39 males and 15 females. The mean age was 30.6 years. The functional outcome was analyzed using the Constant score, rate of bone union, complication, and earliest time of return to work.

RESULTS

All fractures united well, with an average time of 7.5 weeks. Follow-up period ranged between 12 months and 18 months (average, 14 months). 24 out of 54 patients had closed nailing, while 30 had minimal open reduction. The average size of ESIN was 2 mm (range, 1.5-3 mm). The average Constant score was 97.8 (range, 95-99). There were no major complications, but minor complications occurred, viz. skin irritation in 15 patients, temporary paresthesia in five patients, and three patients who developed superficial infections. One case had implant migration and perforation at the lateral cortex, and one case had delayed union. There were few implant-related problems, as the authors used a standard protocol to remove it after radiological union. All patients returned to work within 10 weeks of the post-operative period.

CONCLUSION

ESIN is a safe, minimally invasive, engenders rapid healing with good cosmesis, and provides an excellent functional outcome in terms of patient satisfaction, with fewer complications.

Minimally invasive intramedullary nailing of clavicular fractures by a new titanium elastic nail

Objectives

The aim of this study was to evaluate clinical results of a new design titanium elastic nail (TEN) for displaced midshaft clavicular fractures.

Patients and methods

Between February 2012 and December 2013, a total 36 patients with displaced midshaft clavicular fractures were treated with intramedullary nailing stabilization with our new design TEN. Blood loss, mean times of operation, postoperative complications, hospital stays and time to bone union was recorded. The outcomes were evaluated with radiographic assessment, visual analog scale (VAS) score, the Constant-Murley, and the disabilities of the arm, shoulder, and hand (DASH) scores.

Results

The mean blood loss was 50.278 ± 10.753 ml, while the mean operation, hospital stay and bone union times were 46.417 ± 9.232 min, 10.056 ± 2.672 days and 11.583 ± 2.729 weeks, respectively. After removal of the TENs at a mean of 10.2 months (range, 8-13 months) after surgery, no re-fracture and nonunion was found in any patient. Two cases of shoulder back stabbing pain were spontaneously resolved later. The mean fracture healing time was 12 weeks. The VAS score and motion ranges of shoulder joint were significantly improved postoperatively (P < 0.001). The shoulder function recovery showed the excellent results with the mean Constant-Murley score of 93.389 ± 2.749 and DASH scores of 2.528 ± 1.567.

Conclusion

Our new TEN design used in intramedullary fixation might be a safe and effective technique for treatment of displaced midshaft clavicular fractures.

Level of evidence: Level IV, therapeutic study.

•

A new our self designed TEN was used for clavicular fractures.

•

The new TENs were individual designed with various types for different patients.

•

Satisfactory clinical therapeutic effects and few complications were obtained.

Closed vs open nailing for displaced middle third fracture of clavicle. Does it matter?

BACKGROUND

Intramedullary nailing for fractures of middle third clavicle has become increasingly popular. Though open nailing has been widely described, closed nailing finds less mention.

OBJECTIVES

In this study we compared closed nailing with open nailing in fractures of middle third of clavicle to assess if the former holds any advantage.

MATERIAL AND METHODS

34 patients with closed nailing were compared to 31 patients with open nailing in terms of operative time, length of incision, pain, time to union and functional outcome.

RESULTS

Only operative time and length of incision were significantly more in open group than in closed group.

DISCUSSION

We believe that closed reduction can be attempted in all patients undergoing nailing for middle third clavicle fracture but surgeon should have a low threshold to open the fracture if closed reduction fails as functional outcome and time to union remains unaffected.

Bilateral Clavicle Fractures: A Report of Three Cases

Bilateral clavicle fractures are uncommonly reported in the literature with the incidence being less than 0.5% of all the clavicle fractures. Bilateral clavicle fractures are caused either by high-energy transfer of compression forces across both shoulder girdles or by a direct trauma to one clavicle followed by that to the other clavicle. These fractures could be missed due to their association with more severe chest injuries or a more symptomatically displaced fracture on one side or due to inadequate chest radiographs. We report three cases of traumatic bilateral clavicle fractures with three modes of injuries in different age groups. All the fractures were treated conservatively with good functional outcomes without any sequelae. Bilateral clavicle fractures should be actively sought by every trauma team with proper clinical examination and chest radiographs including both shoulder joints in high-energy trauma cases or with bilateral shoulder compression injuries.

Intramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages

Historically, management of displaced midshaft clavicle fractures has consisted of nonsurgical treatment. However, recent literature has supported surgical repair of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plate and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure. For the last two decades, the use of Rockwood and Hagie pins represented the most popular form of IM fixation, but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, and construct stability. Second-generation IM implants have been developed to reduce the limitations of earlier IM devices. Although anatomic and clinical studies have supported IM fixation of midshaft clavicle fractures, further research is necessary to determine the optimal fixation method.

Plating versus intramedullary fixation for mid-shaft clavicle fractures: a systemic review and meta-analysis

Background. Plate fixation and intramedullary fixation are the most commonly used surgical treatment options for mid-shaft clavicle fractures; the latter method has demonstrated better performance in some studies.

Objectives. Our aim was to critically review and summarize the literature comparing the outcomes of mid-shaft clavicle fracture treatment with plate fixation or intramedullary fixation to identify the better approach.

Search Methods. Potential academic articles were identified from the Cochrane Library, MEDLINE (1966-2015.5), PubMed (1966-2015.5), EMBASE (1980-2015.5) and ScienceDirect (1966-2015.5). Gray studies were identified from the references of the included literature.

Selection Criteria. Randomized controlled trials (RCTs) and non-RCTs comparing plate fixation and intramedullary fixation for mid-shaft clavicle fracture were included.

Data Collection and Analysis. Two reviewers performed independent data abstraction. The I² statistic was used to assess heterogeneity. A fixed- or random-effects model was used for the meta-analysis.

Results. Six RCTs and nine non-RCTs were retrieved, including 513 patients in the intramedullary fixation group and 521 patients in the plating group. No significant differences in terms of the union rate and shoulder function were found between the groups. Patients in the intramedullary fixation group had a shorter operative time, less blood loss, smaller wound size, and shorter union time than those in the plating group. With respect to complications, significant differences were identified for all complications and major complications (wound infection, nonunion, implant failures, transient brachial plexopathy, and pain after 6 months). Similar secondary complications (symptomatic hardware, hardware irritation, prominence, numbness, hypertrophic callus) were observed in both groups.

Conclusions. Intramedullary fixation may be superior to plate fixation in the treatment of mid-shaft clavicle fractures, with similar performance in terms of the union rate and shoulder function, better operative parameters and fewer complications.

Biomechanical properties of titanium elastic nail applied to a cadaveric clavicle model

BACKGROUND

The goal of this study was to examine biomechanical properties of titanium elastic nail fixation method that was applied to cadaveric clavicles with different thicknesses and lengths.

METHODS

To test stiffness and failure load of clavicle with titanium elastic nail fixation, 12 pairs of clavicles were obtained. A short oblique fracture line (AO/OTA classification: 15-B1.2) was created at midpoint of the cadaveric bones. They were divided into four groups according to the nails with different thickness and length/diameter ratios. The fixated bones were situated on a jig that allows 3-point bending to measure stiffness and load failure.

RESULTS

The stiffness was measured to be mean 3.49 ± 1.49 N/mm in group 1. The stiffness for group 2 was mean 10.41 ± 2.18 N/mm, and for groups 3 and 4, the stiffness was mean 11.89 ± 2.99 N/mm and mean 24.44 ± 4.86 N/mm, respectively. When analyzed with statistics, group 1 had significant differences from groups 2 (P < 0.006), 3 (P < 0.001), and 4 (P < 0.000), and group 4 also had statistical significances from rest of the groups (P < 0.000).

CONCLUSIONS

For 2.5 mm titanium elastic nail, it is necessary to make fixation with a titanium elastic nail that is longer than 3 diameter lengths, and length that is longer than and equal to 3 diameter length titanium elastic nail was required for 3.5 mm titanium elastic nail to provide appropriate stiffness for firm fixation. Also, variances in both thickness and length have shown a similar effect.

STUDY DESIGN

Cadaveric study.

