22/07/2008
AO Technical Commission Approved

Elastic stable intramedullary nailing of the clavicle

Fractures of the clavicle are common and seen across all age groups; however women are at almost four time's greater risk of non-union than men (Nowak). The traditional treatment of midshaft clavicle fractures has been non operative. Although minimally displaced fractures do well, outcome studies have shown higher incidences of fracture malunion, non-union, and patient dissatisfaction after non operative treatment of displaced midshaft clavicle fractures. A meta-analysis by Hill found a non-union rate of 15.1% following non-operative care of these fractures.

Clavicular malunion is a distinct clinical entity with characteristic orthopaedic (weakness and easy fatigability), neurovascular (neurogenic compression syndrome, thoracic) and aesthetic (droopy, asymmetric shoulder, difficulty with backpacks, shoulder straps etc.) symptoms (McKee).

The subcutaneous position of the clavicle lends itself to less invasive surgical techniques.

Titanium Elastic Nail

The Titanium Elastic Nail was invented primarily for fixation of fractures where the medullary canal is narrow or flexibility of the implant is needed. It is used for treatment of humeral, femoral and tibial fractures in adolescents and children, or small statured adults.

The TEN is available in six diameters: 1.5, 2.0, 2.5, 3.0, 3.5, and 4.0mm. The 1.5mm diameter TEN is 300mm long. All other size diameters come in a length of 440mm.

Use of the Titanium Elastic Nail (TEN) in displaced clavicle fractures offers a means of minimally invasive fixation that allows for early motion and function, immediate pain reduction and a lower rate of fracture non-union and malunion compared to non operative treatments. The risks of infection and non-union often associated with open reduction and internal plate fixation can be minimized by a percutaneous procedure (Keener). A study by Rehm reported on 136 fractures in 132 patients treated with the TEN with 78 placed entirely percutaneously, and the remaining required a limited exposure for fracture reduction. All but one healed, with follow-up revealing outstanding functional results.

Jubel showed that the use of the TEN in displaced midclavicular fractures was successful in terms of clinical outcome and rapid resumption of sporting activities. They recommended intramedullary nailing as preferred treatment of athletes compared to non-operative treatment.

Intramedullary nailing of the clavicle was shown to have a higher union rate with a lower complication rate than plating (Wu).

Surgical Technique and post-operative management

The operative technique as described by Rehm starts with a skin incision just above the sternal end of the clavicle. Approximately one cm lateral to the sternoclavicular joint, a hole is drilled into the anterior cortex. A titanium nail varying in diameter between 2.5 to 3.5 mm is mounted on a universal chuck with T-handle. With oscillating movements the TEN is advanced until it reaches the fracture site. If closed reduction manoeuvres are unsuccessful, an additional skin incision has to be made at the level of the fracture site enabling direct manipulation of the fragments.

Postoperatively, no immobilization is performed. Patients are encouraged to move the arm as much as tolerated and to use it in daily activities.

Bibliography

Hill JM, McGuire MH, Crosby L (1997). Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surgery; 79B(4): 537-41.

Jubel A, Andemahr J, Bergmann H, Prokop A, Rehm, K, Fay M (2003). Elastic stable intramedullary nailing of midclavicular fractures in athletes. British Journal Sports Med; 37(6): 48084.

McKee MD (2006). Displaced fractures of the clavicular shaft: Fact and fallacy. AO Dialogue; 1: 26-29

Nowak J, Holdersson M, Larsson S (2005). Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop; 76(4): 496-502.

Rehm K, Andermahr J, Jubel A (2004). Intramedullary Nailing of Midclavicular Fractures with an Elastic Titanium Nail. Operat Orthop Traumatol; 4: 365-79.

Keener JD, Dahners LE (2006). Percutaneous Pinning of Displaced Midshaft Clavicle Fractures.  Techniques in Shoulder & Elbow Surgery; 7(4): 175-81

Wu CC, Shih CH, Chen WJ, Tai CL (1998). Treatment of clavicular aseptic non-union: Comparison of plating and Intramedullary nailing techniques. The Journal of Trauma; 45(3): 429-45 (26 ref.): 512-16.

Additional instruments

Cases provided by Vinzenz Smekal, Innsbruck, Austria

Case 1: Male, 56 years, Bicycle accident


Case 2: 51 years, male, hit by tree

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