Anterior-inferior plating of middle-third fractures of the clavicle

Introduction

Various techniques have been reported for the treatment of middle-third clavicle (collar bone) fractures. This prospective study was conducted to evaluate the results of anterior-inferior plating using a 3.5-mm reconstruction plate for the treatment of middle-third clavicle fractures.

Patients and methods

Twenty-six patients with middle-third clavicle fractures were treated with anterior-inferior plating. The indications for surgery included complete displacement, severe comminution, and marked shortening of the clavicle (>2 cm).

Results

The mean time to union was 14 weeks (range 8–20 weeks). At the time of latest follow-up, all of the patients had returned to their pre-injury activity level. The plates were removed in ten patients after the fractures healed. No patients required plate removal due to implant-related problems.

Conclusion

Anterior-inferior plating is an effective treatment modality for middle-third clavicle fractures, with few complications and early return of shoulder function. The procedure provides stable fixation, avoids risk to vital structures below the clavicle, and is associated with a low rate of implant-prominence problems.     

Surgical treatment of vertically unstable lateral clavicle fractures (Neer 2b) with locked plate fixation and coracoclavicular ligament reconstruction

Introduction

The present study evaluates the outcome of patients treated with a combination of locked plate fixation and minimal-invasive coracoclavicular (CC) ligament reconstruction for unstable lateral clavicle fractures type IIb according to Neer.

Patients and methods

Fourteen patients with an unstable lateral clavicle fracture were treated with a combination of locked plate fixation and a minimal-invasive CC ligament reconstruction. At a mean follow-up of 38 months, patients were re-evaluated using the Constant-Murley score, the Acromioclavicular (AC) joint instability score and the TAFT score. Furthermore, anterior–posterior (ap) stress radiographs and axillary views were performed in order to detect any recurrent instability.

Results

Bony union was achieved in all cases within 6–10 weeks. The mean Constant-Murley score of the affected shoulder was 93.5 points compared to 97.2 of the contralateral unaffected shoulder. The mean Taft score was 11.2 points and the mean AC joint instability score was 92 points in comparison to 96 points on the unaffected side. The mean CC distance at the time of the injury was 21 mm compared to 8.5 mm after surgery and 12 mm a the final follow-up examination. The CC distance did not differ between the postoperative X-rays and those at the time of follow-up (p = 0.068). Three plates had to be removed because of implant irritation.

Conclusion

A combination of locked plate fixation and CC ligament augmentation in a minimal-invasive manner can be regarded as suitable for the treatment of vertically unstable lateral clavicle fractures and is associated with excellent clinical and radiological outcomes and a low complication rate.     

A new fixation method for Hoffa fracture

Purpose

To investigate the clinical effect of a new fixation method for Hoffa fractures.

Methods

We treated eleven patients with Hoffa fracture using the new fixation method (fixation with one screw inserted from the femoral intercondylar notch and two screws inserted from the nonarticular lateral (or medial) surface of the fractured condylar fragment; the two sets of screws were crossed).

Results

After an average follow-up period of 24 months (range 5–28 months), all fractures had healed. The average healing time was 11.6 weeks (range 9–14 weeks). On the version of the Knee Society Score modified by Dr. John Insall in 1993, the average score was 174.6 points (range 125–199 points).

Conclusions

The new fixation method for Hoffa fracture is effective, and may provide a new way to treat Hoffa fractures.     

Die laterale Klavikulafraktur

Objective

Reposition and fixation of unstable distal clavicle fractures with a low profile locking plate (Acumed, Hempshire, UK) in conjunction with a button/suture augmentation cerclage (DogBone/FibreTape, Arthrex, Naples, FL, USA).

Indications

Unstable fractures of the distal clavicle (Jäger and Breitner IIA) in adults. Unstable fractures of the distal clavicle (Jäger and Breitner IV) in children. Distal clavicle fractures (Jäger and Breitner I, IIB or III) with marked dislocation, injury of nerves and vessels, or high functional demand.

Contraindications

Patients in poor general condition. Fractures of the distal clavicle (Jäger and Breitner I, IIB or III) without marked dislocation or vertical instability. Local soft-tissue infection.

Surgical technique

Combination procedure: Initially the lateral part of the clavicle is exposed by a 4 cm skin incision. After reduction of the fracture, stabilization is performed with a low profile locking distal clavicle plate. Using a special guiding device, a transclavicular–transcoracoidal hole is drilled under arthroscopic view. Additional vertical stabilization is arthroscopically achieved by shuttling the DogBone/FibreTape cerclage from the lateral portal cranially through the clavicular plate. The two ends of the FibreTape cerclage are brought cranially via adjacent holes of the locking plate while the DogBone button is placed under the coracoid process. Thus, plate bridging is achieved. Finally reduction is performed and the cerclage is secured by surgical knotting.