Plate Versus Intramedullary Fixation Care of Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Prospective Randomized Controlled Trials

In recent decades, there has been a growing trend to the operative treatment of displaced midshaft clavicular fractures. Open reduction and internal plate fixation, and intramedullary nailing fixation are 2 of the widely used techniques for operative treatment, but the optimal fixation method for these types of fractures remains a topic of debate. The objective of this study was to determine the effectiveness of plate fixation versus intramedullary nailing fixation for displaced midshaft clavicle fractures by comparing their clinical results.Literature searches of the Pubmed, EMBASE, and Web of Science were performed from 1966 to April, 2015. Only randomized controlled clinical trials comparing plate and intramedullary nailing treatment for displaced midshaft clavicle fractures were included. Literature was screened, data were extracted, and methodological quality of the eligible trials was assessed by 2 independent reviewers accordingly.Seven randomized controlled trials involving 421 patients were included. Compared to intramedullary nailing fixation, plate fixation had a relatively longer mean surgical time and a trend towards a faster functional improvement during the first 6 months after surgery; apart from this, the pooled results revealed no significant differences in functional scores after 6 months postoperatively, complication rate and patients' satisfaction between plate fixation and intramedullary fixation.Our results demonstrated that these 2 methods were comparable and safe in the treatment of displaced midshaft clavicle fractures. We advocate both techniques for the treatment of displaced midshaft clavicle fractures, and the superior surgical technique was those that the surgeon was originally trained to perform.

Titanium Elastic Nail versus plate fixation of displaced midshaft clavicle fractures: A retrospective comparison study

This study has two purposes: (1) to compare the clinical results between the Titanium Elastic Nail (TEN) and plate fixation of the displaced midshaft clavicle fracture; and (2) to demonstrate the relationship between length shortening and functional outcome after TEN fixation, especially in the comminuted fracture pattern. A retrospective, case-controlled study was conducted and 55 patients were included in our study: 25 in the TEN fixation group (TEN group) and 30 in the plate fixation group (plate group). All patients were classified into four subgroups: simple fracture in the TEN group (ST; n = 13), simple fracture in the plate group (SP; n = 15), comminuted fracture in the TEN group (CT; n = 12), and comminuted fracture in the plate group (CP; n = 15). Wound size was significantly smaller in the TEN group (p < 0.001). The injured clavicular length after fracture healing was significantly shorter in the TEN group (p = 0.036). There was no significant difference in the mean Constant and DASH scores. Injured clavicle shortening was significantly larger in the CT subgroup (p = 0.018). However, there was no statistically significant difference in Constant score and DASH score while comparing the CT subgroup to other subgroups. Although TEN fixation may lead to a higher degree of length shortening after bony union especially in cases of comminuted fracture pattern, no statistically significant difference was observed in objective functional results as compared to other subgroups. Therefore, TEN can be used to fix a displaced midshaft clavicle fracture even in cases of comminuted fracture pattern, which overall is an effective and less surgically invasive procedure.

Minimally invasive fixation of midclavicular fractures with threaded elastic intramedullary nails

BACKGROUND

Intramedullary fixation of midclavicular fractures has been described as a minimally invasive operation with few complications. The purpose of this study was to assess the effectiveness of the threaded elastic intramedullary nail (TEIN, made in Kang Li Min Medical Devices Co. Ltd., Tianjin, China) in the treatment of midclavicular fractures.

METHODS

Between 2010 and 2013, 45 patients with midclavicular fractures, who received closed reduction and intramedullary fixation, were treated with the TEIN in our department. Clinical outcomes were evaluated after a follow-up of 14 (3-42) months. We used the Constant score and the disabilities of the arm, shoulder and hand (DASH) scale to determine the outcomes.

RESULTS

The mean time of the operation was 22.4 (13-40) min. The rate of the closed reduction was 64 %. The mean time of the follow-up was 14 (3-42) months. With regard to complications, there was no occurrence of neurovascular impairment, pulmonary injuries, infection, shortening, refracture or nonunion. All of the patients displayed excellent shoulder function, with a mean Constant shoulder score of 96.5 (64-100) and a mean DASH score of 1.4 (range 0-100) at the latest follow-up.

CONCLUSION

Closed reduction and intramedullary fixation of midclavicular fractures with the TEIN present a safe and minimally invasive surgical technique, achieving excellent aesthetic and early recovery after surgery.

LEVEL OF EVIDENCE

Treatment Study, Level II.

Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial

BACKGROUND

Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing. The objective of this study was to compare these methods in terms of clinical and radiographic results.

METHODS

In this prospective, randomized controlled trial, fifty-nine patients with displaced midshaft clavicular fractures were randomly assigned to receive fixation with either a reconstruction plate (thirty-three patients), known as the plate group, or elastic stable intramedullary nailing (twenty-six patients), known as the nail group. The primary outcome was the six-month Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes included the Constant-Murley score, time to fracture union, residual shortening, level of postoperative pain, percentage of satisfied patients, and complication rates.

