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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 86-89

Is intramedullary K-wire fixation still indicated in treatment midshaft clavicle fractures without comminution?


Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission15-Nov-2018
Date of Acceptance11-Apr-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Medhat Tawfik Maaty
Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_43_18

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  Abstract 


Background: Middle third clavicle fractures consist of up to 85% of clavicle fractures. Intramedullary (IM) fixation devices can be accomplished with less soft tissue dissection, more cosmetic incisions, and they may permit callus formation due to the relative stability with a different complication profile from plate fixation. Patients and Methods: Between July 2013 and November 2015, 25 patients presented by fracture midshaft clavicle without comminution were treated at our institution by minimal invasive retrograde IM k-wires. Results: The fractures union ranged from 12 to 16 weeks both clinically and radiologically. The results were excellent in 21 patients (84%) and good in 3 patients (12%). One (4%) had a poor result. All patients returned to their preinjury activities and jobs or sports activities. Conclusions: Surgical treatment of midshaft clavicle fracture without comminution through minimal invasive retrograde IM k-wire fixation improved the results and compared favorably with other techniques.

Keywords: Clavicle fracture, k-wire, midshaft, minimal invasive


How to cite this article:
Maaty MT. Is intramedullary K-wire fixation still indicated in treatment midshaft clavicle fractures without comminution?. J Orthop Traumatol Rehabil 2021;13:86-9

How to cite this URL:
Maaty MT. Is intramedullary K-wire fixation still indicated in treatment midshaft clavicle fractures without comminution?. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 May 17];13:86-9. Available from: https://www.jotr.in/text.asp?2021/13/2/86/333562




  Introduction Top


Fracture of the clavicle is a frequently seen injury which represents about 10%–15% of all fractures in adults.[1] Midshaft fractures consist of up to 85% of these fractures.[2] Standard treatment for this fracture pattern is nonoperative, using an arm sling or figure-of-eight bandage for external fixation.[3] Recent studies have found higher rates of delayed union, nonunion, shoulder pain, and shoulder weakness, and residual pain with nonoperative treatment.[4] More recent data indicate a decrease in clavicle nonunion and improved functional improvement and cosmesis of the shoulder girdle after operative fixation.[5] Operative management of clavicular fractures includes external fixation, intramedullary (IM) fixation, and osteosynthesis with a plate and screws.[6] IM fixation devices can be accomplished with less soft tissue dissection, more cosmetic incisions, and they may permit callus formation due to the relative stability with a different complication profile from plate fixation.[7],[8],[9],[10]

The aim of this study is to evaluate the results of treatment midshaft clavicle fracture without comminution through miniopen retrograde IM k-wire fixation.


  Patients and Methods Top


Between July 2013 and November 2015, 25 patients presented by fracture midshaft clavicle without comminution were treated at our institution by minimal invasive retrograde IM k-wires. The study was done under the local ethical committee. Furthermore, informed consent was obtained from all participants. The patients were selected after a thorough history and full clinical examination of the affected shoulder. Radiographic evaluation of the clavicle included anteroposterior views and 45° cephalic tilt views. In this study, 18 patients (72%) were male and 7 patients (28%) were female. The right side was injured in 20 patients, the left side in 5 patients and the dominant arm in 15 patients. All patients were employed or active and 5 patients had sports activities. The injury resulted from a fall on their shoulders in 13 patients, sports activity in 6 patients, and road traffic accident in6 patients. The mean age of patients was 36 years (range: 22–61 years). The indications for surgery include the need for earlier functional mobilization in the patient with an isolated injury, shortening of over 15 mm[8] and axial malalignment of over 30 with no cortical bone contact.[11] Patients were excluded if they had fractures with marked comminution, duration of >4 weeks, open fractures, preexistent morbidity of the ipsilateral arm, shoulder or hand, presence of neurovascular injury, and ipsilateral injuries.

Surgical technique

After general anesthesia, the patients are positioned at the beach-chair position. A minimal skin incision was done directly at fracture site for direct manipulation of the main fragments, the subcutaneous dissection was done and the fracture bone ends were exposed. K-wires of different diameters varying from 2 to 3.5 mm, were used and introduced retrograde at distal fragment to pierce the skin. Then, the fracture was reduced to its anatomic position and the k-wire was introduced to the medial fragment as far as possible under image intensifier. The soft tissue was repaired very well to add stability [Figure 1]. A shoulder sling was prescribed for all patients for 6 weeks, after 3 weeks the patients were allowed to use their operated limp for passive activities. The shoulder flexion and abduction movement beyond 90 degrees were prohibited until 6–8 weeks. The k-wires were removed after bone healing. The complications were recorded. Nonunion if unsuccessful bone healing of the bone after 6 months, superficial infection, Deep infection if the infection requiring k-wire removal. Refracture is a fracture of the clavicle within 3 months of implant removal without any history of retrauma. The follow-up visits, all patients were evaluated clinically at 1st, 2nd, 4th, 6th, 12th, 18th months, and last follow-up to assess outcomes of fracture fixation like fracture union time, union rate, shoulder, and arm function. Shoulder function was evaluated according to the ConstantMurley Shoulder Score. During follow-up, the patients were evaluated for pain, range of motion, and patient satisfaction.[12]
Figure 1: Intraoperative photo