Postoperative management

Use of an arm sling for 6 weeks.

Results

Due to the fact that the described technique is a relatively new procedure, long-term results are lacking. In the short term, patients postoperatively report high subjective satisfaction without persistent pain.     

Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating

Introduction

Pain and impaired shoulder function are the predominant symptoms of midshaft clavicle non-unions. Obtaining consolidation and improvement of shoulder function is often successfully achieved with osteosynthesis and bone grafting. Most data in the literature pertain to plate osteosynthesis, placing the plate on the subcutaneous superior aspect of the clavicle. Although union rates are generally high, most patients require hardware removal as the plate is prominent under the skin causing pain and cosmetic problems.

Materials and methods

In the current retrospective study, we followed a cohort of 21 consecutive cases (20 patients) with a midshaft clavicular delayed or non-union, treated with anteroinferior plating using a 3.5 mm locking compression plate (LCP) for a mean of 30 months.

Results

We operated on 10 males and 10 females with a mean age of 48.2 years (range 16–65). There was one early plate failure that needed revision. Two patients required hardware removal because of prominence of the plate. All but two patients were satisfied with the final cosmetic result. The average DASH score at follow up was 22.8.

Discussion and conclusions

Anteroinferior plating with a 3.5 mm LCP is a reliable and reproducible treatment of midshaft clavicular delayed and non-union regarding consolidation, function, cosmesis and reduction of second surgery.     

Intramedullary clavicle fixation with single large fragmentary screw

Background

The treatment of clavicle fractures has historically been nonoperative, but several studies have recently shown the merits of operative management for specific fractures patterns. We developed a novel technique utilizing a 6.5-mm cannulated screw for fixation of displaced midshaft clavicle fractures.

Materials and methods

We present 15 consecutive patients treated with this technique between 2007 and 2012. All patients were male, and all 15 suffered a traumatic injury involving a fall directly onto the affected side. Mean time from injury to surgery was 12 days (range 3–24 days). Decision for surgery was based on the displacement and shortening of the fracture, either at least 20 mm of shortening or displacement with no bony apposition. After surgery, all patients were placed in an abduction brace for 6 weeks. No motion was allowed for the first 3 weeks, followed by passive shoulder motion below 90° of forward flexion under the supervision of a therapist for the next 3 weeks.

Results

All 15 patients progressed to union at an average of 5.7 months (range 3–12). Three patients had superficial wound infections. Hardware removal was performed in 6 of the 15 patients at an average of 12 months (range 5–24). All patients regained full range of motion and strength in comparison with contralateral extremity.

Conclusion

This novel technique limits soft tissue stripping. It has the advantages of using an implant familiar to most orthopedists and available in most hospital settings. We believe this technique is ideally suited for transverse fractures patterns, less than 14 days old, in males greater than 180 cm with clavicles large enough to accommodate a 6.5-mm screw.

     

Periphere Talusfrakturen

Objective

Open reduction and internal fixation with screw(s) for fragments with sufficient size, and resection of smaller fragments.

Indications

Displaced fragments with (typical) involvement of joint surface.

Contraindications

Active infection and severe peripherial vascular disease.

Surgical technique

Positioning and approach are adapted to the fracture location. Fractures of the talar head and talar shoulders, supine position and anteromedial/-lateral approach. Fractures of the lateral talar process, lateral position on contralateral side and lateral approach. Fractures of the posterior talar process, prone position and posterolateral approach. Fractures of the medial, supine position and medial approach. Open reduction and internal screw fixation. Cartilage-surgical procedures for concomitant chondral defects.

Postoperative management

For the first 6 weeks, 15 kg partial weight bearing without orthosis in a standard shoe. Thrombosis prophylaxis following the local standard during the time of partial weight bearing.

Results

At a specialized orthopedic hospital with a supraregional frequented department for foot and ankle surgery, 8 patients with peripherial talar fractures were treated in 2012 (medial/posterior talar process, each n?=?1, lateral talar process, n?=?2, medial and lateral talar shoulder, each n?=?2). One fragment was fixed with 1–3 screws, and additional cartilage reconstruction with matrix-associated stem cell transplantation was performed in 4 cases (lateral talar process, n?=?2, medial and lateral talar shoulder, each n?=?1). Bony fusion was registered at the 6-week follow-up in all cases. Further follow-up is not completed. Complications have not been registered so far.     

Risk factors for nonunion in 337 displaced midshaft clavicular fractures treated with Knowles pin fixation

Background

Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures.

