A comprehensive, integrated study of the clavicle: Its topographical anatomy, biomechanical architecture and function; pathological anatomy of mid-shaft fractures and the decision-making process for a surgical approach when planning an intramedullary impl: Part 8 Ideal approaches to the insertion of an intramedullary implant for fixation of diaphyseal fractures

Gandhi  Harjeet Singh

doi:10.24297/ijct.v26i.9864

Authors

Gandhi Harjeet Singh Hamilton Health Sciences, Ontario

DOI:

https://doi.org/10.24297/ijct.v26i.9864

Keywords:

Clavicle, Mid-diaphyseal fractures, Intramedullary fixation, Antegrade approach, Retrograde approach, Supraclavicular nerves, Biomechanics

Abstract

Highlights: The shape and form of the clavicle is neither S, z nor like the f-musical key, but rather resembles a swan’s neck. Therefore, fractures in its 3/5th and 4/5th sections lend well to an intramedullary implant. The primary function of an intramedullary device is to reduce and realign displaced fragments and hold them in place until there is sufficient stabilizing woven callus.

Stability depends on the length, diameter and interference fit of an intramedullary implant bridging the fracture. The antegrade approach to insert an IM implant is suitable for fractures in the 5/10th and 6/10th sections, and the retrograde approach for the 6/10th and 7/10th sections from the sternal end of the clavicle. There is less than 30 degrees of clavicle rotation under 90 degrees of arm elevation, which is less than 45 degrees of the screw turn or quarter of its pitch, so it can scarcely cause a significant loosening of a threaded implant.

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References

Aira, J. R., Simon, P., Gutiérrez, S., Santoni, B. G., & Frankle, M. A. (2017). Morphometry of the human clavicle and intramedullary canal: A 3D, geometry-based quantification. Journal of Orthopaedic Research, 35(10). https://doi.org/10.1002/jor.23533

Allman, F. L. (1967). Fractures and ligamentous injuries of the clavicle and its articulation. The Journal of Bone and Joint Surgery. American Volume, 49(4). https://doi.org/10.2106/00004623-196749040-00024

Andermahr, J., Jubel, A., Elsner, A., Johann, J., Prokop, A., Rehm, K. E., & Koebke, J. (2007). Anatomy of the clavicle and the intramedullary nailing of midclavicular fractures. Clinical Anatomy, 20(1). https://doi.org/10.1002/ca.20269

Bachoura, A., Deane, A. S., & Kamineni, S. (2012). Clavicle anatomy and the applicability of intramedullary midshaft fracture fixation. Journal of Shoulder and Elbow Surgery, 21(10). https://doi.org/10.1016/j.jse.2011.10.032

Bachoura, A., Deane, A. S., Wise, J. N., & Kamineni, S. (2013). Clavicle morphometry revisited: A 3-dimensional study with relevance to operative fixation. Journal of Shoulder and Elbow Surgery, 22(1), e15–e22. https://doi.org/10.1016/j.jse.2012.01.019

Bernat, A., Huysmans, T., Van Glabbeek, F., Sijbers, J., Gielen, J., & Van Tongel, A. (2014). The anatomy of the clavicle: A Three-dimensional Cadaveric Study. Clinical Anatomy, 27(5). https://doi.org/10.1002/ca.22288

Butcher, C. C., & Atkins, R. M. (2003). (ii) Principles of deformity correction. Current Orthopaedics, 17(6), 418–435. https://doi.org/10.1016/j.cuor.2003.10.001

Chung, H. J., Hong, K. J., & Kim, D. S. (2015). Biomechanical properties of titanium elastic nail applied to a cadaveric clavicle model. Orthopaedics and Traumatology: Surgery and Research, 101(7). https://doi.org/10.1016/j.otsr.2015.06.023

Claes, L. E., Heigele, C. A., Neidlinger-Wilke, C., Kaspar, D., Seidl, W., Margevicius, K. J., & Augat, P. (1998). Effects of mechanical factors on the fracture healing process. Clin Orthop Relat Res, (355 Suppl), S132-47. http://www.ncbi.nlm.nih.gov/pubmed/9917634

