A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture

Vol 5 | Issue 1 | Jan-April 2019 | page: 23-27 | Niraj Ranjan, Arvind Agarwal, Atul Garg

Author: Niraj Ranjan [1], Arvind Agarwal [1], Atul Garg [1]

[1] Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi

Address of Correspondence
Dr. Niraj Ranjan,
Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi


Introduction: The overall incidence of distal femur fractures is approximately 37 per 100,000 person-years.1 These fractures are either caused by high energy trauma in younger group or low energy falls in elderly population typically older women. As these fractures can lead to long term disability managing them is challenging task. Operative treatment for fracture fixation is recommended for optimal outcome. Although different modes of fracture fixation have evolved in and no single method is uniformly successful. In our study we have compared fixation of distal femur fracture using locking plate and intramedullary nail.
Materials and Methods: Retrospectively collected data of operated distal femur fracture of 60 patients was included. Out of these 30 patients were operated with retrograde distal femoral nail and 30 were operated with locking distal femur plate. Patients were assessed with plain radiographs and CT scan was done for complex and intra articular fractures. AO ( Muller) classification was used to classify the fracture type. Postoperative functional results were evaluated using Schatzker and Lambert critera at 1 year follow up.
Results: Mean age of the patients in the study was 45 yrs. with 73.33 % male and 26.67 % female patients. There were 41 extra articular fractures (type A) while 19 were intrarticular fractures (type C). 22 type A and 8 type C fractures were treated with retrograde nailing while 19 type A fractures and 11 type C fractures were treated with locking plate. In LCP group 28.57% cases had excellent result while 42.86% cases had good result while in retrograde supracondylar nail 13.33% had excellent result and 23.33 % had good result. There were 2 cases of infection, one in each group and 3 cases of malunion, which were managed with nail. Delayed union was encountered in 3 patients, two of them were managed with LCP.
Conclusion: Open reduction and internal fixation of distal femur has achieved excellent to good functional results with locking plate construct in all types of fractures while retrograde supracondylar nail can achieve comparable results when used in simple extraarticular fractures.For other fractures it is difficult to maintain length, alignment and rotation with retrograde nail.
Keywords: distal femur fracture, Retrograde intramedullary nail, locking distal femur plate, minimally invasive plating technique, Schatzker and Lambert criteria.


1. Neer C. Fractures of the clavicle. In: Rockwood CA Jr., Green DP, editors. Fractures in Adults. 2nd ed. Philadelphia, PA: Lippincott; 1984. p. 707-13.
2. Lenza M, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev 2015;5:CD007428.
3. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4:107-12.
4. Crenshaw AH. Fractures of the shoulder girdle, arm and forearm. In: Crenshaw AH, editor. Campbell’s Operative Orthopedics. 8th ed. St Louis: Mosby; 1992. p. 989-1053.
5. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11.
6. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
7. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD, Evidence-Based Orthopaedic Trauma Working Group. et al. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the evidence-based orthopaedic trauma working group. J Orthop Trauma 2005;19:504-7.
8. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9.
9. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: A prospective study of 222 patients. Acta Orthop 2005;76:496-502.
10. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-65.
11. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85-A:790-7.
12. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.
13. Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev 2009;2:CD007121.
14. 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;89:1-0.
15. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004;13:479-86.
16. Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, 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.
17. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead NJ) 2009;38:341-5.
18. Smekal V, Irenberger A, Attal RE, Oberladstaetter J, Krappinger D, Kralinger F, et al. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients. Injury 2011;42:324-9.
19. Böhme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C, et al. Current treatment concepts for mid-shaft fractures of the clavicle results of a prospective multicentre study. Z Orthop Unfall 2011;149:68-76.
20. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: A prospective cohort study. J Orthop Trauma 2011;25:31-8.

How to Cite this article: Ranjan N, Agarwal A, Garg A. A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture. Trauma International Jan – Apr 2019;5(1):23-27

(Abstract)(Full Text HTML)   (Download PDF)

The Screw Intra-medullary Elastic Nail Fixation in fresh Displaced Mid Shaft Clavicle Fractures – Technical note

Vol 2 | Issue 2 | May – Aug 2016 | page:53-55 | Wasudeo Gadegone, Vijayanad Lokhande, Yogesh Salphale

Author: Wasudeo Gadegone [1], Vijayanad Lokhande [1], Yogesh Salphale  [1]

[1] GMC Chandrapur, Maharashtra, India.
[2] Shushrusha Multispecialty hospital, Chandrapur, India.
[3] Smt. Kashibai Navale Medical College and General Hospital, Pune

Address of Correspondence
Dr. W.M. Gadegone.
VivekNagar Mul-Road Chandrapur 442402, Maharashtra, India.