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  Results Top


The minimum follow-up time after surgery was 18 months. It ranged from 18 to 27 months, with an average of 23 months. There were no intraoperative complications. The immediate postoperative radiograph showed an anatomical reduction of the clavicle in all patients. Also, postoperatively there was neither deep infection nor tender scar. In the early follow-up, 3 obese patients gained a superficial pin tract infection which resolved with local wound care and a short course of antibiotics. At the final follow-up we observed 8 cases (32%) presented by a minor displacement <3 mm of the distal clavicle which was observed on the final X-ray and none of these cases were symptomatic or complicated by nonunion. One implant failure (4%) (P = 0.41) occurred within 3 months of the primary surgical procedure which underwent open reduction and plating plus autogenous bone grafting in this case finally resulted in the good bone union. The remaining 16 patients (64%) showed anatomical reduction and fully united fracture on the final radiograph [Figure 2]. The fractures union ranged from 12 to 16 weeks both clinically and radiologically. Fatal complications like implant migration into the chest cavity have not been observed. No cases of malunion or shortening of the clavicle were observed. No cases of refracture were observed after k-wire removal. Although the elevations above the shoulder level were not allowed for the first 6–8 weeks, after a short period and early range of motion exercises, patients could elevate and abduct their shoulder >90° within 3 months postoperative. At final follow-up, all patients were pain-free with a full range of motion except in 3 patients (12%) who had slight limitation in the abduction and all of them were satisfied with the postoperative shoulder function. The average Constant score was 95.3 points ranged 85–100. The results were excellent in 21 patients (84%) and good in 3 patients (12%). One patient (4%) had a poor result and underwent plating and bone graft. All patients returned to their preinjury activities and jobs or sports activities.
Figure 2: Final X-ray

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  Discussion Top


There is a controversy in the treatment strategy for displaced midshaft clavicle fractures which remains a topic of debate. Conservative management remains the mainstay in treatment for these fractures. Studies have showed 5% nonunion rate and a poorer outcome in cases of displaced midshaft clavicle fractures that were treated conservatively[13],[14],[15] operative treatment included three types of fixation

for middle-third clavicle fractures: plates and screws, IM devices, and external fixators. The IM fixation included Steinman pins, k-wires, Knowles pins, Hagie pins, Rush pins and cannulated screws.[16],[17],[18]

Open reduction and plate fixation provides immediate rigid stabilization, pain relief, facilitates the early mobilizations and the return to preinjury activities. plate fixation associated with greater risk of injury to underlying neurovascular structures and subsequent prominence of the plate may necessitate its removal.[8],[19],[20] Other complications related to plate fixation are infection, implant failure, hypertrophic or dehiscence scars, implant loosening and nonunion.[21],[22] The complication rate in plate fixation was reported in 34% and a re-operation rate of 18% (most for hardware removal), in our series we encountered complications in one (10%) case of implant failure and nonunion and reoperation for plate fixation and bone graft.[23]

For patients with a high demand on shoulder function. The minimally invasive procedure is an alternative to nonoperative management and meet the patients' expectations which provides restoration of the clavicular length combined with early resumption of training, complete functional recovery, and a good cosmetic result. In our study, there is a significant difference between k-wires and plate fixation in the amount of blood loss, length of operation, and skin breakdown which are fewer in k-wire fixation [Figure 3]. Liu et al. in their study concluded that there is no difference between pins and plate fixation in the clinical and functional results of the two methods in the treatment of midshaft clavicular fractures.[24] Lee et al., in their study comparing the results of Knowles pin and plate fixation in 88 patients with midshaft clavicular fractures, treated 56 patients by Knowles pin and 32 patients by plate and he finally concluded that if the surgery of midshaft clavicular fractures is indicated, fixation with a Knowles pin is more advantageous than plate fixation.[25] In our study, the average constant score was 95.3 points ranged 85–100. The results were excellent in 21 patients (84%) and good in 3 patients (12%). One patient (4%) had a poor result and underwent plating and bone graft. All patients returned to their preinjury activities and jobs or sports activities. In our study, the success of k-wire technique is due to a good selection of the fracture site in midshaft which increase the length of bone contact with k-wires and the absence of comminution which provide fracture stability also due to good purchase of k-wire in the clavicle as the k-wires was introduced IM up to the medial end of the clavicle and regular follow-up and also for good soft tissue repair. No injury to supraclavicular nerves and there is good preservation of soft tissue envelop which encourages good blood supply and encourage good bone healing.
Figure 3: Clinical photo