Methods

The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion.

Results

A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion.

Conclusions

Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.     

Intraoperative evaluation of dorsal screw prominence after polyaxial volar plate fixation of distal radius fractures utilizing the Hoya view: a cadaveric study

Background

The irregular nature of the dorsal surface of the distal radius makes it difficult to detect prominent screws with volar plate fixation for distal radius fractures using standard fluoroscopic images. This study evaluates the accuracy of a new radiographic method, the Hoya view, for the assessment of dorsal cortical screw penetration with volar plate fixation.

Methods

Eight cadaveric upper extremities underwent application of a volar distal radius plate with polyaxial locking screws placed distally. Utilizing a mini C-arm, lateral and Hoya views were obtained with notation of any dorsal cortical screw prominence. Dissection of the cadavers was then performed for direct visualization of screw prominence. The screws were then exchanged sequentially for screws 2-mm longer than their initial measurements with repeated imaging and direct visualization.

Results

The Hoya view revealed that 9.4 % of the screws penetrated the dorsal cortex with an average screw prominence of 1.08 mm (range 0.5–2 mm). None of the six prominent screws were detected with lateral views. With the Hoya view, six of six prominent screws were identified. With locking screws exchanged for screws 2-mm longer, 76.6 % of the screws had violated the dorsal cortex; of these, 24.5 % were detected with lateral imaging versus 100 % with the Hoya view.

Conclusions

This study supports the intraoperative use of the Hoya view to evaluate screw length and dorsal cortical screw penetration in volar plate fixation of distal radius fractures. However, this view may be difficult to obtain in patients with limitations in elbow or shoulder range of motion.     

Dorsal percutaneous screw fixation of delayed or nonunion of scaphoid fractures

Purpose

The purpose of the present study is to evaluate scaphoid delayed fractures or nonunions treated by percutaneous fixation with MRI correlations.

Methods

We evaluated 33 consecutive scaphoid delayed unions or nonunions treated by dorsal percutaneous fixation at a mean 16 months (range, seven to 48 months) after the operation. There were 31 male and two female patients with an average age of 29 years (range, 25–33 years).

Results

Pre-operative MRI revealed no signs of avascular necrosis. At the latest follow-up, all patients had good or excellent results.

Conclusion

We suggest dorsal percutaneous screw fixation for scaphoid delayed fractures or nonunions after eliminating the presence of AVN by pre-operative MRI examination.     

Bioabsorbable sutures versus screw fixation of displaced tibial eminence fractures: a biomechanical study

Background

In 1995, we developed a simple and safe arthroscopic technique of anterograde stable fixation of the displaced tibial eminence fractures using a cannulated screw and washer, allowing immediate mobilisation and weight bearing. Some authors described similar end results by arthroscopic fixation of this abruption with trans-osseous sutures. We proved with the biomechanical study that the fixation with strong trans-osseous sutures provides a comparable stable fixation the same as the cannulated screw and washer. We developed a test machine for cyclic loading and a machine for measuring of the pull-out strength for this study.

Methods

A standard osteotomy of the tibial spine was performed during the cadaveric biomechanical study. We performed an arthroscopic fixation with the cannulated screw and washer in ten knees, and in another group of ten knees, arthroscopic fixation was made using two trans-osseous Orthocord? sutures. The operating time for each procedure was measured, and any possible technical complications were recorded. One thousand cycles of flexion from 0° to 90° were performed on a special loading device on all knees. The macroscopic dislocation of the fragment was measured. After the cyclic loading, all soft tissue was resected except the anterior cruciate ligament with the fixed fragment. The pull-out strength defined as translation of the tibia in anterior direction by breakage was measured with a custom-made measuring device.

Results

The average time for the screw and washer fixation was 20 min, and average time for the sutures fixation was 48 min. After cyclic loading, we did not see any dislocation of the fragment. Average pull-out strength at which fixation with a cannulated screw and washer fell was 253.42 N and mean pull-out strength at which fixation with trans-osseous sutures fell was 330.32 N. Fixation of the fragment with trans-osseous sutures was statistically significantly stronger—Wilcoxon–Mann–Whitney’s test, p = <0.00.

Conclusion

Fixation with strong trans-osseous sutures is stronger than fixation with a cannulated screw and washer on cadaveric knees. It appears that fixation with strong trans-osseous sutures allows immediate mobilisation and weight bearing like fixation with a cannulated screw and washer. Meanwhile, the time for fixation with trans-osseous sutures is significantly longer.     

