Published: 2016-12-29

Evaluation of minimally invasive fixation with ESIN in the management of displaced mid-shaft clavicle fractures: a case series with minimum of 2 years follow-up

Sourabh Chachan, Biswajit Sahu


Background: Over the last few years, operative treatment has become the standard for treatment of clavicle fractures. Both plating and intra-medullary pinning techniques are available for treating clavicle fractures. The aim of the study was to evaluate the role of minimally invasive technique using elastic stable intramedullary nailing (ESIN) in surgical treatment of displaced mid-shaft clavicle fractures.

Methods: It is a prospective case series study conducted at the Department of Orthopaedics of a tertiary care centre. 44 cases of acute displaced mid-shaft clavicle fractures with a mean age of 32.7 years were treated by intramedullary pinning with titanium elastic stable nails and were followed-up for a mean period of 30.6 months(range= 24-40 months). Functional outcomes were evaluated by using Constant Shoulder score. The results obtained were analysed using student’s t-test.

Results: Union was achieved in all except one case which showed delayed union. 7 cases were complicated by telescoping (incidence= 15.9%) and 6 out of these 7 cases also had medial nail protrusion (incidence= 13.6%) simultaneously. 9 cases had shortening of less than 1cm and 2 had shortening of more than 1cm.  No other complication was reported from any of the case. Mean constant shoulder scores improved from 15 to 85.6 (p value <0.001) after 12 months from surgery. However, no further improvement was seen after 12 months of surgery, with no statistical difference (p value= 0.789) between the mean scores at 12 (85.6) and 24 (85.7) months.

Conclusions: ESIN offers the advantages of treating displaced mid-shaft clavicle fractures with minimal incision and decreased surgery time with minimal intra-operative blood loss. The results were excellent in terms of functional outcomes. The complication rates were low and return to normal activity was quiet fast. ESIN is a minimally invasive technique with good cosmetic and functional results. This method should be seen as an alternative to plate fixation and non-operative treatment.


Clavicle shaft fracture, Elastic stable intramedullary nail (ESIN), Constant shoulder score

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Robinson CM. Fractures of clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80:476–84.

Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle fractures in adults: End result study after conservative treatment. J Orthop Trauma. 1998;12:572–6.

Golish SR, Oliviero JA, Francke EI, et al. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg. 2008;3:28.

McKee MD. Optimal treatment of displaced midshaft fractures of the clavicle. Philidelphia: Saunders; 2009: 126-132.

Drosdowech DS, Manwell SE, Ferreira LM, Goel DP, Faber KJ, Johnson JA. Biomechanical analysis of middle third fractures of the clavicle. J Orthop Trauma. 2011;25:39–43.

Renfree T, Conrad B, Wright T. Biomechanical comparison of contemporary clavicle fixation devices. J Hand Surg Am. 2010;35:639–44.

Bostman O, Manninen M, Pihlajamaki H. Complications of plate fixation in fresh displaced midclavicular fractures. J Trauma. 1997;43:778-83.

Boehme D, Curtis RJ, DeHaan JT, Kay SP, Young DC, Rockwood CA Jr. Nonunion of fractures of the midshaft of the clavicle. Treatment with a modified Haigie intramedullary pin and autogenous bonegrafting. J Bone Joint Surg Am. 1991;73:1219-26.

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 Br 1998;80:106-8.

Grassi FA, Tajana MS, D'Angelo F. Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma. 2001;50:1096-100.

Millett PJ, Hurst JM, Horan MP, Hawkins RJ. Complications of clavicle fractures treated with intramedullary fixation. J Shoulder Elbow Surg. 2011;20:86–91.

Jubel A, Andermahr J, Schiffer G, Tsironis K, Rehm KE. Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail. ClinOrthopRelat Res. 2003;408:279-85.

Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of clavicle gives poor results. J Bone Joint Surg Br. 1997;79:537–9.

Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: A prospective study of 222 patients. Acta Orthopaedica. 2005;76:496–502.

Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaftclavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89:1–10.

Ali Khan MA, Lucas HK. Plating of fractures of the middle third of the clavicle. Injury. 1978;9:263-7.

Shen WJ, Liu TJ, Shen YS. Plate fixation of fresh displaced midshaft clavicle fractures. Injury. 1999;30:497–500.

Kloen P, Sorkin AT, Rubel IF, Helfet DL. Anteroinferior plating of midshaft clavicular nonunions. J Orthop Trauma. 2002;16:425-30.

Verborgt O, Pittoors K, Van Glabbeek F, Declercq G, Nuyts R, Somville J. Plate fixation of middle-third clavicle fractures in the semi-professional athlete. Acta Orthop Belg. 2005;71:17–21.

Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Evidence-Based Orthopaedic Trauma Working Group. 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.