Cunningham, B. P., McLaren, A., Richardson, M., & McLemore, R. (2013). Clavicular length: The assumption of symmetry. Orthopedics, 36(3). https://doi.org/10.3928/01477447-20130222-24

Edelson, J. G. (2003). The bony anatomy of clavicular malunions. Journal of Shoulder and Elbow Surgery, 12(2). https://doi.org/10.1067/mse.2003.2

Fuglesang, H. F. S., Flugsrud, G. B., Randsborg, P. H., Oord, P., Benth, J., & Utvåg, S. E. (2017). Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle. Bone and Joint Journal, 99B(8). https://doi.org/10.1302/0301-620X.99B8.BJJ-2016-1318.R1

Gandhi, H. S. (2022a). In-silico patient-specific and patient-appropriate engineering method to judiciously select an ameliorative implant design in a single-patient using finite element-n-of-1 (fe-n-of-1) empirical test analysis to reconstruct mid-sagittal osteochondrotomy of the sternum following cardiac surgery. International Journal of Computer & Technology, (Forthcoming).

Gandhi, H. S. (2022b). Patient-appropriate and patient-specific quantification: Application of biomedical sciences and engineering principles for the amelioration of outcomes following reconstruction of osteochondrotomy of the sternum to access the mediastinum. INTERNATIONAL JOURNAL OF COMPUTERS & TECHNOLOGY, 22, 86–113. https://doi.org/10.24297/ijct.v22i.9229

Guerra, E., Previtali, D., Tamborini, S., Filardo, G., Zaffagnini, S., & Candrian, C. (2019). Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis. The American Journal of Sports Medicine, 47(14), 3541–3551. https://doi.org/10.1177/0363546519826961

Halvachizadeh, S., & Pape, H.-C. (2020). Perren’s Strain Theory and Fracture Healing. In Essential Biomechanics for Orthopedic Trauma (pp. 17–25). Springer International Publishing. https://doi.org/10.1007/978-3-030-36990-3_2

Harnroongroj, T., & Jeerathanyasakun, Y. (2000). Intramedullary pin fixation in clavicular fractures: A study comparing the use of small and large pins. Journal of Orthopaedic Surgery, 8(2). https://doi.org/10.1177/230949900000800203

Harrington, M. A., Keller, T. S., Seiler, J. G., Weikert, D. R., Moeljanto, E., & Schwartz, H. S. (1993). Geometric properties and the predicted mechanical behavior of adult human clavicles. Journal of Biomechanics, 26(4–5). https://doi.org/10.1016/0021-9290(93)90005-Y

Hill, J. M., McGuire, M. H., & Crosby, L. A. (1997). Closed treatment of displaced middle-third fractures of the clavicle gives poor results. The Journal of Bone and Joint Surgery, 79(4), 537–539. https://doi.org/10.1302/0301-620X.79B4.7529

Houwert, R. M., Wijdicks, F. J., Steins Bisschop, C., Verleisdonk, E. J., & Kruyt, M. (2012). Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: A systematic review. In International Orthopaedics (Vol. 36, Number 3). https://doi.org/10.1007/s00264-011-1422-4

Imazato, H., Takahashi, N., Sawaguchi, A., Hirakawa, Y., Yamaguchi, Y., Hiyoshi, M., Tajima, T., & Chosa, E. (2023). Insertion sites of the muscles attached to the clavicle: a cadaveric study of the clavicle. BMC Musculoskeletal Disorders, 24(1). https://doi.org/10.1186/s12891-023-06266-4

Inman, V. T., Saunders, J. B., & Abbott, L. C. (1944). Observations of the function of the shoulder joint. The Journal of Bone and Joint Surgery, 26-A(1), 1–30. https://doi.org/10.1097/00003086-199609000-00002

Ito, K., & Perren, S. (2007). Biology and Biomechanics in Bone Healing. In T. Ruedi, R. Buckley, & C. Moran (Eds.), AO Principles of Fracture Management (2nd ed., pp. 9–31). Thieme Verlag.