RESULTS

The mean six-month DASH score was 9.9 points in the plate group and 8.5 points in the nail group (p = 0.329). Similarly, there were no differences in the twelve-month DASH and Constant-Murley scores. Time to union was equivalent (p = 0.352) between the groups at 16.8 weeks for the plate group and 15.9 weeks for the nail group, whereas the residual shortening was 0.4 cm greater in the plate group (p = 0.032). The visual analog scale pain score and the satisfaction rate were similar between the groups. Implant-related pain was more frequent in the nail group (p = 0.035). There were no differences in terms of major complications.

CONCLUSIONS

Reconstruction plates and elastic stable intramedullary nailing yielded similar functional results, time to union, level of postoperative pain, and patient satisfaction rates. Both methods were safe in terms of major complications.

[Bent titanium elastic nail in clavicular non-union. Case report and review of the literature]

Fractures of the clavicle can often be treated conservatively. For severely dislocated but simple fractures in which conservative treatment often fails, intramedullary nailing with titanium elastic nails (TEN) shows similar results to stable plate osteosynthesis. We present the case of a 28-year-old female patient who had been treated with TEN osteosynthesis 4 years previously but clavicular non-union developed. Due to a new traumatic incident, the implanted intramedullary titanium nail was bent and migrated into the manubrium sterni. We were able to remove the wire and stable plate osteosynthesis was carried out. Bending and migration of titanium wires used in clavicular fractures are relatively rare complications and patients must be informed accordingly. These complications can be avoided by removal of the wire 3-12 months after implantation when the fracture has healed.

Treatment of midshaft clavicular fractures with elastic titanium nails

BACKGROUND

One of the modern techniques for the treatment of clavicle fracture (Fx) is elastic titanium intramedullary nailing. But, there are different opinions about this technique. We studied this technique in 12 patients with clavicle Fx and assessed its outcome.

OBJECTIVES

We aimed to study the prognosis of midshaft clavicular Fx treated via minimally invasive stable elastic intramedullary nailing.

PATIENTS AND METHODS

We operated on 13 clavicle Fx in 12 patients from 2008 through 2012. We used a new technique called minimally invasive titanium elastic intramedullary nailing for operating patients with midshaft clavicular Fx.

RESULTS

Clinical union was achieved 3-5 weeks after the operation with no pain over Fx sites upon physical examination. Radiologic union appeared at 6 to 12 weeks .We did not encounter nonunion or infection, but one of the comminuted Fx united 1 cm shorter; however, it had a solid union with a good score. All but two patients had good scores.

CONCLUSIONS

Although controversy exist regarding intramedullary nailing of clavicle Fx, our results using this technique for minimally comminuted midshaft clavicular Fx were very good.

Comparison of treatment of fracture midshaft clavicle in adults by external fixator with conservative treatment

PURPOSE

High rate of malunion and non union in displaced fracture clavicle treated conservatively lead to use of different types of internal fixation methods which also were found to be associated with various complications. Moreover their superiority over conservative treatment has not been established. This study was designed to compare clinical outcome of conservative treatment with external fixator in cases with displaced midshaft clavicle fractures.

METHODS

Fifty adult consenting cases of acute midshaft fracture clavicle, displaced >15 mm were included. Twenty five cases were allotted to conservative (group A) and external fixator (group B) each. In group A treatment was given in form of clavicle brace. In group B schanz pins were inserted obliquely between supero-inferior and anterior-posterior direction and connected with rod. The outcome was measured by Constant score, union time and complications.

RESULTS

Mean radiographic union time in group A was 23.45 ± 1.40 weeks (with 8% non union and 80% malunion) and in group B it was 9.36 ± 1.49 weeks. Mean Constant score at 6 months in group A was 78.28 ± 6.45 and in group B 92.72 ± 1.48. Mean shortening at 6 months in group A was 19.36 mm. In group B shortening at 6 months was noticed in three cases (6, 5, 6 mm).

CONCLUSION

Close reduction of acute fracture mid clavicle and application of external fixator is a simple procedure providing the benefits of rigid fixation and undisturbed fracture environment. Pain relief is faster, union time is shorter and there are no hardware related problems.

Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating

Background

This prospective comparative study was done to evaluate the effectiveness of implants of different design (titanium elastic intramedullary nail versus anatomical precontoured dynamic compression plate) in treatment of displaced midshaft clavicular fractures.

