We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management

We are presenting a prospective study of 25 patients with clavicle fracture treated with Rockwood Intramedullary pin fixation. Operative management is required for open fractures, neurovascular injury or compromise, displaced fractures with impending skin compromise and displaced middle third fractures with 20mm or more shortening. Plate osteosynthesis or intramedullary fixation devices are used for operative management. Patients and Methods: 25 patients with clavicle fractures underwent fixation of clavicle fractures with threaded intramedullary Rockwood pin. The indications for internal fixation were persistent wide separation of fracture with interposition of soft tissue in 12, symptomatic non-union in 3, associated multiple injuries in 3,one of them had a floating shoulder, impending open fracture with tented skin in 4 and associated acromioclavicular joint injury in 3 and one of whom had bilateral fracture clavicle.. All patients underwent open reduction through an incision centred over the fracture site along the Langer line. Intramedullary pin was inserted in a retrograde manner. Autologous bone grafting from iliac crest was done in all patients with nonunion. Radiographic and functional assessment conducted using DASH scores. Results: There were 21 male and 4 female patients with a mean age of 34 yrs (range 17 to 64 yrs). Mean follow up was 12 months (range 5 months to 30 months). Radiographic union occurred in all patients within 4 months. In our study the commonest indication for Rockwood pin fixation was displaced middle third clavicle fracture followed by impending open fractures. Commonest complication was skin irritation at the distal end of the pin with formation of a tender bursa occurring in 9 patients, 3 of whom had skin breakdown. Fracture union occurred in all these patients with no further intervention and wounds healed completely after removal of the pin. One patient developed non-union and was later treated with ORIF with DCP and bone-graft. There were no deep infections, pin breakage or migration or re-fractures after pin removal. At the time of last follow up the average DASH score was 25 with a range of 18 to 52. Conclusion: Open reduction and intramedullary fixation of clavicle fractures with Rockwood pin is a safe and effective method of treatment when surgical fixation of displaced or non-union of middle third clavicle fracture is indicated. This technique has an advantage of minimal soft tissue dissection, compression at the fracture site, less risk of migration and ease of removal, along with early return to daily and sports activities

Aims

The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery.

The December 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Long term-changes in hip morphology following osteotomy; Arthrogrypotic wrist contractures are surgically amenable; Paediatric femoral lengthening over a nail; Current management of paediatric supracondylar fractures; MRI perfusion index predictive of Perthes’ progression; Abduction bracing effective in residual acetabular deformity; Hurler syndrome in the spotlight; and the Pavlik works for femoral fractures too!