Surgical treatment of midshaft clavicular fractures using intramedullary nail
Authors:
Martin Vlček; M. Niedoba; J. Jakubička; J. Pech; J. Kalvach
Authors‘ workplace:
Ortopedická klinika 1. LF Univerzity Karlovy a FN v Motole
Published in:
Rozhl. Chir., 2018, roč. 97, č. 4, s. 176-188.
Category:
Original articles
Overview
Introduction:
The aim of our study was to assess treatment outcomes in fractures of the middle part of the clavicle using an intramedullary nail.
Methods:
We have evaluated a total of 58 patients with a clavicle bone fracture stabilized by the Hofer Clavicula Pin implant (HCP, Hofer GmbH & Co KG, Fürstenfeld, Germany). A static implant was used in 43 cases, and a dynamic implant was used in the remaining 15. The mean age of patients was 39.1 years (range 18−71, SD 4.4), the male-to-female ratio being 43:15. The right collarbone was broken in 26 patients, the left one in 32. The average time between accident and surgery was 10.2 days (range 2–19, SD 4.4). The set included 24 two-, 14 three- and 20 four-fragment fractures of the clavicle midshaft. Open reduction was used in all the cases. The implant was introduced by the indirect method: first, insertion of the pin from the fracture antegrade into the lateral fragment took place, then it was inserted retrogradely into the medial fragment.
Results:
The average patient follow-up was 7.1 months (range 6−23, SD 5.5). X-ray signs of healing were evident in all cases, with healing occurring at 8.4 weeks on average (range 6−20, SD 4.1). In one case (1.7%), however, healing did not occur – refracture was diagnosed 18 days following pin extraction with no clear mechanism of injury; two more refractures were caused by a new accident. The apex of the pin was broken in four cases (6.9%). In two cases (3.4%), angulation of the pin occurred; however, full fracture healing was satisfactorily achieved. Pin prominence was observed in a total of 23 cases (39.7%), requiring premature extraction of the implant due to perforation or irritation of skin and pain in 13 (22.4%) cases. 10 cases (17.2%) of prominence were asymptomatic. Six cases with skin perforation by the implant developed clinical signs of infection, wound healing was always achieved after extraction of the pin and application of antibiotics. A very good functional finding in the shoulder joint was observed in 57 patients (98.2%). The DASH score reached an average of 8.1 points (range 0.8–30.8, SD 4.4). Constant score was 93.1 (range 42.8–98.1, SD 3.2).
Conclusion:
Intramedullary stabilization of two-, three- and four-fragment fractures of the middle part of the clavicle using the Hofer Clavicula Pin provides very good stability during healing and leads to good healing of fractures. The complications of the method are soft tissue irritation or even skin perforation in the region of the lateral end of the implant. Preventive insertion of the pin closer to the bone may prevent such complications, but also result in difficult pin extraction.
Key words:
fractures – clavicle – osteosynthesis – intramedullary − complications
Sources
1. Knĕzek J. Zlomeniny klíční kosti – operovat nebo ne? Acta Chir Orthop Traumatol Cech 1988;55:365−71.
2. Grassi FA, Tajana MS, D’Angelo F. Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma 2001;50:1096−100.
3. Donnelly TD, Macfarlane RJ, Nagy MT, et al. Fractures of the clavicle: an overview. Open Orthop J 2013;7:329−33.
4. Narsaria N, Singh AK, Arun GR, et al. Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating. J Orthop Traumatol 2014;15:165−71.
5. Sang QH, Gou ZG, Zheng HY, et al. The treatment of mid-shaft clavicle fractures. Chin Med J (Engl) 2015;128:2946−51.
6. Ban I, Nowak J, Virtanen K, et al. Overtreatment of displaced midshaft clavicle fractures. Acta Orthop 2016;87:541−5.
7. Robinson CM, Goudie EB, Murray IR, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013; 95:1576–84.
8. Košťál Z. Nestandardní léčba zlomeniny klíční kosti (kazuistika). Rehabil Fyz Lék 2004;1:40−4.
9. Murray IR, Foster CJ, Eros A, et al. Risk factors for nonunion after nonoperative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg Am 2013;95:1153–8.
10. Golish SR, Oliviero JA, Francke EI, et al. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res 2008;3:28.
11. Celestre P, Roberston C, Mahar A, et al. Biomechanical evaluation of clavicle fracture plating techniques: Does a locking plate provide improved stability? J Orthop Trauma 2008;22:241–7.
12. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1−10.
13. Gilde AK, Jones CB, Sietsema DL, et al. Does plate type influence the clinical outcomes and implant removal in midclavicular fractures fixed with 2.7-mm anteroinferior plates? A retrospective cohort study. J Orthop Surg Res 2014;9:11–7.
14. Wendsche P, Veselý R, et al. Traumatologie. Praha, Galén 2015.
15. Žvák I, Brožík J, Kočí J, et al. Traumatologie ve schématech a RTG obrazech. Praha, Grada Publishing 2006.
16. Millett PJ, Hurst JM, Horan MP, et al. Complications of clavicle fractures treated with intramedullary fixation. J Shoulder Elbow Surg 2011;20;86−91.
17. Lu H, Jiang BG. Surgical treatment of internal fixation failure after clavicular fracture operation. Beijing Daxue Xuebao Yixueban 2014,46;766−70.
18. Payne DE, Wray WH, Ruch DS, et al. Outcome of intramedullary fixation of clavicular fractures. Am J Orthop (Belle Mead NJ) 2011;40:E99−E104.
19. Tamaoki MJS, Matsunaga FT, Costa ARFD, et al. Treatment of displaced midshaft clavicle fractures: Figure-of-eight harness versus anterior plate osteosynthesis: A randomized controlled trial. J Bone Joint Surg Am 2017;99:1159−65.
20. Coppa V, Dei Giudici L, Cecconi S, et al. Midshaft clavicle fractures treatment: threaded Kirschner wire versus conservative approach. Strategies Trauma Limb Reconstr 2017;12:141−50.
21. Fuglesang HFS, Flugsrud GB, Randsborg PH, et al. Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle: a prospective randomised controlled trial. Bone Joint J Br 2017;99:1095−101.
22. Liu HH, Chang CH, Chia WT, et al. Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures. J Trauma 2010;69:E82–E87.
23. Jokl M, Vlček M, Streck M, et al. Srovnání operačních léčebných metod zlomenin klíční kosti z pohledu počtu komplikací. Úraz chir 2016;24:99−104.
24. Ngarmukos C, Parkpian V, Patradul A. Fixation of fractures of the midshaft of the clavicle with Kirschner wires. Results in 108 patients. J Bone Joint Surg Br 1998;80:106−8.
25. Ackland D, Griggs I, Hislop P, et al. An intramedullary Echidna pin for fixation of comminuted clavicle fractures: a biomechanical study. J Orthop Surg Res 2017;12:122.
26. Zehir S, Zehir R, Şahin E, et al. Comparison of novel intramedullary nailing with mini-invasive plating in surgical fixation of displaced midshaft clavicle fractures. Arch Orthop Trauma Surg 2015;135:339−44.
27. Mudd CD, Quigley KJ, Gross LB. Excessive complications of open intramedullary nailing of midshaft clavicle fractures with the Rockwood Clavicle Pin Clin Orthop Relat Res 2011;469:3364−70.
Labels
Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2018 Issue 4
Most read in this issue
- Surgical treatment of midshaft clavicular fractures using intramedullary nail
- Artificial bowel sphincter ten years later
- Liver surgery for colorectal liver metastases
- Radiotherapy in the treatment of rectal cancer − is it time to move on?