Management of acute displaced midshaft clavicular fractures using Herbert cannulated screw: Technique and results in 114 patients

Purpose:

A new and simple operative technique has been developed to provide internal fixation for midshaft clavicle fractures. This involves the use of a large fragment Herbert Screw that is entirely embedded within the bone. Screw fixation is combined with bone grafting from intramedullary reamings of the fracture fragments. The purpose of this report is to assess the outcomes following treatment of midshaft clavicular fracture using this method.

Materials and Methods:

One hundred and fourteen patients with acute displaced midshaft fracture were identified between 2002 and 2007. All patients were followed until fracture union. Patients’ medical records were reviewed. Disability of the Arm, Shoulder, and Hand questionnaire (DASH), and American Shoulder and Elbow Surgeons Elbow form (ASES) were posted to all patients. Outcome measures included union rate, time to union, implant removal rate, DASH, and ASES scores.

Results:

Patients’ median age was 29.5 years (interquartile range, 19-44 years). The most common injury mechanism was sports injury (28%). The median time from injury to surgery was 5 days (interquartile range, 2-9 days). Union occurred in an average of 8.8 weeks. Non-union occurred in three cases (2.6%). The re-operation rate for symptomatic hardware prominence screw was 1.7%. The median DASH score was 0.83 and the median ASES was 100 (n = 35).

Conclusions:

Intramedullary fixation using cannulated Herbert screw can be used as an effective approach for operative management of midshaft clavicular fractures. Using this method, an appropriate outcome could be achieved and a second intervention for implant removal could be avoided in great majority of cases.

Level of Evidence:

Level III     

Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle

Outcome after surgical treatment for nonunion and malunion of midshaft displaced clavicle fractures has generally been described as favorable and equal to results of acute repair. This assumption has been based on subjective criteria, however, and no direct comparison is available in the literature. This study used objective measurements of limb function to compare outcome in patients who underwent delayed operative intervention for nonunion and malunion with the outcome of patients who underwent immediate open reduction and internal fixation after displaced clavicle fracture. All patients had sustained completely displaced, closed, isolated midshaft clavicle fractures, of whom 15 had undergone acute open reduction and internal fixation with a compression plate at a mean of 0.6 months after injury (acute group). Another 15 patients had undergone delayed reconstruction with open reduction, bone grafting, and compression plate fixation for nonunion or malunion a mean of 63 months after injury (delayed group). The 2 groups were similar in age, gender, original fracture characteristics, and mechanism of injury. Complete assessment included standard history and physical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score, subjective rating of outcome satisfaction, and objective muscle strength testing using a previously validated and published protocol on the Baltimore Therapeutic Equipment (BTE) work simulator. There were no significant differences between acute fixation and delayed reconstruction groups with regard to strength of shoulder flexion (acute, 94%; delayed, 93%; P = .82), shoulder abduction (acute, 97%; delayed, 97%; P = .92), external rotation (acute, 97%; delayed, 90%; P = .11), or internal rotation (acute, 98%; delayed, 96%; P = .55). Constant scores in the acute group were superior (acute, 95; delayed, 89; P = .02), but differences in DASH scores were not significant (acute, 3.0; delayed, 7.2; P = .15). Shoulder flexion muscle endurance was significantly decreased in the delayed group (acute, 109%; delayed, 80%; P = .05). Differences in muscle endurance in other planes were not significantly different (abduction endurance: acute, 107%; delayed, 81%; P = .24). Both groups rated their satisfaction with the procedure as excellent. Late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle is a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair. This information should not be used to justify primary operative repair in isolation but is useful in decision-making when counseling patients with displaced midshaft fractures of the clavicle.     

缝合锚钉在治疗粉碎性肱骨大结节骨折的临床应用

目的探讨有限切开应用缝合锚钉治疗粉碎性肱骨大结节骨折的初期临床疗效。方法 2007年11月至2009年11月,本组有限切开应用缝合锚钉治疗粉碎性肱骨大结节骨折16例,男9例,女7例,年龄42～73岁,平均58.7岁。根据Neer分型,均为Ⅱ部分大结节骨折,骨折块至少三块,其中新鲜骨折10例,陈旧骨折4例,2例翻修;经肩关节外侧切口做有限切开,较大的骨折块用Herbert或中空螺钉固定,粉碎者在解剖颈骨折处拧入5.0mm锚钉,用其缝线经肩袖肌腱缝合固定。末次随访时采用美国肩肘外科医师（ASES）评分,Constant-Murley评分标准进行评分。结果 16例患者获得术后平均11.2个月（7～16个月）随访,X线片显示骨折对位满意,所有患者骨折均愈合,平均愈合时间8.6周（6～12周）。根据ASES及ConstantMurley肩关节评分系统,本组患者的ASES评分平均95.4分（82～100分）,Constant-Murley评分平均96.2分（84～100分）;肩关节功能：前屈上举平均167°（100°～180°）;体侧外旋平均60.5°（40°～90°）,内旋手指尖可到达T7-T8（T12-T5）棘突水平。本组未出现内固定失效、骨折移位和腋神经损伤等并发症。结论应用缝合锚钉是治疗用常规方法无法固定的粉碎性肱骨大结节骨折的一种安全有效方法。     