Conservative treatment remains the gold standard in treatment of simple undisplaced midshaft clavicle fractures, but for displaced and comminuted fractures surgical intervention is appropriate especially in young active adults. Surgical stabilisation can be achieved using either a plate or an intramedullary device. One of dreaded complication of intramedullary device in migration of the implant. We have used a screw intramedullary device with screw mechanism at one end which can get hold in the medial cancellous bone, thus preventing chances of migration. This report describes the technique of using the screw intramedullary nail for displace clavicle fracture.
Keywords: clavicle fracture, intramedullary nailing.


Although conservative treatment is the gold standard for clavicle fractures, there may be some issues like shoulder impairement, a bump at the fracture site that is cosmetically unacceptable or nonunions which happen when grossly displaced fractures are treated conservatively. Surgical stabilisation may be additionally indicated in cases with completely displaced fractures (gap of > 20mm), potential skin perforation, shortening of clavicle by more than 20 mm, neurovascular injury, and floating shoulder injury. Plating is an option which is used commonly, but leads to scarring and may need repeat surgery of implant removal. Intrameduallry nailing has been successfully used by few authors but has a complications like nail migration. We are using a screw intrameduallry device (Fig. 1) which anchors to the metaphyseal bone by the wide screw head at the end of the nail. This technicaal note simply describes the technique.


Screw elastic intramedullary nail is available in diameter of 2, 2.5, and 3 mm. The nails are 5-6 cm in length , with screw portion of 10mm length and 4.5mm in diameter. The screw head is of 3.5 mm size where the appropriate screw driver fits (Fig. 1). The nail is made of either steel of titanium and is sufficiently elastic  to bend as it traversed the canal from the point of insertion and resilient enough to spring back in the curvature when finally seated. However it is still rigid enough to withstand the torsional, rotational,  and angulatory forces.]Nail has a bevelled tip at one end and a threaded head positioned at other. This design allows the self-cutting thread to be advanced and screwed in with a 3.5 mm screw driver. The distal beveled end of the nail aids in fracture reduction and helps in engaging in the subchondral area of the bone, thereby imparting stability. The inserter should firmly grasp the nail in order to control rotation, insertion and nail withdrawal. It is best to mount the nail on a T handle while inserting but other devices can also be used (Fig. 2)

Surgical Technique:

Operative procedure is carried out under interscalanae block or general anaesthesia. Affected shoulder is elevated by a bolster so that clavicle becomes more prominent. This position also helps to restore length and increase exposure of the clavicle (Fig. 3). The procedure is performed under fluoroscopic guidance. A one centimeter skin incision is made over medial end of clavicle and a hole is drilled in the anterior cortex with a 3.2 mm drill bit and guide. The insertion point is made approximately 1 cm lateral to the sternoclavicular joint. The entry portal is then enlarged with an awl (Fig.3).

The reaming of canal is done with sequential reamer and then an elastic nail of appropriate diameter and length is inserted in the medullary canal of clavicle with a universal chuck and T-handle (Fig. 4).

With oscillating movements the nail is advanced until it reaches the fracture site. With the help of percutaneously placed towel clips fracture fragments are approximated (Fig. 5). The reduction is checked in image-intensifier and then the nail is advanced through the fracture site till it reaches distal end of clavicle. Generally nail can be negotiated one cm short of acromioclavicular joint. If closed reduction is unsuccessful, an additional skin incision is made at fracture site for open reduction of the fragments (Fig. 5).

Although clavicle is S shaped, tip of the nail is curved which helps the surgeon to pass the elastic nail into distal fragment. After adequate engagement of the distal fragment, the medial end of screw nail is screwed in the metaphyseal region of the medial end of clavicle and skin closed over it (Fig. 6).

Postoperatively arm pouch sling is given for three weeks. Gentle pendulum exercises of the shoulder are allowed as per pain tolerance immediately after surgery.  We tend to limit extreme overhead activities for 3-6 weeks. At four to six weeks, active assisted range of motion in all planes was allowed. When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to twelve weeks, Isometric and isotonic exercises were prescribed for shoulder girdle muscles with return to full activities (including sports) at three months (Fig. 7).


Percutaneous elastic screw intramedullary nailing of the clavicle is a safe, reliable method for fixation of displaced midshaft clavicle fractures. It is less invasive and allows rapid healing by callus formation. Complication rates are low, with better functional and cosmetic results.

How to Cite this article: Gadegone W, Lokhande V, Salphale Y. The Screw Intra-medullary Elastic  Nail  Fixation in fresh Displaced Mid Shaft Clavicle Fractures – Technical note. Trauma International May – Aug 2016;2(2):53-55.

(Abstract)      (Full Text HTML)      (Download PDF)