Materials and methods

Sixty-six patients between 18 and 65 years of age were included in this study. They were randomized in two groups to be treated with either elastic intramedullary nail (EIN) or plate. Clinical and radiological assessments were performed at regular intervals. Outcomes and complications of both groups over 2 years of follow-up time were compared.

Results

Length of incision, operation time, blood loss and duration of hospital stay were significantly less for the EIN group. American Shoulder and Elbow Surgeons (ASES) and Constant Shoulder scores were significantly higher (p < 0.05) in the plating group than the EIN group for the first 2 months but there was no significant difference found between the two groups regarding functional and radiological outcome at the 2-year follow-up. Significantly higher rates of refracture after implant removal (p = 0.045) in the plating group was observed. Infection and revision surgery rates were also higher in the plate group, but this difference was insignificant (p > 0.05).

Conclusions

EIN is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures.

Level of evidence

Level 2.

Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures

Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.

Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures: A comparative study

BACKGROUND

With changing trends in treatment of displaced midshaft clavicle fractures (DMCF), plating remains the standard procedure for fixation. An attracting alternative method of fixation is the titanium elastic nailing (TEN). However, prospective randomized studies comparing the two methods of fixation are lacking. We assessed the effectiveness of minimally invasive antegrade TEN and plating technique for the treatment of DMCF.

MATERIALS AND METHODS

80 unilateral displaced midclavicular fractures operated between October 2010 and May 2013 were included in study. This prospective comparative study was approved by the local ethical committee. Followups were at 2(nd) and 6(th) weeks and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Primary outcome was measured by the Constant score, union rate and difference in clavicular length after fracture union. Secondary outcome was measured by operative time, intraoperative blood loss, wound size, cosmetic results and complications.

RESULTS

During analysis, we had 37 patients in the plate group and 34 patients in the TEN group. There was no significant difference in Constant scores between the two groups. However, faster fracture union, lesser operative time, lesser blood loss, easier implant removal and fewer complications were noted in the TEN group.

CONCLUSION

The use of minimally invasive antegrade TEN for fixation of displaced midshaft clavicle fractures is recommended in view of faster fracture union, lesser morbidity, better cosmetic results, easier implant removal and fewer complications; although for comminuted fractures plating remains the procedure of choice.

Fractures of the clavicle: an overview

Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management.

A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted.

The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.

Percutaneous plating for comminuted midshaft fractures of the clavicle: a surgical technique to aid the reduction with nail assistance

INTRODUCTION

Due to the complex anatomy of the clavicle, percutaneous plating with indirect reduction for comminuted midshaft fracture of the clavicle is challenging. The aim of this series was to report on a novel technique of nail-assisted percutaneous plating and to evaluate the radiographic and clinical outcomes in comminuted midshaft fractures of the clavicle.

MATERIALS AND METHODS

Between 2009 and 2010, with nail assistance for the reduction and its maintenance, percutaneous plating was performed in 14 patients with comminuted midshaft fracture of the clavicle. The mean follow-up period was 17.6 months (range, 15-31 months). A retrospective review of the clinical and radiologic results for these patients was conducted.

RESULTS

All fractures healed within a mean period of 15.6 weeks (range, 11-18 weeks) without loss of reduction. Regarding complications, there was no occurrence of implant failure or infection. All patients showed excellent shoulder function, with a mean Constant shoulder score of 99, and a mean Disabilities of the Arm, Shoulder and Hand (DASH) score of 4.2 (range, 0-22) at the latest follow-up. No significant difference in mean proportional length was observed between injured and uninjured clavicles, with a mean of 0.4% (range, -1.5% to 2.4%).

CONCLUSIONS

Minimally invasive percutaneous plating for comminuted midshaft fractures of the clavicle, combining the advantages of elastic intramedullary nailing and percutaneous plating, may be a good option.

Systematic review of complications after intramedullary fixation for displaced midshaft clavicle fractures

BACKGROUND

The number of displaced midshaft clavicle fractures treated surgically is increasing, and open reduction and intramedullary fixation is an emerging surgical treatment option. The study quality and scientific levels of published evidence in which possible complications of this treatment are presented vary greatly.

METHODS

We performed systematic computer-based searches of EMBASE and PubMed/MEDLINE. Studies included for review reported complications after intramedullary fixation alone or in comparison to either treatment with plate fixation and/or nonoperative treatment. The Level of Evidence rating and Quality Assessment Tool were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence.