Operative Treatment of Clavicle Midshaft Fractures: Comparison between Reconstruction Plate and Reconstruction Locking Compression Plate

Background

To compare the outcomes of reconstruction plate and reconstruction locking compression plate (LCP) for the treatment of clavicle midshaft fractures.

Methods

Forty one patients with a clavicle midshaft fracture were treated by internal fixation with a reconstruction plate (19 patients) or reconstruction LCP (22 patients). The clinical and radiological results were evaluated according to the Quick Disability of the Arm, Shoulder, and Hand (DASH) score and plain radiographs.

Results

The mean time to union was 14.6 weeks in the reconstruction plate group compared to 13.2 weeks in the reconstruction LCP group (p > 0.05). The mean score to Quick DASH was 33.85 points in the reconstruction plate group compared to 34.81 points in the reconstruction LCP group (p > 0.05). The complications in the reconstruction plate were hypertrophic scarring in 2 cases, painful shoulder in 2 cases, limitation of shoulder motion in 2 cases, and screw loosening in 3 cases. In addition, the complications in the reconstruction LCP group was hypertrophic scarring in 4 cases, painful shoulder in 1 case and a limitation of shoulder motion in 1case (p > 0.05).

Conclusions

This study showed radiologically and clinically satisfactory results in both groups. Overall, operative treatment with a Reconstruction plate or reconstruction LCP for clavicle shaft fractures can be used to obtain stable fixation.     

钛制弹性髓内针在成人锁骨中段骨折中的应用

目的:探讨弹性髓内针治疗锁骨中段骨折的手术技巧、注意事项和并发症,评价治疗效果。方法:2006年6月至2009年1月收集锁骨中段完全移位性骨折28例,男19例,女9例;年龄19～67岁,平均39.0岁;左侧14例,右侧14例;简单骨折15例,楔形骨折8例,粉碎型骨折5例;平均病程2.9 d。术前患者肩部肿胀畸形,上臂贴胸不能活动,X线片示锁骨中段完全移位性骨折。术前平均缩短率6.76%,骨折愈合后测量锁骨长度,肩部功能采用Constant和Murley肩关节评分,上肢活动障碍程度采用DASH(Disability of the Arm,Shoulder,and Hand)评分。结果:钛制弹性髓内针闭合治疗26例,开放复位穿钉2例,均获得满意解剖复位。平均随访时间10个月,骨折平均愈合时间11.5周,无严重并发症发生。愈合后锁骨平均缩短率3.38%,较术前改善。Constant和Murley肩关节评分平均(97.0±4.2)分,DASH评分平均(3.4±4.8)分。患者对功能和外观满意。结论:钛制弹性髓内针治疗锁骨中段骨折具有诸多优点,可作为钢板治疗和非手术治疗替代方法。     

Outcome analysis following open rotator cuff repair. Early effectiveness validated using four different shoulder assessment scales

Evaluation of upper extremity function after reconstructive surgery is increasingly important both to predict outcome and for the control of cost-effectiveness. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients with rotator cuff deficiency and correlated to the Constant-Murley Shoulder Score and a visual analogue scale for satisfaction. Seven women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 ± 10.5 years, r/l: 14/9, follow-up 57.8 ± 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). Additionally, a visual analogue scale for satisfaction was employed. All four scores and the visual analogue scale revealed improvement at a statistically significant level (P < 0.01) after surgery. All questionnaires showed a significant correlation with the Constant-Murley Shoulder Score (ASES: r = 0.871, P < 0.01; DASH: r = –0.758, P < 0.01, SST: r = 0.494, P < 0.05, Pearson’s correlation coefficient). Taken together, all questionnaires were easy to apply, and reliable evaluation of shoulder function was possible with significant correlation to the Constant-Murley Shoulder Score postoperatively. The SST was easy to apply, and compound outcome analysis was possible with the ASES Shoulder Index and DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination, which is advantageous but restricts the application to the office. For postoperative assessment without the patient having to return to the clinic, the ASES Shoulder Index is preferred because of its good correlation to the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762). Received: 4 October 1999     

