Limited open reduction and inner fixation with titanium rubber band nails is a safe and minimally invasive surgical procedure for the treatment of move midclavicular fractures in adults and achieves good running results and high patient satisfaction. A mean follow-up of 14.5 months ( range 7–24 molybdenum ) revealed radiographic fracture union in all patients with an average clinical curative time of 2.2 months. Mean immanent pain 3 days after surgery was importantly lower than the day before operating room ( phosphorus < 0.001 ). The mean compass of gesture 3 days after operation was significantly improved compared with the sidereal day before surgery ( p < 0.001 ). The nails were removed in all patients a beggarly of 7.2 months ( range 5.4–9.5 missouri ) after surgery, and no fractures recurred. The mean postoperative DASH score was 2.5 ( range 0.5–8.0 ) and the mean postoperative Constant score was 95.2 ( range 86.5–97.0 ). From February 2005 to February 2007, 41 patients with preempt midclavicular fractures received open reduction and internal fixation with a titanium elastic nail inserted through the sternal goal of the clavicle. We evaluated the ocular analogue scale ( VAS ), the Constant score and the Disabilities of the Arm, Shoulder and Hand ( DASH ) scale to determine outcomes. Midclavicular fractures are common clinically, accounting for about 76 % of all clavicular fractures. holocene studies have revealed a previously unrecognized incidence of nonunion and malunion after bourgeois treatment of more hard midclavicular fractures. Our target was to evaluate the clinical outcomes of midclavicular fractures treated with titanium elastic nails.