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  Conclusions Top


Surgical treatment of fracture midshaft clavicle without comminution through minimal invasive retrograde IM k-wire fixation improved the results and compared favorably with other more invasive techniques. Furthermore, it is a relatively short, simple procedure, safe and it is not associated with serious complications.

Ethical standards

This study was approved by the local ethical committee all patients gave their informed consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Klonz A, Hockertz T, Reilmann H. Clavicular fractures. Unfallchirurg 2001;104:70-80.  Back to cited text no. 1
    
2.
Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg 2002;11:452-6.  Back to cited text no. 2
    
3.
Schwarz N, Leixnering M. Failures of clavicular intramedullary wire fixation and their causes. Aktuelle Traumatol 1984;14:159-63.  Back to cited text no. 3
    
4.
Mouzopoulos G, Morakis E, Stamatakos M, Tzurbakis M. Complications associated with clavicular fracture. Orthop Nurs 2009;28:217-24.  Back to cited text no. 4
    
5.
McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85:790-7.  Back to cited text no. 5
    
6.
Schuind F, Pay-Pay E, Andrianne Y, Donkerwolcke M, Rasquin C, Burny F. External fixation of the clavicle for fracture or non-union in adults. J Bone Joint Surg Am 1988;70:692-5.  Back to cited text no. 6
    
7.
Preston CF, Egol KA. Midshaft clavicle fractures in adults. Bull NYU Hosp Jt Dis 2009;67:52-7.  Back to cited text no. 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.  Back to cited text no. 8
    
9.
Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: A meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2011;20:1008-15.  Back to cited text no. 9
    
10.
Millett PJ, Hurst JM, Horan MP, Hawkins RJ. Complications of clavicle fractures treated with intramedullary fixation. J Shoulder Elbow Surg 2011;20:86-91.  Back to cited text no. 10
    
11.
Assobhi JE. Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures. J Orthop Traumatol 2011;12:185-92.  Back to cited text no. 11
    
12.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.  Back to cited text no. 12
    
13.
Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;31:353-8.  Back to cited text no. 13
    
14.
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 2004;86:1359-65.  Back to cited text no. 14
    
15.
Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg 2006;88:35-40.  Back to cited text no. 15
    
16.
Kyle RF, Schmidt. Open reduction and internal fixation of fractures and nonunions. In: Thompson RC, editor. The Shoulder. New York: Raven Press; 1995. p 183.  Back to cited text no. 16
    
17.
Neviaser RJ, Neviaser JS, Neviaser TJ. A simple technique for internal fixation of the clavicle: A long-term evaluation. Clin Orthop 1975;109:103.  Back to cited text no. 17
    
18.
Ngarmukos C, Parkpian V, Patradul A. Fixation of fractures of the midshaft of the clavicle with Kirschner wires: Results in 108 patients. J Bone Joint Surg 1998;80B: 106.  Back to cited text no. 18
    
19.
Mullaji AB, Jupiter JB. Low-contact dynamic compression plating of the clavicle. Injury 1994;25:41-5.  Back to cited text no. 19
    
20.
Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate location and selection on the stability of midshaft clavicle osteotomies: A biomechanical study. J Shoulder Elbow Surg 2002;11:457-62.  Back to cited text no. 20
    
21.
Poigenfürst J, Rappold G, Fischer W. Platng of fresh clavicular fractures: Results of 122 operatons. Injury 1992;23:237-41.  Back to cited text no. 21
    
22.
Freeland A. Unstable adult midclavicular fracture. Orthopedics 1990;13:1279-81.  Back to cited text no. 22
    
23.
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;89:1-10.  Back to cited text no. 23
    
24.
Liu HH, Chang CH, Chia WT, Chen CH, Tarng YW, Wong CY. Comparison of plates versus intramedullary nails for fxation of displaced midshaft clavicular fractures. J Trauma 2010;69:E82-7.  Back to cited text no. 24
    
25.
Lee YS, Huang HL, Lo TY, Hsieh YF, Huang CR. Surgical treatment of midclavicular fractures: A prospective comparison of Knowles pinning and plate fxation. Int Orthop (SICOT) 2008;32:541-5.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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