Open reduction and plating for displaced mid third clavicle fractures – A prospective study

IntroductionDisplaced middle third clavicle fractures were treated conservatively with figure of ‘8’ harness in the past. Current management trend in treating displaced clavicle fractures with internal fixation provide rigid immobilization and pain relief avoiding non-union, shortening and deformity. This study prospectively evaluates the functional outcome of 25 patients with clavicle fractures treated surgically.Materials and methods25 patients with displaced mid third clavicle fractures were included in the study. Open reduction and internal fixation with clavicular locking plate placed superiorly was done. Patients were followed up on 3, 6, 8, and 12 weeks. Functional outcome was assessed using DASH scores and Simple Shoulder Test (SST). Statistical analysis was done using One-way ANOVA.ResultsOut of the 26 clavicles operated (one patient had bilateral fracture), 6 were comminuted (23%) and the rest were 2 part displaced fractures. Interfragmentary screws were used in 3 cases with butterfly fragment. All fractures united (mean = 6.8 weeks). The DASH scores reduced to a significant negligible level by 8 weeks in all but 4 cases with comminution where it took longer than 8 weeks to reach negligible levels. The SST showed significant improvement in all cases by 8 weeks after surgery. All patients were satisfied with the outcome. 84% of patients returned to their work by 6 weeks.ConclusionPrimary plating of displaced mid third clavicle fractures with superiorly placed locking plate avoids complications of non-operative management and leads to early return to pre injury activities.     

Biomechanical evaluation of fixation of clavicular fractures

Reproducible fractures of the midshaft of the clavicle were created in 14 fresh frozen human cadaveric clavicles. Under the three-point bending loading by a materials testing machine, the load to failure of fixation of the clavicular fractures treated with steel reconstruction plates (five specimens) and Herbert cannulated bone screw (nine specimens), was compared with a group control formed by five specimens of clavicles without osteosynthesis material. No statistically significant differences were observed between the three groups. In consequence and in terms of biomechanics, in clavicular acute fractures, both plating and intramedullary Herbert cannulated bone screw may be utilized in the treatment of these lesions.     

Extra-articular locking plate and trans-articular clavicle hook plate for displaced medial clavicle fractures

IntroductionFracture of the medial end of the clavicle is very rare. There is no consensus on the standard surgical strategy for medial clavicle fracture, and treatment is challenging. This study aimed to retrospectively evaluate the efficacy of internal plate fixation for displaced medial clavicle fracture.MethodsPatients who underwent internal plating of a displaced medial clavicle fracture were included in this retrospective study. Each patient underwent open reduction and fixation with an internal extra-articular locking plate or trans-articular hook plate based on their fracture type. Postoperative follow-up included radiographs for assessment of bone union, Constant-Murley score for shoulder function, Disability of the Arm, Shoulder, and Hand (DASH) questionnaire for upper limb function, and visual analog scale (VAS) for pain. Any complications were also recorded.ResultsBetween May 2014 and July 2021, 34 patients (9 females, 25 males; mean age, 50.0 ± 14.8 years) were treated with internal plate fixation and included in this study. The fracture line was located in the medial fifth of the clavicle in 32 patients, and 20 patients had intra-articular fracture. Eighteen patients had the fracture fixed with a locking plate, namely an inverted distal clavicle plate (n = 7), straight locking plate (n = 3), distal fibular plate (n = 3), and T-plate (n = 5); the other 16 patients were treated with a clavicle hook plate. During a mean follow-up of 30.7 ± 26.5 months, 33 patients achieved bone healing, the average Constant-Murley score was 90.9 ± 11.0 points, the mean DASH score was 6.0 ± 6.6 points, and the mean VAS was 0.4 ± 1.1 points. Complications occurred in five patients.ConclusionsBoth locking plates and hook plates are effective in treating displaced medial clavicle fracture. A locking plate is recommended when there is enough bone stock in the medial fragment for stable fixation. A clavicle hook plate is recommended for cases in which the medial clavicle fracture is too small, comminuted, or has signs of sternoclavicular joint instability.     