Midclavicular fractures are common clinically, accounting for about 76 % of all clavicular fractures. Nondisplaced or minimally displace midclavicular fractures respond well to conservative discussion. 1 however, holocene studies have revealed a previously unrecognized incidence of nonunion and malunion after bourgeois treatment of more dangerous midclavicular fractures. 2 – 4 Hill and colleagues 3 reported that when midclavicular fractures with a cram shorten of more than 2 curium in length were treated conservatively, a 15 % incidence of nonunion could result, and 31 % of the patients would be dissatisfied with their outcomes. Robinson 4 reported a nonunion rate of 21 % in the treatment of displace midclavicular fractures ; thus, he considered substantial fracture supplanting or comminution as gamble factors for delayed coupling or nonunion. nonunion of midclavicular fractures normally leads to shoulder pain, failing and asymmetry, thus compromising function and cosmetic appearance. We herein evaluated the treatment of displace midclavicular fractures using inner fixation with titanium elastic nails ( TENs ). We used SPSS interpretation 10.0 statistical software ( SPSS Inc. ) to perform opposite metric ton tests on the trouble ocular analogue scale and the degree of shoulder mobility. We deemed differences to be statistically meaning at phosphorus < 0.05. The degree of affected role gratification regarding treatment consequence was subjectively obtained by questioning patients during follow-up visits. We evaluated shoulder joint performance, including incision site apathy, red and swell, and obviousness of scars. In addition, we evaluated complications, including TEN migration or breakage, nonunion, symptomatic malunion and infection. The presence of clavicular malunion, defined as postunion shortening as compared with the unmoved side, was determined by radiogram. An experienced professor ( B.Z. ) who was not part of the surgical team performed the result evaluations, including the rendition of radiogram. Shoulder joint performance was evaluated by the surgeons who performed the surgery. We defined radiographic marriage as fade of the fracture line and satisfactory growth of inner and out callus on radiographic examen. We defined clinical fracture healing as absence of tenderness with firm palpation over the fault web site, a full crop of motion and the presence of convention military capability of the amphetamine extremity. We measured immanent pain with a ocular analogue scale ( VAS ) 1 day before and 3 days after surgery. The VAS ranged from 0 ( no pain ) to 100 ( worst pain conceivable ). Patients were asked to mark a item on the scale corresponding to their trouble at that time. We evaluated shoulder motion, including abduction and flexion, 1 day before and 3 days after surgery. We evaluated shoulder serve with constant 6 and Disabilities of the Arm, Shoulder and Hand ( DASH ) 7 scales at concluding follow-up. immediately after operating room, the involve limb was supported with a neck–wrist sling for 4 weeks. The slingshot prevented the arm from drooping and interfering with cram union while allowing passive exercises in the early postoperative time period. Shrugging exercises began 1 day after surgery. When a forearm sling was required to support the affect limb, passive non–weight bearing exercises began immediately after operation and were continued for 2 weeks. The image of shoulder abduction was gradually increased but kept within 90º during the first 3 weeks after operation. General anesthesia or combined brachial plexus–cervical plexus steel block were administered, and the affected role was placed in the beach professorship position. About 1 centimeter lateral to the sternoclavicular joint, a horizontal incision 1 centimeter in length was made along the bloc of the clavicle. According to the width of the medullary cavity, a desirable ten of 2.5–3.0 mm in diameter was selected and inserted into the medullary pit of the clavicle through its sternal end. In most patients, the diameter of the medullary cavity of the clavicle ranged from 2.8 to 3.0 mm, therefore, a 2.5-mm TEN was most normally used. A 2.0-mm TEN was used if the diameter of the medullary cavity of clavicle was smaller, and a 3.0-mm TEN was used if the diameter was larger. At the fracture web site, a curl incision 2 centimeter in length was made perpendicular to the clavicle shaft. The skin flap was retracted, taking care to preserve the branches of supraclavicular nerves. The fracture line was exposed without stripping the periosteum, and the TEN was advanced across the fracture site under management visual image to reduce the fracture. The TEN was further advanced laterally under C-arm radiographic guidance until the complete point reached the acromial end of the clavicle. Nail peak curvature was adjusted to optimize fracture realignment. The TEN was cut at the sternal end, leaving 1.0–1.5 centimeter extending out of the clavicle. The end of the TEN was buried subcutaneously. From February 2005 to February 2007, 41 patients had displaced midclavicular fractures treated by open reduction and home obsession with TENs inserted through the sternal conclusion of the clavicle. We classified the fractures based on the Orthopaedic Trauma Association ( OTA ) classification dodge for midclavicular fractures. 5 Inclusion criteria included displacement of more than 2 centimeter and minimal to slight comminution ; OTA type C fractures were excluded. express open reduction and internal fixation with a TEN was carried out in all cases within 1 week of injury. We obtained written inform accept from all participants, and the study protocol was approved by the ethics review board of Shanghai Sixth People ’ s Hospital. At concluding follow-up, the bastardly shoulder joint Constant score was 95.2 ( SD 1.9, range 86.5–97.0 ) points, and the mean DASH score was 2.5 ( SD 1.6, range 0.5–8.0 ) points. All patients were satisfied with the treatment result except 2 ; 1 felt the incision scar was unpleasant and 1 complained of inconveniences in daily life because of penetration of the nail tip off out of the lateral pass lens cortex until removal. No shoulder asymmetry was observed in this series. At each follow-up visit, patients were asked about any problems that had occurred. Slight numbness at the skin incision occurred in 2 ( 4.8 % ) patients. Skin red and swelling at the nail entrance locate occurred in 8 ( 19.5 % ) patients. One affected role ( 2.4 % ) complained of an obvious scar at the skin incision. The intend VAS score decreased significantly from 15.5 ( SD 2.4 ) the sidereal day before surgery to 7.7 ( SD 1.2 ) by the end of the third base postoperative day (, p < 0.001 ). Preoperatively, average shoulder flexure was 25.1° ( SD 3.4° ) and think of abduction was 23.3° ( SD 1.9º ). Three days after surgery, mean shoulder flexure was 95.1° ( SD 4.6º ) and mean abduction was 88.7° ( SD 3.2º ). Shoulder range of movement 1 sidereal day before surgery and 3 days after operation demonstrated a significant dispute ( and ; both, phosphorus < 0.001 ). Of the 41 patients included in the study, there were 30 men and 11 women with a mean age of 38.3 ( standard deviation [ SD ] 9.0, range 18–60 ) years. patient demographic and clinical data are presented in. Based on the OTA categorization scheme for midclavicular fractures, 5 28 fractures were type A and 13 type B. The mean patient follow-up was 14.5 ( SD 3.7, range 7–24 ) months. Clinical and radiographic healing occurred in all patients with a hateful clinical mend time of 2.2 ( SD 0.3 ) months ( ). No infection, hard wire breakage or migration occurred. The distal end of the TEN penetrated the cortex in 1 patient ; however, function was not hindered. This was a short-run problem without any promote complications or residual deficit. In this patient ’ mho lawsuit, the concluding Constant and DASH scores were 86.5 and 8.0 points, respectively. The nails were removed from all patients after a hateful time period of 7.2 ( range 5.4–9.5 ) months. No refractures after collar removal occurred. Healing in the anatomic place occurred in 38 patients, whereas cram abridge ( as compared radiographically with the unmoved clavicle ) over 5 mm in length was observed in 3 patients. A representative subject is illustrated in.