Evaluation of the use of the hook plate in Neer type 2 lateral clavicle fractures and Rockwood types 3–5 acromioclavicular joint dislocations

Purpose

For most types of acromioclavicular (AC) injuries, treatment is well established. For Neer type 2 lateral clavicle fractures and Rockwood types 3–5 AC dislocations, the ideal treatment is still a point of debate. The purpose of this study was to evaluate the functional and radiological outcome in patients treated for one of these two lesions in our hospital.

Methods

Our study group consisted of 30 patients with a Neer type 2 lateral clavicle fracture (n = 19) or Rockwood types 3–5 AC dislocation (n = 11) treated with the clavicle hook plate. All implants were removed after healing. At a mean follow-up of 40 months (12–92), data were collected by the analysis of questionnaires (DASH, NSST, OSS, SF-36), clinical examination (Constant–Murley score), and radiological evaluation (Zanca view).

Results

The mean Constant score was 88 [standard deviation (SD) 8] compared to 92 (SD 6) on the contralateral non-operated side. The questionnaires resulted in the following scores: median DASH: 4.5 (0–70); median NSST: 100 (8–100); mean OSS: 41 (SD 8); mean SF-36: 81 (SD 12). The mean coracoclavicular (CC) and AC distances were not significantly different.

Conclusions

This study suggests that hook plate fixation is a reliable treatment for Neer type 2 lateral clavicle fractures and Rockwood types 3–5 AC injuries. It results in a good and comparable function of the shoulder when compared to the contralateral side, high union rate, good to excellent objective and subjective results, and allows early active motion with limited abduction. A disadvantage is the necessity to remove the plate.     

Management of acute unstable distal clavicle fracture with a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system

Background

Fracture of the distal clavicle is not uncommon. Despite the vast literature available for the management of this fracture, there is no consensus regarding the gold standard treatment for this fracture.

Purpose

To assess the clinical and radiographic outcomes and complications of acute unstable distal clavicle fracture when treated by a modified coracoclavicular stabilization technique using a bidirectional coracoclavicular loop system.

Methods

Thirty-nine patients (32 males, 7 females) with acute unstable distal clavicle fractures treated by modified coracoclavicular stabilization using the surgical technique of bidirectional coracoclavicular (CC) loops seated behind the coracoacromial (CA) ligament were retrospectively reviewed. Mean follow-up time was 35.7 months (range 24–47 months). The outcomes measured included union rate, union time, CC distances when compared to the patients’ uninjured shoulders, and the Constant and ASES shoulder scores, which were evaluated 6 months after surgery.

Results

All fractures displayed clinical union within 13 weeks postoperatively. The mean union time was 9.2 weeks (range 7–13 weeks). At the time of union, the CC distances on the affected shoulders were on average 0.9 mm (range 0–1.6 mm) longer than the unaffected shoulders. At 6 months after surgery, the Constant and ASES scores were on average 93.4 (72–100) and 91.5 (75–100), respectively. No complications related to the fixation loops, musculocutaneous nerve injuries, or fractures of coracoid or clavicle were recorded. One case of surgical wound dehiscence was observed due to superficial infection. Enlargement of the clavicle drill hole without migration of the buttons was observed in 9 out of 16 cases at a follow-up time of at least 30 months after the original operation.

Conclusions

Modified CC stabilization using bidirectional CC loops seated behind the CA ligament is a simple surgical technique that naturally restores stability to the distal clavicle fracture. It also produces predictable outcomes, a high union rate, good to excellent shoulder function, and a low complication rate. The buttons and suture loops were routinely removed in a second operation in order to prevent late stress fracture of the clavicle.

     

Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

Background

Clavicle fractures are common, accounting for 5–12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials.

Materials and methods

Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified.

Results

Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively.

Conclusions

Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential.

Level of Evidence

Level 1.     

Titanium elastic nails,open reduction internal fixation and non-operative management for middle third clavicle fractures: a comparative study

Objectives

To compare clinical outcomes between titanium elastic nails (TENS), open reduction internal fixation (ORIF) and non-operative treatment options at mean 30 months in Allman type 1 fractures of the clavicle.

Design

Retrospective case matched.

Setting

Tertiary Trauma Centre, UK.

Patients

Treatment method was based on surgeon choice although there was no difference between groups in terms of age or gender. Those treated non-operatively tended to have a less severe fracture pattern. There were 25 patients treated with TENS, 24 with ORIF and 41 treated conservatively. Main outcome measurements are qDASH questionnaire, patient satisfaction question and clinical complication rate.

Results

Patients managed with TENS had significantly better clinical outcomes than both plate fixation and non-operatively managed groups.

Conclusions

This study supports the use of TENS fixation of middle third clavicle fractures in significantly displaced Allman type 1 injuries.     

