Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures

Abstract

Background: Nonoperative management of midshaft clavicle fractures (MSCFs) is standard; however, it is now generally accepted that displaced midshaft clavicle fractures benefit from internal fixation. Plating and intramedullary fixation have become the accepted methods of fixation. The purpose of this study was to see if one method of fixation of clavicle fractures has a lower complication rate and higher union rate than the other.

Materials and methods: Between December 2003 and September 2008, 38 patients were treated randomly by either plating (plate group) or retrograde nailing (RTEN group). Primary outcome measures included functional Constant scores, radiological union rate and union time. Clinical and radiological assessments were performed at the 6th week and the 3rd, 6th and 12th month postoperatively. Secondary outcome measures included the perioperative data (mean surgery time, blood loss, wound size, and hospital stay), and the complication rates.

Results: Similar results were found between the two groups regarding functional and radiological outcome after the 12th week (P > 0.05). However, earlier union and functional recovery were obtained at the 6th week for the RTEN group (P < 0.05). The rate of complications was significantly higher (15.8%) in the plate group compared with the RTEN group (0%; P > 0.05). In the plate group, significantly higher values were obtained for the perioperative data (P < 0.001).

Conclusion: Both techniques are equally effective at treating displaced midclavicular fractures, and give better function and fewer complications than nonoperative treatment. The RTEN technique has more advantages and lower complications than plating, making its use more favorable. It is recommended for athletes and young active individuals, and can be used as an alternative to conservative treatment or plate fixation.

Fig. 1

The principle of the open retrograde TEN fixation technique. a Top view of a right shoulder shows that the medial fragment is held away from the fracture by bone forceps, and drilling is aimed obliquely at its anterior cortex. b The common diameters of the titanium elastic nails that are suitable for clavicle fixation are, from top to bottom, 2, 2.5, and 3 mm. c Insertion of the nail through the reamed canal until it is out of the anterior cortex. The nail is withdrawn from its back end until the curved tip is lying flush to the fracture surface. d The fracture is then reduced and the nail is pushed inside the medullary canal of the lateral fragment

Fig. 2

Operative photos of the RTEN technique. a A small incision is made over the fracture site (black arrowhead). The medial fragment is grasped with bone forceps and lifted up in the wound. The medullary canal is reamed with a drill bit with a diameter similar to the nail (usually a 2.5 mm bit is required). When the drill bit has penetrated the anterior cortex and is felt under the skin, a tiny incision is made over it. b A nail is inserted through the medullary canal and allowed to come out through the small medial incision. c The fracture is reduced and the nail is pushed inside the lateral fragment under fluoroscopic control. d Bending of the tip of the nail before wound closure

Fig. 3

Plate fixation technique. The plate is contoured in an S-shape manner to fit the clavicle curvature. A k-wire (black arrowhead) can be used for temporary fracture fixation until a lag screw (white arrowhead) is inserted away from the plate in the oblique fracture. While drilling the screws through the plate holes, a drill stopper (white arrow) is used to avoid injury to neurovascular structures

Fig. 4

Radiological assessment of surgically treated groups. a A preoperative X-ray of a 33 year old heavy manual laborer in the RTEN group. b Immediate postoperative anteroposterior radiograph showing good alignment. c Follow-up radiograph at the 3rd month at 45° cephalic tilt showing complete bone consolidation. d A preoperative radiograph of a 40 year old heavy manual laborer with a displaced midshaft clavicular fracture with some comminution (patient was in the plate group). e Immediate postoperative anteroposterior radiograph showing good alignment. f Follow-up radiograph with complete bone union at 6 months