Displacement of the two main fragments of more than shaft diameter
Comminution
Clavicle shortening of more than 1.5 cm compared to uninjured side
Angulation of more than 30°
Open fractures or impending skin perforation
Neurovascular compromise
Multiple injuries of the shoulder girdle, bilateral clavicle fractures, floating shoulder, flail chest
Intolerable pain
Plate osteosynthesis is the accepted treatment of choice in severely displaced and comminuted midshaft fractures. Plates with small dimensions have cosmetic advantages and they are easier to contour according to the shape of the clavicle. Small-dimensioned implants however risk failing due to bending and rotational forces that act on the clavicle during elevation of the arm. Therefore, the use of larger dimensioned implants is recommended [18, 19]. However, due to the invasiveness of open reduction and plate osteosynthesis, a relevant complication rate and hardware-related discomfort, intramedullary nailing is gaining popularity as an alternative treatment option.
Nails have biomechanical advantages: forces acting under varying loads on an intramedullary implant are less pronounced than on an extramedullary implant. Intramedullary nailing moreover is technically less invasive and results in smaller scars and a shorter hospital stay compared to plate fixation [20].
Several intramedullary nailing techniques have been described for the clavicle over the past 50 years. Disastrous and sometimes even life-threatening complications due to implant migration forced to improved implant designs and modified surgical techniques [21, 22]. Currently used techniques of nailing include both the open retrograde stabilization with a lateral starting point using straight and rigid pins (Hagie, Knowles and Rockwood pin) and antegrade elastic stable intramedullary nailing (ESIN) with a medial starting point using a flexible titanium endomedullary nail (TEN) [22].
Due to its elasticity, the TEN blocks itself attaining a 3-point fixation within the S-shaped clavicle. This leads to a firm anchorage within the intramedullary canal.
Table 10.2 shows the general indications for the treatment of clavicle fractures with ESIN.
Table 10.2
Indications for Elastic Stable Intramedullary Nailing of clavicle fractures, depending on fracture morphology
Fracture type | ESIN | Comment |
|---|---|---|
Non comminuted | ||
B1.1 spiral | Yes | Closed reduction, open reduction if required |
B1.2 oblique | Yes | Closed reduction, open reduction if required |
Plate fixation in long oblique fractures recommended | ||
B1.3 transverse | Yes | Closed reduction, open reduction if required |
Wedge | ||
B2.1 spiral wedge | Yes | Closed reduction, open reduction if required |
B2.2 bending wedge | Yes | Closed reduction, open reduction if required |
B2.3 comminuted wedge | Yes | Closed reduction, open reduction if required |
Segmental | ||
B3.1 spiral | Yes | Open reduction, resorbable cerclage suture recommended |
Plate fixation in long spiral fractures | ||
B3.2 transverse | No | Plate fixation recommended |
B3.3 complex comminuted | No | Plate fixation recommended |
This minimally invasive technique is easy to perform in simple fracture types with few complications and leads to excellent functional results [23]. Length and alignment can be sufficiently restored regardless of the extent of initial displacement and shortening. Good results with rapid recovery and early return to sports and daily activities can be achieved [23].
Several authors suggested expanding the indications to more complex fracture patterns. The enlarged spectrum of indications however raised the number of technical problems and complications. In segmental, comminuted or long oblique fractures, the TEN is less appropriate for two reasons. Primarily, a stable 3-point fixation on the inner aspect of the cortex cannot be achieved. Secondly, bony contact between the main fragments is lacking or not existing. The TEN itself is not stable enough to resist bending forces produced at the comminuted fracture site and failure of fixation is likely to occur.
The eligibility of ESIN in multi-fragmentary fractures depends on the amount of initial displacement and shortening. A CT-scan can be helpful for better analysis. Moderate initial displacement has a lower risk of fracture collapse and medial nail protrusion. The latter can be reduced by adapting a more cautious aftertreatment protocol.
Long oblique fractures and comminuted fractures with severe displacement and shortening should not be treated with ESIN, due to high risk for complications and re-operations.
