Medial clavicle fractures often involve the rupture of sternoclavicular surface and/or ligament, which is an unstable fracture [15]. Non-surgical treatment is difficult to obtain anatomical reduction with delayed healing and high nonunion rate, although without anesthetic risk, osteomyelitis, vascular nerve injury and other surgical complications [16]. Therefore, surgical treatment should be performed as soon as possible if the general condition of the patient allowed for surgery. The purposes of operation aim to dissect and reduce the fracture, prevent shortening deformity, avoid deformity healing, and strengthen and fix the fracture firmly. It does not affect the activity of the sternoclavicular joint and the functional exercise of the early shoulder joint. As described previously, the traditional fixation methods have a high failure rate and many complications in the treatment of the medial clavicle fractures. And, what kind of internal fixation method is perfect for medial clavicle fixation is still a major problem.
The advantages of double-plate fixation technique in the successful treatment of distal clavicle Neer II B fractures have been confirmed, which can effectively improve the fixation effect [10, 11]. In this research, we chose two 2.4/2.7 mm locking compression plates to vertically fix medial clavicle fracture with 4—6 slender screw locking plates. This double-plate fixation system possesses several advantages. I. Double-plate fixation could provide sufficient fixation, and small fracture fragments have better gripe. This vertical arranged plate and screws system could ensure the stable fixation of the medial clavicle end; II. Double row screws pressurized fixation in different directions could make sure more secure fixation. This theory has been verified by the biomechanical study that the opposing force of the screw in the front of the medial clavicle is the lateral shear force load, which could reduce the axial strength and stress shielding effect [17]; III. seven patients were over 50 years old is this study, and no patients turnout bone nonunion and plate fixation failure, indicating a reliable fixation even for patients with osteoporosis; IV. The sternoclavicular joint is not involved in the screw fixation, and the activity of the sternoclavicular joint is not affected, so the shoulder joint function exercise could be started in the early postoperative period.
Besides effectively reducing the internal fixation failure, the double-plate technology could also provide anatomical reduction and exhibited excellent bone healing with an average healing time for 3.6 months with minimal complications, such as plate breakage, slight restriction, and pain during overhead work. Stable fixation also provided favorable conditions for early functional exercise. The Constant Murley score of treated shoulder and contralateral shoulder was similar at the last follow-up. Rowe score and ASES score also indicate good recovery of the shoulder function.
The attentions of using double-plate technique for the treatment of the medial clavicle fractures should be noted: I. Avoid to cut and separate too much soft tissues in case of sternoclavicular joint dislocation and affecting the medial clavicle stability; II. For patients with osteoporosis, the operative action should be gentle and attention should be payed to avoid further crushing of the fracture; III. Anatomical reduction should be achieved, especially for the fracture in the sternoclavicular joint, to prevent the loss of clavicle length and the rotational deformity; IV. The plate combinations should be selected according to the distance between the fracture and the sternoclavicular joint as well as the fracture type: a straight or two-hole row plate could be used for upper fracture fixation, and a three-hole L-shaped plate or a T-shaped plate could be used for front fracture fixation. V. The plates should be pre-shaped according to the shape of the clavicle to make sure better attachment to the clavicle. VI. At least 3 screws, usually 4—6 screws, should be used for fixing the medial clavicle fracture with rafting technique.
Limitations
This is a relatively new technique with small number of cases involved. Meanwhile, there is the theoretically possibility of damaging the nerves and blood vessels behind the clavicle. Hence, our research needs to be confirmed by a larger randomized controlled study including preoperative assessment and conservatively treated control group.