**4. Operative technique**

We have developed an operative technique which exposes the fracture directly, allowing mobilisation of the fractured ends of the midshaft clavicle and preparation of the intramedullary canal of the main shaft elements, which are essentially straight. The lateral end of the clavicle curves anteriorly to become the acromioclavicular joint, thus lateral reaming deliberately perforates the posterior cortex behind the acromio-clavicular joint. A straight guide pin can then be directed posteriorly to allow a percutaneous incision to be made through which the pin can be pushed. The fracture can then be reduced over the pin and advanced medially into the medial fragment. The intramedullary device can be further advanced to achieve reduction and fixation of the fracture akin to similar fixations in other long bones fixed with intramedullary devices, like a midshaft tibia or femoral fracture.

If the fracture is comminuted as in the Xray in **Figure 3**, the butterfly fragments can be carefully pushed to the side maintaining their periosteal soft tissue attachments and (thus their vascularity) and sutured back into place around the reduced fracture. Bone graft can be harvested from the drill bits used to open the medullary canal, which can then be used to primarily bone graft the fracture site, promoting earlier fracture healing. The wound can then be closed in layers, first with muscular sutures and then with dermal and subcuticular dissolvable sutures to re-cover the clavicle.

Elements of the operative technique are illustrated in **Figures 4–11**, and **Figure 12** provides a stepwise diagrammatic representation of the procedure.

A more detailed demonstration video of the procedure can be accessed at Vumedi.com [30].

#### **Figure 3.**

*Plain radiograph of a comminuted midshaft clavicular fracture, shortened and displaced more than 20mm.*

#### **Figure 4.**

*Positioning of patient supine with their head on a donut ring, at the edge of the bed and secured to the table with head strapping. A rolled towel or litre bag of saline placed under scapula aids fracture reduction and arm is positioned on arm board.*

#### **Figure 5.**

*Manipulation of medial and lateral shaft fragments with small fragment bone clamps to allow preparation and ultimate bony reduction.*

**Figure 6.** *Preparation of intramedullary canal with handheld drill bits.*

#### **Figure 7.**

*Preparation of lateral fragment, initially by hand, and ultimately perforation of postero-lateral cortex with power.*