10.4 Technique of Elastic Stable Intramedullary Nailing
10.4.1 Positioning
The patient is placed supine on an operating table, which is tilted in slight upright position (30°) with a radiolucent shoulder pad. A safety sling is put over the patient’s abdomen and fixed on the table.
The head is positioned on an adjustable support and is slightly bent to the contra- lateral side. The patient is positioned as far as possible sideward on the table and a small pillow is placed in between the shoulder leaves to enable fracture distraction.
The arm of the patient remains free and movable (Fig. 10.1). The surgeon stands on the opposite, non-injured side.
Fig. 10.1
The patient is positioned supine sideward on the operation table with the left shoulder supported by a radiolucent shoulder pad. The surgeon stands on the contralateral side
10.4.2 Entry Point
A 1.5–2 cm incision is made along the Langer lines of the skin over the sternal end of the clavicle. The subcutaneous tissue is mobilised and the plathysma muscle dissected until the medial end of the clavicle is visualized. The muscle should remain in contact with the periosteum. A small part of the bony surface is exposed subperiostally. Haemostasis is very important in this area to prevent complications due to bleeding.
10.4.3 Elastic Nail Insertion
A 2.5 mm drill hole is made 1–2 cm lateral to the medial edge on the anterior aspect of the clavicle. It is recommended to use an image intensifier to verify the correct entry point. In order not to slip of the bone, the drill should initially be kept in a 70–90° angle until the cortex is perforated. The angle should then be lowered towards 45° when entering into the medullary canal. The monocortical drill hole is widened gently with a curved awl towards lateral. A titanium elastic nail (TEN) is mounted in a Jacobs chuck and carefully introduced into the medullary canal. The curved tip of the TEN should point away from the posterior cortex to enable easy gliding and minimize the risk of dorsal perforation. The implant is driven laterally towards the fracture side with small oscillating movements.
In our experience, a 2.5–3 mm TEN can be used in male and a 2–2.5 mm TEN in female patients. The nail diameter is determined according to the diameter of the medullary canal.
Closed reduction of the fracture is performed under image intensifier control by direct manipulation or with the help of two pointed reduction forceps which are inserted percutaneously on both main fragments. Not more than three attempts of closed reduction should be undertaken. If closed reduction cannot be achieved, a 2 cm incision at the fracture site allows direct manipulation of the main fragments (Fig. 10.2a–c). If soft tissues are interposed and impair reduction, they should be removed. After reduction, the elastic nail is driven into the lateral fragment using small oscillating movements. When the tip of the TEN reached its target area in the lateral fragment, it is cut close to the clavicle bone at the insertion site. Due to the thin structure of the posterolateral cortex, there is a risk of perforation. For this reason, we recommend image intensifier control during nail insertion. Soft tissues are reinserted at the end of the procedure and the skin is closed.
Fig. 10.2
(a) Type B 2.3 clavicle fracture in a 29 year old male patient. (b) The fracture was reduced through a limited open approach and ESIN performed. (c) Postoperatively radiographs show ideal implant positioning and fracture reduction without shortening
In case of gross displacement of additional fragments, a resorbable cerclage suture can be placed around the wedge fragments to align and close the fracture without damaging the blood supply. As an alternative, the fragments can be left untouched.
10.5 Tips, Tricks and Pitfalls
An entry point too far medial may lead to irritation and compromise of the sterno-clavicular joint. A safe distance of 1.5–2 cm from the medial edge of the clavicle should be obtained to avoid this complication. The cortex structure is very thin in the anterior quadrant of the medial portion of the clavicle at the location of the entry point. The pre-bent TEN produces considerable biomechanical forces acting on the inside of the bone. This may lead to an anterior cut-out of the implant. Correspondingly, multiple cases of medial nail migration and protrusion have been observed. Therefore, the nail should be shortened as far as possible at the level of the insertion site in order to minimize the risk of medial skin irritation (6 % of the cases) [9].
It is recommended to insert the TEN with a power tool in the oscillating mode. Due to the oscillating movement of the TEN, a penetration out of the intramedullary canal is less likely to occur. Please note that fracture reduction and insertion of the tip of the implant into the lateral fragment should be done by hand force.