Locking versus nonlocking superior plate fixations for displaced midshaft clavicle fractures: A prospective randomized trial comparing clinical and radiografic results

BackgroundIt is unknown whether locking or nonlocking superior plate fixation is better for managing displaced midshaft clavicle fractures. Therefore, we aimed to compare the clinical and radiographic outcomes of locking and nonlocking superior plate fixation of displaced midshaft clavicle fractures.MethodsA total of 102 consecutive patients with displaced midshaft clavicle fractures (2B1 and 2B2 in Robinson classification) participated in this randomized controlled trial; 12 patients were excluded. Surgeries were performed using a 3.5-mm Locking Compression Plate (LCP) between 2007 and 2015. Patients were treated either with a locking plate (group L, n = 45) or a nonlocking plate (group N, n = 45). In both groups, the plates were fixed to the proximal and distal clavicle with two and/or three screws, respectively.The main outcome measures were complication rates, time to bone union, and Constant score.ResultsForty-two patients in group L (mean age, 45.9 years) and 41 in group N (mean age, 43.6 years) were followed. The overall complication rates in groups L and N were 7.2% (three peri-implant fractures) and 7.3% (non-union, deformed plate, and peri-implant fracture), respectively (p = .98). The average time to union significantly differed between groups (L vs. N: 13.0 ± 4.1 vs. 17.5 ± 6.3 weeks; p < .01). However, the Constant score at the final follow-up was not significantly different between groups (L vs. N: 87.0 ± 12.3 vs. 89.8 ± 9.1).ConclusionsSimilar complication rates and clinical results were found for locking and nonlocking superior plate fixation for displaced midshaft clavicle fractures. However, the time to bone union was shorter with the locking plate. This study suggests that both plating systems are effective for treating displaced midshaft clavicle fractures.Level of evidenceTherapeutic, level I.     

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.     

应用肱骨近端锁定钢板治疗肱骨近端骨折的临床结果分析

目的探讨应用肱骨近端锁定钢板（LPHP）治疗肱骨近端骨折的临床效果和适应证选择。方法2004年9月至2006年3月收治的84例肱骨近端骨折患者中75例患者获得随访,平均随访时间17个月（12—30个月）。新鲜骨折60例,陈旧骨折15例,均行切开复位LPHP内固定。应用美国肩肘外科医师评分（ASES）、Constant-Muxley评分、UCLA评分系统以及简易肩关节测验（SST）问卷评估治疗结果,观察肩关节活动范围,肌力、疼痛情况,并对比新鲜骨折与陈旧骨折的治疗效果。结果75例患者肩关节活动范围平均为前屈上举（147．3±17．7）°,外旋（30．5±16．2）°,内旋达Tq水平。ASES平均为86．7±12．7;Constant-Murley评分为87．4±10．5;UCLA评分系统为30．1±4．2,总体优良率为89．3％。与新鲜骨折相比,陈旧骨折患者前屈上举的范围和ASES评分存在明显差异（均为P〈0．05）。在9例出现晚期并发症的患者中ASES、UCLA、Constant-Murley评分与无并发症的患者相比均存在明显差异（P〈0．05）。结论正确选择手术指征和掌握操作技术,应用肱骨近端锁定钢板治疗存在明显移位的肱骨近端骨折可以获得较为满意的临床结果。     

Outcomeanalyse nach offener Rekonstruktion von Rotatorenmanschettenrupturen Eine vergleichende Beurteilung neuer Bewertungsverfahren

Outcome evaluation is becoming increasingly important for reconstructive surgery in musculoskeletal diseases. In addition to established shoulder-scores, new outcome-scores are being developed to cover all effects caused by a disease or intervention. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients suffering from rotator cuff deficiency. These were correlated to the Constant-Murley Shoulder Score and to a visual analogue scale for satisfaction. 7 women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 +/- 10.5, r/l: 14/9, FU 57.8 +/- 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons Shoulder Index (ASES), the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). In addition, a visual analogue scale for satisfaction was employed. All four scores as well as the visual analogue scale revealed improvement at a statistically significant level (paired, two-tailed t-test, P < 0.01) after surgery. All questionnaires had a significant correlation with the Constant-Murley Shoulder Score (Pearson's correlation coefficient: ASES: r = 0.871, P < 0.01; DASH: r = -0.758, P = < 0.01; SST: r = 0.494, P < 0.05). All were easy to apply and provided a reliable, postoperative evaluation of shoulder function. The SST was easy to apply, however compound outcome analysis was only possible with the ASES Shoulder Index and the DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination which is advantageous but must be carried out in the clinic. For postoperative assessment, without the patient having to return to the clinic, the ASES Shoulder Index is preferred as it correlates well with the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).     

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.     