The effect of inferomedial screw on postoperative shoulder function and mechanical alignment in proximal humerus fractures

Aim

The aim of the study was to evaluate the clinical and radiologic results of locking plate fixation with or without inferomedial screw (IMS) in surgically treated proximal humerus fractures.

Patients and methods

Thirty-six patients with displaced proximal humerus fractures from two centers were operated using locking plate. All of the fractures were classified according to the Neer classification. In 18 of the cases, an additional IMS running through the medial curvature of the surgical neck was used. There was no significant difference among both groups in terms of height, gender, weight, and mechanism of injury. The fractures were evaluated according to the radiographic and functional findings during follow-up period of 14 months in average (range 8–32 months). At the end of first year, shoulder radiographs were received and shoulder examinations were performed using ASES scores. Humeral head-shaft angles were measured by true AP projections. Head-shaft angle measurements were categorized as varus if <125, normal if between 125 and 145, and valgus if >145.

Results

Mean time for fracture healing was 18 weeks. Complete union was achieved in 35 patients by the end of 6 months. In one of the 18 displaced proximal humerus fractures of IMS (+) group, the head-shaft angle was measured to be <125, whereas six patients had varus deviation in IMS (?) group at follow-up (p < 0.05). Mean ASES scores of IMS (+) group and IMS (?) group were 58.21 ± 5.82 and 38.61 ± 3.44, respectively (p < 0.001).

Conclusion

Use of inferomedial screw running through the medial curvature of surgical neck prevents varus deformity and improves functional outcome after surgical treatment for proximal humerus fractures.     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Operative versus non-operative treatment for clavicle fracture: a meta-analysis

Purpose

The purpose of this study was to assess the effects of operative and non-operative treatment on clavicle fractures.

Method

Relevant clinical trials on the operative and non-operative treatment for clavicle fractures were retrieved through searching the databases MEDLINE, Embase, OVID and the Cochrane Central Register of Controlled Trials up to December 2011. The quality of the included studies was assessed by two authors. A meta-analysis was carried out on homogeneous studies. Five studies involving 633 clavicle fractures were included.

Results

The differences in nonunion [risk ratio (RR) 0.12, 95 % confidence interval (CI) 0.05–0.29], malunion (RR 0.11, 95 % CI 0.04–0.29) and neurological complications (RR 0.45, 95 % CI 0.25–0.81) were statistically significant between operative and non-operative treatment. There was no statistically significant difference in delayed union (RR 0.78, 95 % CI 0.31–1.95).

Conclusion

Operative treatment is better than non-operative treatment, but decisions should be made in accordance with specific conditions for clinical application.     

Elastisch stabile intramedull?re Nagelung nach Korrekturosteotomie von symptomatisch fehlverheilten Klavikulafrakturen

Objective

To restore alignment and length of the clavicle, to relieve typical symptoms of malunion, and to improve functional outcome and aesthetic results.

Indications

Symptomatic malunion after clavicular fractures, including local pain and tenderness, weakness and rapid fatigability of the shoulder girdle muscles, impairment of overhead mobility, numbness, parasthesia, and pain of the arm and fingers during overhead movements due to brachial plexus irritation (thoracic outlet syndrome), and dissatisfaction with the appearance of the shoulder girdle.

Contraindications

Atrophic nonunions, osteoporosis, asymptomatic malunion.

Surgical technique

A 5-cm skin incision is made above the deformity of the malunited clavicle. The osteotomy plane is determined under fluoroscopic guidance, within the callus separating the two original main fracture fragments. Under fluoroscopic guidance, the medullary canal is reopened on both sides with a 2.7?mm drill bit. Afterwards a 1.5?cm skin incision is made just above the sternal end of the clavicle. The anterior cortex is drilled and a titanium nail (diameter 2.5?mm) is introduced. Under rotational movement, the nail is advanced to the osteotomy site. The nail is inserted into the lateral fragment. Then the inserted nail is cut back as far as possible on the medial entry point. Wound closure.

Postoperative management

No immobilization, movement not restricted. Patients are encouraged to use the arm in daily activities. Heavy weight bearing is not allowed until osseus consolidation.

Results

In 5?patients (3?men, 2?women) with a mean age of 34?years (range, 23?C44?years) with symptomatic malunion after clavicular fractures, a corrective osteotomy and elastic stable intramedullary nailing (ESIN) was performed. After 6?months (mean 4.4?months), all osteotomies were healed and the nails were removed. There were no complications. At final follow-up (12?months), the DASH and Constant scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with the appearance of the shoulder girdle and overall outcome.