An Improved Clavicle Pin

BEN F. PERRY, M.D., Leesburg, Florida

S INCE the introduction of intramedullary fixation of clavicular fractures by Murray

[1] in 1940, various modifications have been made with regard to pin type. At the present time various wire and pin Variations, threaded, unthreaded, and part ly threaded, are in wide use since the method of intramedullary fixation has been so uniformly accepted.

The complication of migration of these pins, sometimes into dangerous locations such as the mediastinum, pleural cavity, and-lung, and into the spinal canal deserves careful attention [24]. Another difficulty presents itself to the patient when the pin tip beneath the skin of the shoulder breaks through and begins to extrude.

With an understanding of these problems after clavicle pinning, I designed a simple pin which has thus far been notable as to the ab- sence of untoward problems in the postopera- tive period. (Fig. 1.)

I t was thought that a properly pinned clavicle should be a usable clavicle within a relatively short period after surgery in the sense that the patient should be able to go

Fro. 1. T h e clavicle pin i l lus t ra ted is 1~ illch in d i ame t e r wi th a t rocar poin t ; t h e eyelet precise ly a c c o m m o d a t e s a s t a n d a r d bone screw. Also i l lus t ra ted is a B a b y L ane c l amp for e levat ion of t he p rox ima l f r a g m e n t and a Lewin c lamp which is s l ipped a b o u t t he dis ta l f r a g m e n t to allow elevat ion. T h e use of t he se i n s t r u m e n t s grea t ly faci l i ta tes dri l l ing of t h e channe l for t he pin.

about all but heavy work with minimal diffi- culty. On the other hand, the surgeon should be assured that the situation is stable enough to allow such activity. Accordingly, three points were emphasized in approaching the problem: (1) two cortex fixation was adopted to allow the fracture to maintain full contact; (2) posi- tive prevention of migration was achieved by a single screw fixation through the eyelet in the pin; (3) simple office removal under local anesthesia was achieved by using the eyelet for traction.

TECHNIC

The incision is made along the clavicle from a point just distal to the sternoclavicular joint and carried laterally to the fracture site. If identified, supraclavicular nerve branches are retracted, and spotty hypesthesia encoun- tered thus far has been insignificant. After visualization of the fracture site and blunt dis- section with a dull periosteal elevator, the proximal frag~nent is lifted from the wound us- ing a Baby Lane clamp. The intramedullary canal is reamed out to form a channel for the pin; we prefer to use a 1/~ inch drill point for the 3/~ 2 inch pin, and a 9/~¢ inch drill point for the 1/4 inch pin. The drill point emerges on the an- terior cortex of the proximal fragment, and the point of emergence may be m a r k e d with a mosquito hemostat since a minimum of soft tissue stripping is advised. Attention i s then turned to the major distal fragment which is elevated easily by slipping a Lewin clamp about it. The channel here is reamed out with the drill point directed obliquely backwards so that it will emerge from the posterior cortex. This point is extremely important, and the surgeon should palpate the drill point and later the pin as it emerges from the posterior cortex. In one of our cases the pin was not identified by palpation, and operating room films seemed to

142 American Journal of Surgery

I m p r o v e d Clavic le P in 143

indicate good placement. However, insertion of the screw caused distraetion of the fracture, and it soon became apparent that the pin was completely intramedullary in position. In this one case the screw was removed in the office ten days postoperatively, and the fracture promptly "fell together" with uneventful even- tual union. The proper pin is selected after the reaming has been completed and is cut off at an estimated proper length. I t is manually directed into the proximal fragment on its an- terior surface and finally tapped in entirely us- ing a small Rush ® pin driver. At this point the fracture should be entirely stable, and the sur- geon should proceed as outlined to palpate the pin tip to ascertain clinically as well as by roentgenogram tha t the pin is neither too long nor too short. If too long, it is a simple ma t t e r indeed to back out the pin upwards through the eyelet using a small bone hook inserted from below. A gentle rotary motion delivers the pin easily, and it may be cut off to the appro- priate length and reinserted.

A 7/~ 4 inch drill hole is placed through the anterior cortex of the proximal fragment, using the eyelet hole as a guide for the drill point. Initially, we pierced both cortices and used a dull periosteal elevator behind the clavicle to protect the subclavian vessels; recently, we have used the anterior cortex only with a a~ or 1/~ inch standard coarse thread Woodruff screw, and this has proved entirely adequate.