RESULTS

Six articles were eligible for inclusion and final quality assessment; 3 studies were graded the highest level of evidence. Major complications like bone-healing problems and deep infections requiring implant removal were reported at a rate no higher than 7%. Reported rates for minor complications, such as wound infection and implant irritation that could be resolved without further surgery, were as high as 31%.

CONCLUSION

The noted rates for major complications requiring additional surgery were low, but implant-related problems that require additional surgery might present with high prevalence. Owing to routine implant removal, treatment with intramedullary fixation often requires an additional surgical procedure.

Complications after plate fixation and elastic stable intramedullary nailing of dislocated midshaft clavicle fractures: a retrospective comparison

PURPOSE

The incidence of operative treatment of dislocated midshaft clavicle fractures (DMCF) is rising due to unsatisfactory results after non-operative treatment. Knowledge of complications is important for selection of the surgical technique and preoperative patient counselling. The aim of this study is to compare complications after plate fixation and elastic stable intramedullary nailing (ESIN) with a titanium elastic nail (TEN) for DMCF.

METHODS

A retrospective analysis of our surgical database was performed. From January 2005 to January 2010, 90 patients with DMCF were treated with plate fixation or ESIN. Complications were evaluated in both treatment groups and subsequently compared.

RESULTS

Seven implant failures occurred in six patients (14 %) of the plate group and one implant failure (2.1 %) was seen in the ESIN group (p = 0.051). Major revision surgery was performed in five cases in the plate group (11.6 %) and in one case (2.1 %) in the ESIN group (p = 0.100). Three refractures (7.0 %) were observed in the plate group after removal of the implant against none in the ESIN group (p = 0.105). Six minor revisions (13 %) were reported in the ESIN group and none were reported in the plate group (p = 0.027).

CONCLUSIONS

Compared to other studies we report higher rates of refracture (7.0 %), major revision surgery (11.6 %) and implant failure (14.0 %) after plate fixation. The frequency of implant failures differed almost significantly for patients treated with plate fixation compared to ESIN. Furthermore, a tendency towards refracture after implant removal and major revision surgery after plate fixation was observed.

Surgical management of uncomplicated midshaft clavicle fractures: a comparison between titanium elastic nails and small reconstruction plates

BACKGROUND

This study compared titanium elastic nail (TEN) fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures.

METHODS

The records of 57 patients with midshaft clavicular fractures that were operated on within 2 weeks after injury at Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan, were retrospectively analyzed. Each patient received either TENs (n = 25) or fixation with a 3.5-mm reconstruction plate (n = 32) depending on the preference of the operating surgeon. Operative parameters, postoperative pain and function scores, complications, and fracture union time were determined.

RESULTS

There was no difference in the fracture pattern distribution between the 2 groups, and all operations were performed without complications. Operation time, wound size, blood loss, length of hospitalization, and subjective time to pain relief were less for the TEN group than for the 3.5-mm reconstruction plate fixation group (P < .001 for all). Patients in the TEN group showed a greater range of shoulder motion and higher Constant scores than those in the plate fixation group up to 18 weeks after surgery (P < .001 for all). Fewer patients in the TEN group, 4 (16%), requested removal of the implant, as compared with 12 (37.5%) in the plate group.

CONCLUSION

Fixation of uncomplicated midshaft clavicle fractures with TENs provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates.

Operative treatment of adolescent clavicle fractures with an intramedullary clavicle pin

BACKGROUND

Adolescent clavicle fractures have traditionally been treated nonoperatively; however, recent literature in adults has shown improved outcomes with operative treatment of displaced and shortened clavicle fractures. It has been suggested that these results may translate to adolescents. This study presents an initial look at outcomes for operative treatment of displaced midshaft clavicle fractures in adolescents using an intramedullary clavicle pin.

METHODS

Seventeen adolescent patients treated for a displaced, shortened midshaft clavicle fracture with an intramedullary clavicle pin between November 2007 and August 2009 were evaluated. Preoperative displacement, fracture union, and complications were reviewed, and shoulder scores were determined using the patient self-report section of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form.

RESULTS

Fracture union occurred in all 17 patients by 12 weeks. Average patient age was 15.8 years and ranged from 13 to 18 years. All but 2 implants were electively removed. The most common postoperative complaint was prominent hardware, which resolved after elective removal. There were no infections and only 1 patient reported decreased sensation at the incision site. Ten patients returned the American Shoulder and Elbow Surgeons form at an average time of 16.6 months after surgery. The average pain score was 44.2 of a possible 50 points. The average functional score was 44.3 of a possible 50 points. No patients reported severe difficulty with work activities and only 1 patient reported severe difficulty with sporting activities.

