[Elastic stable intramedullary nailing after corrective osteotomy of symptomatic malunited midshaft clavicular fractures]

V Smekal, R Attal, C Dallapozza, D Krappinger
Operative Orthopädie und Traumatologie 2011, 23 (5): 375-84

OBJECTIVE: To restore alignment and length of the clavicle, to relieve typical symptoms of malunion, and to improve functional outcome and aesthetic results.

INDICATIONS: Symptomatic malunion after clavicular fractures, including local pain and tenderness, weakness and rapid fatigability of the shoulder girdle muscles, impairment of overhead mobility, numbness, parasthesia, and pain of the arm and fingers during overhead movements due to brachial plexus irritation (thoracic outlet syndrome), and dissatisfaction with the appearance of the shoulder girdle.

CONTRAINDICATIONS: Atrophic nonunions, osteoporosis, asymptomatic malunion.

SURGICAL TECHNIQUE: A 5-cm skin incision is made above the deformity of the malunited clavicle. The osteotomy plane is determined under fluoroscopic guidance, within the callus separating the two original main fracture fragments. Under fluoroscopic guidance, the medullary canal is reopened on both sides with a 2.7 mm drill bit. Afterwards a 1.5 cm skin incision is made just above the sternal end of the clavicle. The anterior cortex is drilled and a titanium nail (diameter 2.5 mm) is introduced. Under rotational movement, the nail is advanced to the osteotomy site. The nail is inserted into the lateral fragment. Then the inserted nail is cut back as far as possible on the medial entry point. Wound closure.

POSTOPERATIVE MANAGEMENT: No immobilization, movement not restricted. Patients are encouraged to use the arm in daily activities. Heavy weight bearing is not allowed until osseus consolidation.

RESULTS: In 5 patients (3 men, 2 women) with a mean age of 34 years (range, 23-44 years) with symptomatic malunion after clavicular fractures, a corrective osteotomy and elastic stable intramedullary nailing (ESIN) was performed. After 6 months (mean 4.4 months), all osteotomies were healed and the nails were removed. There were no complications. At final follow-up (12 months), the DASH and Constant scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with the appearance of the shoulder girdle and overall outcome.

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