Jones, G. L., Bishop, J. Y., Lewis, B., Pedroza, A. D., Baumgarten, K., Kuhn, J. E., Cox, C., Wolf, B., Bollier, M., Carey, J. L., McCarty, E. C., Vidal, A. F., Spencer, E. E., Feeley, B., Marx, R. G., Miller, B., Wright, R. W., Brophy, R. H., Smith, M. V., & Abboud, J. (2014). Intraobserver and interobserver agreement in the classification and treatment of midshaft clavicle fractures. American Journal of Sports Medicine, 42(5). https://doi.org/10.1177/0363546514523926

Jubel, A., Andermahr, J., Bergmann, H., Prokop, A., & Rehm, K. E. (2003). Elastic stable intramedullary nailing of midclavicular fractures in athletes. British Journal of Sports Medicine, 37(6). https://doi.org/10.1136/bjsm.37.6.480

Kapandji, I. A. (2005). The physiology of the joints. Volume 1, Upper Limb. In British Journal of Surgery (Vol. 57, Number 8).

Kaur H, & Sahni H. (2002). Length And Curves Of The Clavicle In Northwest Indians’. J Anat. Soc. India, 51(2), 199209.

King, P. R., Ikram, A., Eken, M. M., & Lamberts, R. P. (2019). The Effectiveness of a Flexible Locked Intramedullary Nail and an Anatomically Contoured Locked Plate to Treat Clavicular Shaft Fractures: A 1-Year Randomized Control Trial. Journal of Bone and Joint Surgery - American Volume, 101(7). https://doi.org/10.2106/JBJS.18.00660

King, P. R., Scheepers, S., & Ikram, A. (2014). Anatomy of the clavicle and its medullary canal: A computed tomography study. European Journal of Orthopaedic Surgery and Traumatology, 24(1). https://doi.org/10.1007/s00590-012-1130-9

Kretek, C. (2007). Intramedullary Nailing. In T. Ruedi, R. Buckley, & C. Moran (Eds.), AO Principles of Fracture Management (2nd ed., p. 257284). Thieme Verlag.

Kunkle, B. F., DesJardins, J. D., Campbell, J. R., Eichinger, J. K., Kissenberth, M. J., Shaw, K. A., Tokish, J. M., & Parada, S. A. (2021). Biomechanical evaluation of an intramedullary clavicle screw in simple oblique and butterfly wedge fractures. Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, 235(11). https://doi.org/10.1177/09544119211031052

Lambert, S., Al-Hadithy, N., Sewell, M. D., Hertel, R., Südkamp, N., Noser, H., & Kamer, L. (2016). Computerized tomography based 3D modeling of the clavicle. Journal of Orthopaedic Research, 34(7). https://doi.org/10.1002/jor.23145

Lenza, M., Buchbinder, R., Johnston, R. V., Ferrari, B. A. S., & Faloppa, F. (2019). Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. In Cochrane Database of Systematic Reviews (Vol. 2019, Number 1). https://doi.org/10.1002/14651858.CD009363.pub3

Li, L., Yang, X., Xing, F., Jiang, J., & Tang, X. (2020). Plate fixation versus intramedullary nail or Knowles pin fixation for displaced midshaft clavicle fractures: A meta-analysis of randomized controlled trials. Medicine, 99(39). https://doi.org/10.1097/MD.0000000000022284

Ludewig, P. M., Phadke, V., Braman, J. P., Hassett, D. R., Cieminski, C. J., & Laprade, R. F. (2009). Motion of the shoulder complex during multiplanar humeral elevation. Journal of Bone and Joint Surgery, 91(2). https://doi.org/10.2106/JBJS.G.01483

Luo, C. F. (2004). Reference axes for reconstruction of the knee. In Knee (Vol. 11, Number 4). https://doi.org/10.1016/j.knee.2004.03.003

Nordqvist, A., & Petersson, C. (1994). The incidence of fractures of the clavicle. Clinical Orthopaedics and Related Research, (300), 127–132.

Nordqvist, A., Petersson, C. J., & Redlund-Johnell, I. (1998). Mid-clavicle Fractures in Adults: End Result Study after Conservative Treatment. Journal of Orthopaedic Trauma, 12(8). https://doi.org/10.1097/00005131-199811000-00008

Paley, Dror. (2003). Principles of deformity correction. Springer.