CONCLUSIONS

Operative treatment with an intramedullary clavicle pin seems to be a safe and effective treatment method for displaced midshaft clavicle fractures in adolescents.

LEVEL OF EVIDENCE

Therapeutic level IV.

Volumetric analysis of corticocancellous bones using CT data

OBJECTIVE

To present a method for an automated volumetric analysis of corticocancellous bones such as the superior pubic ramus using CT data and to assess the reliability of this method.

MATERIALS AND METHODS

Computed tomography scans of a consecutive series of 250 patients were analyzed. A Hounsfield unit (HU) thresholding-based reconstruction technique ("Vessel Tracking," GE Healthcare) was used. A contiguous space of cancellous bone with similar HU values between the starting and end points was automatically identified as the region of interest. The identification was based upon the density gradient to the adjacent cortical bone. The starting point was defined as the middle of the parasymphyseal corticocancellous transition zone on the axial slice showing the parasymphyseal superior pubic ramus in its maximum anteroposterior width. The end point was defined as the middle of the periarticular corticocancellous transition zone on the axial slice showing the quadrilateral plate as a thin cortical plate. The following parameters were automatically obtained on both sides: length of the center line, volume of the superior pubic ramus between the starting point and end point, minimum, maximum and mean diameter perpendicular to the center line, and mean cross-sectional area perpendicular to the center line.

RESULTS

An automated analysis without manual adjustments was successful in 207 patients (82.8%). The center line showed a significantly greater length in female patients (67.6 mm vs 65.0 mm). The volume was greater in male patients (21.8 cm(3) vs 19.4 cm(3)). The intersite reliability was high with a mean difference between the left and right sides of between 0.1% (cross-sectional area) and 2.3% (volume).

CONCLUSIONS

The method presented allows for an automated volumetric analysis of a corticocancellous bone using CT data. The method is intended to provide preoperative information for the use of intramedullary devices in fracture fixation and percutaneous cement augmentation techniques.

Retrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures

BACKGROUND

Titanium elastic nails (TENs) are commonly used to repair displaced midshaft clavicular fractures. Although several clinical studies have shown that the use of TENs is more effective and less invasive than traditional plate fixation, high rates of complications associated with TENs have been reported. This retrospective study compared the use of TENs with reconstruction plates in the treatment of displaced midshaft clavicular fractures.

MATERIALS AND METHODS

From January 2005 to July 2007, 141 patients with displaced midshaft clavicular fractures were treated with TEN or plate fixation. At 6 and 24 months postoperatively, we evaluated the patients' general health, operative complications, and functional recovery.

RESULTS

The mean bone union time of TEN patients was 12.4 ± 3.4 weeks, whereas that in the plate group was 14.4 ± 3.7 weeks. The time of union was significantly shorter in the TEN group than that in the plate group. There was no significant difference between these 2 groups' rates of complications such as nonunion or malunion. Shoulder function scores were significantly better in the TEN group than in the plate group at 6 months postoperatively. There was no significant difference at 24 months postoperatively. Patients were more satisfied with the cosmetic appearance and overall outcome after TEN repair than after plate fixation.

CONCLUSIONS

TEN fixation of displaced midshaft clavicular fractures allows for a faster functional recovery, higher patient satisfaction, and a more cosmetically satisfactory appearance than plate fixation. The complication rates of both TENs and reconstruction plates were similar.

Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review

Purpose

The optimal surgical approach for displaced midshaft clavicle fracture remains controversial. The objective of this systematic review is to compare functional outcome and complications after plate fixation and intramedullary fixation for displaced midshaft clavicle fractures.

Methods

A computer aided search of PUBMED and Embase was carried out on January 11th 2011. Every study that was published in the English, German, French or Dutch language was considered for inclusion. A total of four studies could be included of which two compared intramedullary fixation versus plate fixation, and two compared intramedullary fixation and plate fixation versus conservative treatment for displaced midshaft clavicle fractures. Studies that compared plate fixation with intramedullary fixation in patients with fresh unilateral displaced midshaft clavicle fractures were included. Dislocation or displacement had to be mentioned in the inclusion criteria of the study for inclusion in this review. The modified version of the Cochrane Bone, Joint and Muscle Trauma Group’s former quality assessment tool was used. Furthermore, the studies included were scored according to the GRADE approach to assess the quality. The chosen studies were summarised in a data-extraction form. Because of the different study designs and characteristics data were summarised separately for each study.

