No abstract

Intramedullary fixation is used increasingly to treat clavicular fractures. Anatomical variations in the clavicle of relevance to this procedure are analyzed. The length, diameters and curvature of the clavicle were measured in 196 specimens from the dissecting room. The calcium bone density was analyzed in 300 cross-sectional samples of 100 specimens. The thickness of cortical and medullary bone of 70 slices was analyzed from freshly plastinated clavicles with implants in place. The female clavicle was shorter, less curved, and had a lower concentration of calcium than the male clavicle. Measurement of cortical thickness showed a mean value of 1.05 +/- 0.23 mm at the most sternal measuring point, 2.05 +/- 0.29 mm at the midpoint of the clavicle, and 0.95 +/- 0.35 mm at the acromial end. The thinnest regions were the medial ventral cortex and the dorsal acromial cortex. These measurements explain clinical observations on nail perforation. The diameter of the medullary canal measured 6.7 +/- 2.6 mm at its narrowest part, so that reaming (i.e., predrilling the medullary canal) prior to 3.5 mm titanium nail insertion is not necessary. The main difficulties encountered when placing a nail are secondary to the S-curvature of the clavicle. In 80% of fractures, the break is located at the narrowest diameter of the medullary canal. Thus, the clavicle displays definite gender- and side-specific anatomical features in terms of length, diameter, curvature, and calcium concentration. These should be considered when performing intramedullary fixation.

Background: Intramedullary fixation of midclavicular fractures may be a better option than non-operative treatment for high performance/professional athletes because of the potential reduction in recovery time. Objectives: To evaluate the effectiveness of intramedullary fixation in high performance athletes and the time required to return to sporting activity. Methods: Data were taken from a prospective study on intramedullary fixation techniques using the elastic stable Ti nail (TEN, Synthes) for the treatment of displaced midclavicular fractures, initiated in 1996. The patients in 12 cases were classified as high performance/professional athletes. These cases were used to evaluate the technique specifically in this population. Fractures were classified according to the Orthopaedic Trauma Association (OTA) system. Patients were evaluated before and after surgery for shoulder function and subjective pain. After the operation, radiological assessments documented fracture healing, and clinical outcomes scores were obtained. Time required to return to training and competition was documented. Results: All fractures were transverse or oblique. Mean (SD) shoulder abduction increased from 36.3 (8)b efore surgery to 154.2 (17)˚afterwards (p,0.001). Mean subjective pain score using a visual analogue scale (0-100) decreased from 71.7 (18) points before surgery to 19.2 (6) points (p,0.001) three days after. There were no complications. Hospital stay averaged 2.9 (1) days. Mean delay to resumption of training was 5.9 (1) days, and to resumption of competition it was 16.8 (5) days. The mean Constant clinical outcomes score one year after hardware removal was 98.3 (2) points. Conclusions: Intramedullary fixation of displaced midclavicular fracture was successful in terms of clinical outcome and rapid resumption of sporting activities. This treatment should be offered to athletes as an alternative to non-operative treatment.

This prospective study investigated medium-term outcomes for 51 children treated from 1997 to 2001 for displaced diaphyseal forearm fractures with elastic stable intramedullary nailing. Forty-three patients included achieved excellent/good functional results at an average follow-up of 38 months. Four patients required open fracture-manipulation at surgery. Complications included eight cases of soft-tissue irritation at nail-insertion site (three required shortening procedures), two temporary radial nerve branch injuries, four minimal rotational mobility deficits, one 10 degrees elbow extension deficit after splinting, and five small keloid scars. All patients were pain-free, without limitations in activities for daily life or sport/play activities by 12 months after hardware removal. Elastic stable intramedullary nailing is appropriate therapy for these injuries.

Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.