钛制弹性钉与重建钢板在治疗移位锁骨中段骨折中的临床疗效比较

目的 比较钛制弹性钉(TEN)与重建钢板(RP)治疗移位锁骨中段骨折的疗效.方法 2005年1月至2007年7月,对采用TEN或RP治疗且获随访的141例锁骨中段移位骨折患者的资料进行回顾性分析,其中57例患者采用TEN治疗(TEN组),84例患者用3.5 mm RP治疗(RP组).比较两组患者的一般情况、术后并发症、术后6个月及术后2年Constant评分及臂、肩、手功能障碍(DASH)评分.结果 TEN组患者获24～41个月(平均30个月)随访,RP组患者获28～48个月(平均32个月)随访.影像学显示TEN组骨折愈合时间平均为(12.4±3.4)周,RP组平均为(14.4±3.7)周.两组患者骨不连和成角畸形短缩、内置物失败、感染、短暂性神经丛刺激症、内置物移位、皮肤刺激症等并发症的发生情况,差异无统计学意义(P＞0.05).TEN组有17例内置物移位,但程度轻,多数患者无临床症状.术后6个月随访时,TEN组患者DASH评分明显低于RP组(P＜0.05),而Constant 评分明显高于RP组(P＜0.05).术后2年时,两组患者的DASH评分和Constant评分差异无统计学意义(P＞0.05).TEN组患者对术后肩部外形及综合结果较RP组更满意.结论 与RP相比,TEN治疗移位的锁骨中段骨折在术后早期功能锻炼及功能恢复方面有明显的优势.术后早期TEN组患者对肩部外形及术后综合结果方面更为满意.     

A three-dimensional reconstruction plate for displaced midshaft fractures of the clavicle

This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the 3D group (p < 0.05). The percentage comparisons of cortical bone area showed that cortical bone in the superior distal segment is thicker than in the inferior segment, it is also thicker in the anterior mid-section than in the posterior (p < 0.05). If fixation of midshaft fractures of the clavicle with a plate is indicated, a 3D reconstruction plate is better than one placed superiorly, because it is consistent with the stress distribution and shape of the clavicle.     

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

PurposeHigh 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.MethodsFifty 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.ResultsMean 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).ConclusionClose 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.     

Role of autologous bone graft in the surgical treatment of atrophic nonunion of midshaft clavicular fractures

A retrospective study was conducted to evaluate the role of autologous bone graft in treating atrophic nonunion of midshaft clavicle fracture with a limited-contact dynamic compression plate (LC-DCP). Between 1995 and 2008, sixty cases of atrophic nonunion of midshaft clavicle fractures were managed with open reduction and internal fixation with an LC-DCP. The cases were separated into 2 groups to evaluate the effect of autologous bone graft in the enhancement of bone union. In group 1 (n=24), autologous bone graft was not used; in group 2 (n=36), autologous bone graft was used. Pre- and postoperative management were the same in both groups. Radiographic results and functional outcomes according to the Quick Disability of Arm, Shoulder, and Hand score were evaluated. Average follow-up was 25.2 months (range, 24-48 months).No statistically significant difference was found between the 2 groups regarding demography and preoperative functional scores (P>.05). Operative time and hospital stay were statistically significant longer in group 2 (P<.001), and donor site pain was apparent in group 2. All 60 patients had uneventful union. No statistically significant differences were found between the 2 groups regarding union time (average, 9.8 weeks in group 1 and 9.2 weeks in group 2) and postoperative functional scores (P>.05). Limited-contact dynamic compression plate fixation is an effective method for treating atrophic nonunion of midshaft clavicle fractures. Autologous bone graft was not needed.     

Flexible intramedullary nailing for stabilization of displaced midshaft clavicle fractures: technique and results in 87 patients

Background Elastic, stable intramedullary nailing (ESIN) with titanium nails is a promising minimally treatment for displaced midclavicular fractures, which may be an alternative to plate fixation (ORIF) or even nonoperative treatment. We describe the surgical technique and outcome in 87 patients.

Methods The nail was inserted at the medial inferior end of the clavicle in 83 patients and in the acromial end in 12 patients. An open fracture reduction via an additional small incision was necessary in 53 patients and closed manoeuvre was successful in 42. Implant removal was performed in 82 patients.

Results The functional status of 87 patients after 13 months reached 6.8 (0-43) points on the DASH score and 81 (46-100) points on the self-reported Constant score. The fracture healed in correct anatomical axis in 80 of 87 patients, 2 cases ended in a nonunion. Implant migration of the nail occurred in 4 patients, who required early implant removal. Repeated nailing was necessary in 2 patients in whom the nail missed the lateral medullar canal, and plate fixation was necessary in 2 other patients who had secondary dislocation after early nail removal.

Interpretation Flexible intramedullary nailing, a minimally invasive technique for stabilization of displaced midshaft clavicle fractures, has minor risks and complications.