Discussion

In this study, we found that limited receptive reduction and internal arrested development with TENs in the treatment of midclavicular fractures in adults resulted in a high fracture healing rate, rapid functional convalescence and minimal complications. The procedure is minimally invasive and achieve gamey affected role atonement. several options are available for the surgical treatment of clavicle cheat fractures, including plating and nail. Plating is the most normally use surgical treatment ; however, plating requires relatively extensive periosteal strip, which may increase destruction of the blood supply at the fracture site, frankincense hindering fracture curative. Stress shielding produced by inflexible plates can lead to an 8 % refracture pace after plate removal. 8, 9 surgical time is considerable, and infection rates of up to 18 % have been reported. 8 – 11 additionally, the relatively long scratch can be a cosmetic issue in some patients, and some individuals experience discomfort induced by the plate underneath the skin. arrested development with TENs, though a newer remedy method acting, provides fixation that is more coherent with the physiologic bone structure to permit early functional exercise, leads to faster functional recovery, provides early pain relief and avoids the complications associated with longer operating time and periosteal denude. anatomically, the clavicle has an irregular S human body. Titanium elastic nails, manufactured from titanium alloy, are elastic enough to match the form of the medullary pit and strong adequate to stabilize the break up ends. Their crook topple facilitates pinpoint passage within the medullary cavity and allows it to be anchored to the distal cerebral cortex and equip tightly to the inner wall of the cavity, therefore improving fixation stability. When placed, each breeze through provides 3 points for patronize within the medullary canal to efficaciously control rotation, angulation and shorten of the fragments. Titanium rubber band nails were initially designed for the discussion of diaphyseal and metaphyseal fractures of long bones in children. In 1996, they were used to treat displace midclavicular fractures in 12 professional athletes, all of whom returned to trail and competition after a bastardly menstruation of 16.8 days. 12 Jubel and colleagues 13 reported lone 1 case of nonunion in a series of 62 midclavicular fractures treated with TENs with average follow-up of 3.5 years, and the mean postoperative Constant grade was 95.2 points. Mueller and colleagues 14 used TENs to treat 32 displace midclavicular fractures. In that series, with follow-up ranging from 1 to 5 years, nonunion was not observed ; however, 12 clavicles healed with a abridge of more than 5 millimeter. The nails were removed in 29 patients a median of 6 ( range 1.3–15.0 ) months postoperatively, and no refracture occurred after TEN removal. The beggarly Constant score was 95.2 ( SD 1.9 ) points and the mean DASH score was 5.0 ( SD 2.3 ) points. other studies have shown similar cocksure results with TENs for the treatment of clavicular fractures, 15, 16 though some authors point out that the procedure is technically demand, and child complications can be encountered in the postoperative phase. 17 Our study, with a mean follow-up of 14.5 months, revealed union in all 41 patients. Except for 1 patients in whom the distal TEN pierced through the bone lens cortex, there were no other complications after TEN removal, and the concluding beggarly Constant and DASH scores were 95.2 and 2.5 points, respectively. We observed local skin annoyance in early patients of this series when the medial end of the TEN was bent upwards with its tip off located immediately beneath the skin. This complication ceased to occur when nail end management was improved by bending it laterally. It should be noted that TENs are alone indicated in OTA type A and B midclavicular fractures. They are not suited for osteoporotic or/and comminuted fractures in which fixation with a TEN will not obtain 3-point support. The sharp-pointed end of the TEN may easily penetrate the cortical bone in osteoporotic patients, resulting in the TEN slither and thus making the arrested development fluid. In grind fractures, patronize from the center point is not present, which may lead to mentally ill fixation, shortening and malunion. To perform the procedure correctly, several technical points should be considered .

  1. The diameter of the TEN should be correctly determined before placement to allow facilitate of interpolation and prevent potential breakage during early postoperative functional exercises. A ten that is excessively thickly will dam-age the medullary canal, and one that is excessively narrow will not provide adequate stability .
  2. The TEN should be inserted from the median end of the clavicle laterally because the sternal end has a wide medullary cavity. however, the interpolation point should not be located excessively medial, or sternoclavicular joint routine may be affected .
  3. The TEN should be long adequate to reach the lateral pass end of the clavicle for better anchor of its tip and to leave 1.0–1.5 centimeter extending out of the medial clavicle to facilitate tail bending and clip, eliminating skin annoyance.
  4. A second incision is necessity in patients with hearty translation where closed decrease is not potential. Without arrant reduction, the TEN can not be inserted .
  5. The stallion interpolation process of the TEN should be carried out under C-arm radiographic steering .

Limitations

There are some limitations of the learn that should be considered. The number of patients included was relatively humble and nonrandomized, and there was no comparison or control group. We interpreted our results in comparison with those of the studies in the literature that used other methods. however, the outcomes achieved with the technique in this study were favorable. many patients recovered completely within 3–6 months after operation, and all patients had complete convalescence by their final follow-up sojourn .

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