Perren, S. M. (1991). Basic Aspects of Internal Fixation. In Manual of INTERNAL FIXATION (pp. 1–158). Springer Berlin Heidelberg. https://doi.org/10.1007/978-3-662-02695-3_1

Perren, S. M. (2002). Evolution of the internal fixation of long bone fractures: The scientific basis of biological internal fixation: choosing a new balance between stability and biology. The Journal of Bone and Joint Surgery. https://doi.org/10.1302/0301-620x.84b8.13752

Porteus, M., Sudkamp, N., & Schatzkar, J. (2007). Preoperative Planning. In T. Ruedi, R. Buckley, & C. Moran (Eds.), Ao Principles of Fracture Management (2nd ed., pp. 155--162). Thieme Verlag.

Proubasta, I. R., Itarte, J. P., Lamas, C. G., & Cáceres, E. (2004). Midshaft clavicular non-unions treated with the Herbert cannulated bone screw. Journal of Orthopaedic Surgery (Hong Kong), 12(1). https://doi.org/10.1177/230949900401200113

Qiu, X. S., Wang, X. B., Zhang, Y., Zhu, Y. C., Guo, X., & Chen, Y. X. (2016). Anatomical study of the clavicles in a Chinese population. BioMed Research International, 2016. https://doi.org/10.1155/2016/6219761

Richardson, M., Asadollahi, S., & Richardson, L. (2013). Management of acute displaced midshaft clavicular fractures using Herbert cannulated screw: Technique and results in 114 patients. Saeed Asadollahi,1 and Louise Richardson, 7(2), 52–58.

Robinson, C. M. (1998). Fractures of the clavicle in the adult: Epidemiology and Classification. The Journal of Bone and Joint Surgery, 80(3). https://doi.org/10.1302/0301-620x.80b3.8079

Robinson, C. M., Court-Brown, C. M., McQueen, M. M., & Wakefield, A. E. (2004). Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. Journal of Bone and Joint Surgery, 86(7). https://doi.org/10.2106/00004623-200407000-00002

Rowe, C. R. (1968). An atlas of anatomy and treatment of midclavicular fractures. Clinical Orthopaedics and Related Research, 58. https://doi.org/10.1097/00003086-196805000-00006

Ryf, C., & Araf, J. (2007). Postoperative Management: Geberal Considerations. In T. Ruedi, R. Buckley, & C. Moran (Eds.), AO Principles of Fracture Management (2nd ed., pp. 447–467). Thieme Verlag.

Sinha, A., Edwin, J., Sreeharsha, B., Bhalaik, V., & Brownson, P. (2011). A radiological study to define safe zones for drilling during plating of clavicle fractures. Journal of Bone and Joint Surgery - Series B, 93 B(9). https://doi.org/10.1302/0301-620X.93B9.25739

Stanley, D., Trowbridge, E. A., & Norris, S. H. (1988). The mechanism of clavicular fracture. A clinical and biomechanical analysis. Journal of Bone and Joint Surgery - Series B, 70(3). https://doi.org/10.1302/0301-620x.70b3.3372571

Thomas, A., & Round, J. (2023). Basic principles of lower limb deformity correction. Surgery (Oxford), 41(4), 255–261. https://doi.org/10.1016/j.mpsur.2023.02.015

Volgas DA, & Harder, Y. (2007). Surgical Approches: Principles of Soft-tissue Management. In T. Ruedi, Buckley RF, & Moran CG (Eds.), AO Principles of Fracture Management (2nd ed., pp. 189–197). Thieme Verlag.

Walters, J., Solomons, S., & Roche, S. (2010). A morphometric study of the clavicle. South African Orthopaedic Journal, 9(3).

Yan, M. Z., Yuen, W. S., Yeung, S. C., Wing-Yin, C. W., Wong, S. C. Y., Si-Qi, W. W., Tian, E., Rashed, S., Yung, C. S. Y., & Fang, C. X. (2022). Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials. In PLoS ONE (Vol. 17, Number 4 April). https://doi.org/10.1371/journal.pone.0267861