It is not recommended to use a hammer to drive the nail forward within the medullary canal. This could lead to nail penetration, distraction of the fracture fragments with widening of the fracture gap and neurovascular compromise.
Since the cortex in the target area of the tip of the TEN is thin, there is a risk of lateral nail perforation. In the authors’ experience, repositioning of the implant in case of perforation is hardly to achieve. Changing the procedure towards plate fixation is recommended in those cases where penetration cannot be corrected and stable fixation cannot be realized.
If the lateral (distal) fracture fragment is very small, it is an option to insert the TEN from lateral. The entry point is chosen 1.5–2 cm medial to the acromioclavicular joint on the posterior surface of the clavicle.
It also is not recommended to bend the medial end of the TEN into a U-turn. This often leads to painful skin irritation.
The TEN should not be used in osteoporotic fractures since insufficient anchorage leads to nail migration.
Surgery performed a few days after trauma is more likely to require open reduction due to loss of elasticity of the traumatized soft tissues [24]. As a consequence, fracture fragments are less mobile and less easy to reduce. Early fracture fixation therefore has advantages with respect to reduction and alignment.
10.6 Postoperative Treatment
Postoperative immobilization is not necessary. Physical therapy should be started early with active and passive shoulder motion as tolerated. In multi-fragmentary fractures, arm sling protection for 3–6 weeks with restricted motion to 90° of abduction is recommended until callus formation occurs.
10.7 Outcome and Results
ESIN is a minimal invasive technique that leads to favourable functional results with prompt pain relief and fast return to active life [25]. Rate and type of complications; and outcome of the procedure are summarized in Tables 10.3 and 10.4.
Table 10.3
Overview of complications in ESIN of clavicular fractures
Study | Patients (n) | Follow up (months) | % of open reduction | Rate of complications | Type and number of complications |
|---|---|---|---|---|---|
Level of evidence | |||||
Wijdicks et al. (2012) [26] Retrospective study | |||||
IV | 43 | 6 (5–12) | 85.1 % (n = 40) | – | 1 implant failure, 4 superficial Infections, 23 medial TEN protrusions, 3 lateral TEN protrusions, 2 temporary brachial plexus lesions, 2 pain after 6 month |
Smekal et al. (2011) [23] Prospective study | |||||
IIb | 60 | 24 | – | 32 % (n = 19) | 2 delayed unions (healing after 6 month), 7 telescoping, 1 infection, 5 medial skin irritations, 2 implant failures, 1 refracture |
Frigg et al. (2011) [27] Retrospective case-control study, 2 groups with different rehabilitation protocols (group A: unrestricted RoM, group B: limitation to 90° abduction for 6 weeks) | |||||
III | A = 15 | 16.7 (12–28) | 52 % (n = 23) | A 60 % (n = 9) | 4 lateral perforation, 1 nail breakage, 1 nail displacement, 3 medial or lateral pain |
B = 29 | B 17 % (n = 5) | 1 lateral perforation, 1 thrombosis v. subclavia, 1 non-union, 2 medial or lateral pain | |||
Smekal et al. (2009) [28] Prospective randomized controlled trial | |||||
Ib | 30 | 24 | 13.3 % (n = 4) | 33 % (n = 10) | 1 delayed union, 2 implant failures, 2 telescoping, 5 medial nail protrusions |
Frigg et al. (2009) [29] Case series, 2 groups comparing the use of an end cap in ESIN of mid shaft clavicle fractures, group A without end cap, group B with end cap | |||||
IV | A = 19 | 32 (15–52) | 62 % (n = 21) | A 78 % (n = 14) | 7 medial perforation, 6 pain, 3 lateral penetration |
B = 15 | B 60 % (n = 9) | 3 pain, 4 lateral penetrations, 1 TEN breakage, 1 TEN dislocation | |||
Kettler et al. (2007) Retrospective study | |||||
IV | 87 | 13 | – | 11 % (n = 10) | 2 non-unions, 2 malunions, 4 implant dislocations, 2 misplaced nails |
Walz et al. (2006) [30] Retrospective study | |||||
IV | 35 | – | 26 %
Related posts: Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
| ||