Conclusions

High quality evidence from one study and low quality evidence from three studies showed no difference in functional outcome or complications after plate fixation or intramedullary fixation for displaced midshaft clavicle fractures.

Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced?

BACKGROUND

We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach.

QUESTIONS/PURPOSES

We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable.

PATIENTS AND METHODS

From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90° for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months).

RESULTS

The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10° to 20° in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5).

CONCLUSIONS

Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation

BACKGROUND

Intramedullary pin and plate fixation for midshaft clavicular fractures both have their proponents, but little comparative data are available. We performed a retrospective comparison of these 2 techniques.

MATERIALS AND METHODS

A retrospective review was performed on 40 consecutive patients with closed, simple, or wedge-type midshaft clavicular fractures that were identified from a prospectively collected orthopedic trauma database. Eight patients were excluded due to incomplete follow-up. Intramedullary pins were used in 18 patients and plates in 14; of these, 7 plates were placed superiorly, 6 anteriorly, and 1 inferiorly. Treatment method was determined by preference of the treating surgeon.

RESULTS

Among the patients treated with intramedullary pin fixation, all 18 fractures healed, and each underwent a planned procedure for pin removal. Complications included 1 intraoperative pin breakage, 1 superficial wound infection, 2 prominent symptomatic pins, and 1 transient brachial plexopathy. Among the patients treated with plating, delayed union occurred in 1, and refractures occurred in 2 (1 required a second procedure). Three patients underwent plate removal for symptomatic hardware. No patients in either group had significant loss of shoulder motion.

CONCLUSION

Intramedullary pin fixation for acute, simple, or wedge-type midshaft clavicular fractures provides a safe and predictable alternative to plate and screw fixation.

Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures

Background

Nonoperative management of midshaft clavicle fractures (MSCFs) is standard; however, it is now generally accepted that displaced midshaft clavicle fractures benefit from internal fixation. Plating and intramedullary fixation have become the accepted methods of fixation. The purpose of this study was to see if one method of fixation of clavicle fractures has a lower complication rate and higher union rate than the other.

Materials and methods

Between December 2003 and September 2008, 38 patients were treated randomly by either plating (plate group) or retrograde nailing (RTEN group). Primary outcome measures included functional Constant scores, radiological union rate and union time. Clinical and radiological assessments were performed at the 6th week and the 3rd, 6th and 12th month postoperatively. Secondary outcome measures included the perioperative data (mean surgery time, blood loss, wound size, and hospital stay), and the complication rates.

Results

Similar results were found between the two groups regarding functional and radiological outcome after the 12th week (P > 0.05). However, earlier union and functional recovery were obtained at the 6th week for the RTEN group (P < 0.05). The rate of complications was significantly higher (15.8%) in the plate group compared with the RTEN group (0%; P > 0.05). In the plate group, significantly higher values were obtained for the perioperative data (P < 0.001).

Conclusion

Both techniques are equally effective at treating displaced midclavicular fractures, and give better function and fewer complications than nonoperative treatment. The RTEN technique has more advantages and lower complications than plating, making its use more favorable. It is recommended for athletes and young active individuals, and can be used as an alternative to conservative treatment or plate fixation.

[Locking, multidimensional plate osteosynthesis of midshaft clavicle fracture]

BACKGROUND

The goal of this consecutive, retrospective clinical follow-up study was to analyse the quality of treatment with a multidimensional, anatomical locking plate osteosynthesis after comminuted clavicle shaft fracture (Robinson 2B).

PATIENTS AND METHODS

Of 38 operated patients, 35 were examined after locking plate osteosynthesis, with a median follow-up of 32 months (11-65). Four patients had suffered a 2B1 Robinson fracture and 31 patients a 2B2 Robinson fracture. The clinical and functional results were determined based on the standard clinical examination of the shoulder, the Constant and DASH scores, an analogue visual scale and a patient survey.

RESULTS

The clinical examination yielded a mean DASH score of 1.25, a mean Constant score of 98 and a mean VAS score on the visual analogue scale of 0.4 (with a range of 0-6). Neither nonunion nor implant failure was observed. We did, however, have one case of infection of the soft tissue.

CONCLUSION

The treatment of comminuted shaft fractures of the clavicle by means of a multidimensional locking plate is a safe treatment option that includes early functional postoperative care with free range of motion.