Mini-Invasive Intramedullary Fixation of Displaced Midshaft Clavicle Fractures with an Elastic Titanium Nail
Authors: Fuglesang Hendrik F.S. , Oksum Mads A. , Wikerøy Annette K.B. 
Published: May 2018

Background:
The treatment of completely displaced midshaft clavicle fractures is still controversial, but surgical treatment provides a shorter recovery period and higher union rates than nonoperative treatment with a sling
1–5
. Even though the literature does not clearly support surgery for these fractures, surgery is becoming more frequent
6
. Elastic stable intramedullary nailing (ESIN) with a titanium nail is a well-documented mini-invasive procedure with functional outcomes comparable with those of plate fixation after 1 year but a high rate of implant removal of up to 80%
6–8
. The ideal injury for ESIN is a fracture without comminution that is available for surgery within a couple of days. ESIN is also a good option for fractures with comminution, but a somewhat slower functional recovery during the first 6 months should be expected.

Description:
The patient is placed in beach-chair position with the fluoroscope placed on the injured side or cranially in relation to the fracture. The surgeon pushes the skin gently with his/her index finger at the jugular fossa before incising it. This places the skin incision inferior to the implant. A 1 to 2-cm incision down to the bone is then placed about 1 to 2 cm lateral to the sternoclavicular joint. A unicortical entry hole is made at the medial end with a 2.5-mm drill bit and then widened and directed laterally with an awl. Two reduction forceps are placed percutaneously and used by the assistant to align the main fragments. The nail is passed with oscillating movements until it is secured into the lateral fragment. If it is not possible to obtain a closed reduction, an open reduction is performed. The nail is cut short down to the bone, and the myocutaneous layer and skin are closed with sutures. Five to 10 mL of bupivacaine is injected into the fracture area for postoperative pain management. The arm is placed in a simple sling for comfort. A non-weight-bearing active range of motion of <90° is encouraged.

Alternatives:
Closed completely displaced midshaft clavicle fractures can be treated operatively or nonoperatively with a sling. Superior plate fixation is well documented, but use of anterior or several mini-fragment plates is also an option. There are several intramedullary implant techniques, but most require an open reduction.

Rationale:
Most intramedullary implant methods are open procedures, whereas closed reduction and internal fixation is possible with ESIN. This ensures preservation of the fracture hematoma and no periosteal stripping, in contrast with the open intramedullary techniques. The nail enters the fracture medially, which decreases the chance of perioperative pulmonary or neurovascular injury. The procedure is less time-consuming than plate fixation, the result is cosmetically superior, and the functional outcomes after 1 year are equal. When ESIN is used for fractures without intermediary fragments, the functional recovery time is equal to that after plate fixation, although it is longer when used for fractures with intermediary fragments
8
.