Flexible intramedullary nail

Intramedullary nailing of the clavicle is reserved for young and highly active patients who are expected to resume full active function soon after surgery.

It is also a procedure best reserved for bending- and fragmented-wedge fractures in the middle zone of the clavicle

For technical reasons, other fracture patterns are not suitable for nailing.

This procedure is performed only under image intensifier guidance.

The goal of treatment for these types of fractures of the shaft of the clavicle is to achieve as anatomical reduction as possible and then splint them with intramedullary fixation. The shape of the nail and the shape of the bone maintain alignment and rotation. Shortening is prevented by bone contact.

Implant migration and damage to nearby neurovascular structures are potential complications that can be encountered. However, it is a minimally invasive approach that requires less soft tissue dissection, preserves blood supply and biology to improve healing.

Stiff pins or thick K-wires should be avoided as the limited diameter of the intramedullary canal of the clavicle and its curved anatomy presents inherent difficulties during insertion and stabilization of the fracture. Thus, the procedure described will be with a flexible titanium intramedullary nail.

This procedure is normally performed with the patient either in a beach chair or a supine position.

For this procedure a nailing approach is used.

For intramedullary nailing of clavicular fractures, the following reduction techniques are useful:

Shoulder manipulation with inline traction and an external rotation moment often helps to reduce the fracture. (The shoulder should be draped free.)

Pointed reduction clamps can be used either percutaneously or through small stab incisions.

If a closed reduction cannot be achieved, a small incision directly over the fracture site to perform a limited open reduction is helpful and often necessary.

Using image intensifier, the entry point is obtained using a 2.5 mm drill bit in the anterior cortex of the medial clavicle 1.5-2.0 cm lateral to the sternoclavicular joint.

The entry point is enlarged with a small awl in a lateral direction to allow for ease of insertion.

A 2.0 - 3.5 mm titanium elastic nail designed for intramedullary nailing, used for this or other applications, is inserted then with the aid of the universal T-handle chuck. The nail is manually inserted with oscillating movements under image intensifier control and advanced to the fracture site. If significant resistance is encountered, reassess the position of the nail to redirect and complete the passage of the nail.

The tip of the nail has a slight curve, which will assist its passage into the lateral fragment.

The tip of the nail is advanced as far lateral as possible without perforating the cortex.

The medial end of the nail is then cut and buried subcutaneously or slightly proud depending on surgeon preference.

A threaded end cap may be used and inserted over the medial end of the nail to prevent backing out of the nail.

Hardware removal is only indicated if the nail is prominent and threatening or irritating the overlaying soft tissue at the entry point or perforating the far cortex.

Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.

Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.

Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.

Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.

The patient should sleep wearing the sling on his/her back or on the non-injured side.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.

It may be more comfortable sleeping in a sitting or semi reclined position.

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The phases of nonoperative treatment are thus:

• Temporary immobilization
• Passive/assisted range of motion
• Active range of motion
• Progressive resistance exercises

Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.

This is followed by gentle range of motion exercises.

Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.

Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.

After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:

• Straightening and flexion of the elbow
• Open and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion
• Movement of an open hand from side to side

• Squeezing the shoulder blades together, while shoulders remain relaxed

Pendular exercises can be started when pain starts to subside.

Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.

Activated assisted range of motion exercises are started with:

• External rotation
• Internal rotation

• Flexion with arms on table
• Flexion with ball on wall

Sub-maximal isometric exercises with:

• Internal rotation
• External rotation (1)
• Abduction (2)
• Extension

Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.

Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.

Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.

If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.