**2.2 Titanium elastic nails (TENs)**

TENS were originally developed to manage paediatric long bone fractures without causing damage to the epiphyses and have been used to manage midshaft clavicular fractures, with one benefit being a MIPO approach that minimises surgical scars [9]. The inability to manage the implant's length and rotation are potential drawbacks of this method. This restricts their application to more simple configurations, such as transverse or short oblique fractures with minimal comminution [10]. Significant radiation from the C-arm is required to handle the implant with an image intensifier (fluoroscopy), exposing both patient and operators to increased radiation exposure. Additionally, Jubel et al. [11] reported a 15 mm loss of length in the post-operative period following comminuted fracture fixation. Frigg et al. [12] reported a complication rate of 70% and 36% revision rate, using this approach. In this group 44% of the fractures were comminuted. Randomised controlled trials comparing TENs to plate fixation [13, 14] showed high union rates (96–100%) but also significant complication rates (over 60%).