FIO. 2. Demonstration on a plastic shoulder girdle illustrating final placement of the eyelet clavicle pin. The tip of the pin penetrates the posterior cortex of the distal fragment.

Furaein ® powder is then sprinkled along the clavicle and a routine closure performed with running No, 2-0 chromic and interrupted and running No. 2-0 dermal sutures. Oleandomyein intravenously (500 mg. in 500 cc. of 5 per cent dextrose in distilled water) is given initially during surgery.

3 4 b

FIG. 3. This elderly female patient had extremely comminuted fractures of both clavicles and was treated by the method described herein. Union of the right clavicle was followed by removal of the pin at four months, and union of the left clavicle occurred uneventfully also with removal of the pin at eight months.

FIG. 4. A nonunion was evident in this case at two months after fracture. At surgery the ends of the fragments were covered with dense adhesions, and the intramedullary canals were sealed over entirely by bone and scar.

Fro. 5. Treatment of the nonunion consisted of freshening of the bone ends, drilling of the intramedullary canals for pin placement, and the use of heterogenous BOPLANT cancellous graKs. Union has proceeded uneventfully with free use of the shoulder.

17ol. 112, Ju ly 1966

144 P e r r y

The patient is placed in an arm sling and after several days with ice packs on the opera- tive area is usually ready for discharge, A plastic skeleton demonstration of a pin in situ at the conclusion of the procedure indicates the degree of positive fixation. (Fig, 2.)

CASE BXAMPLES

CASE I. The seventy-eight year old woman had fractures of both clavicles which were extremely comminuted, and open reduction and insertion of pins were performed as outlined herein. (Fig. 3.) The right clavicle healed rapidly and the pin was removed at four months. The left clavicle was slower in uniting, and the patient returned for a few months to another part of the country, later, she returned with full union and more at our insistence than hers the pin was removed eight months after surgery. She had had no complaints, and the only deformity noted prior to removal of the pin was the obvious presence of the screw head in its subcu- taneous position.

CASB II. The forty-six year old man in this instance was referred with a nonunion at two months after fracture. (Fig. 4.) This fracture was pinned using the method noted, and in addition cancellous BOPLANT ® graftswere used at the fracture site after freshening of the clavicular fragments. Fixation was stable (Fig. 5) and the patient was discharged with the knowledge that his tendency to overuse the arm would not interfere with union.

REMOVAL OF THE PIN

Office removal of the pin using 2 per cent Carbocaine ® anesthesia has been carried out with no difficulty whatsoever. There is no problem either in locating the eyelet and screw or in extraction. After infiltration of 2 to 3 co. of Carbocaine, a 1/~ inch incision is made over the screw head and by sharp and blunt dissec- tion carried down to the screw. A small self-

retaining finger retractor is inserted for proper visualization. The screw is then backed out and removed, and the eyelet is visualized. The small bone hook we have used has the hook thinned down slightly and flattened so that it may be passed upwards into the eyelet from below. A rotary motion on the bone hook or gentle tapping with a hammer backs out the pin.

SUMMARY AND CONCLUSIONS

1. A simple clavicle pin is described. I t trans- fixes the cortex of the clavicle in both proximal and distal fragments, allowing contact and rapid union. No migration of the pin is possible, allowing for early usage of the shoulder for all light activities.

2. The necessity of ascertaining posterior ,penetration of the distal fragment is em- phasized to prevent distraction of the frag- ments.

3. The use of several available instruments is recommended, specifically the Baby Lane forceps, the Lewin clamp, and a thinned out bone hook for removal of the pin. We have found these to be of great help in simplifying the procedure described.

REFI~RGNCES

1. MURRAY, O. A method of fixation for fracture of the clavicle. J. Bone & Joint Surg., 22: 616, 1940.

2. KRI~MEIVS, V. and GLAUSER, F. Unusual sequela fol- lowing pinning of medial clavicular fracture. Am. J. Roentgenol., 76: 1066, 1956.

3. 1VfAZET, R., JR. Migration of Kirsehner wire from the shoulder region into the lung: report of two cases. J. Bone & Joint Surg., 25: 477, 1943.

4. ~,~ORRI~LL, H., JR. and LLEWELLYN, R. C. Migration of a threaded Steinmann pin from an acromio- clavicular joint into the spinal canal. A case re- port. J. Bone & Joint Surg., 47A: 1024, 1965.

American Journal of Surgery