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. 2025 Apr 7;15:11870. doi: 10.1038/s41598-025-95975-y

Limitations in rotational correction: 3D displacement analysis of midshaft clavicle fractures with titanium elastic nails

Junwei Zhang 1, Weizhi Nie 1, Hongzheng Bi 1, Jinyong Hou 1, Zhaohui Li 1, Zhenyuan Ma 1, Laibao Duan 1, Lingling Chen 1, Peng Zhang 2, Hongjiang Jiang 3,✉
PMCID: PMC11976972  PMID: 40195423

Abstract

To investigate the three-dimensional displacement of midshaft clavicular fractures after closed reduction and fixation with titanium elastic intramedullary nails. From January 2019 to January 2023, 74 patients with midshaft clavicle fractures (classified according to the AO/OTA system as groups A, B, and C) underwent closed reduction and titanium elastic nail fixation. Preoperative bilateral clavicular CT data and postoperative CT data of the affected clavicle were recorded and processed using Mimics software. Clavicle length, clavicle shortening, separation, and rotational displacement along the X/Y/Z axes were measured and recorded. Within-group comparisons showed a significant reduction in clavicle shortening and separation displacements, with a notable restoration of clavicle length postoperatively (p < 0.05). Except for Z-axis rotational displacement in Group A, no significant differences were observed in clavicle rotational displacement along the X/Y/Z axes between preoperative and postoperative measurements (p > 0.05). Between-group comparisons showed that preoperative separation displacement was significantly associated with AO/OTA classification (H = 6.427, p = 0.040), while no significant differences were observed in other displacements between preoperative and postoperative measurements across groups. Titanium elastic intramedullary nails effectively restore clavicular length and correct shortening and separation displacement in midshaft fractures, but do not significantly improve rotational displacement along the X/Y/Z axes.

Keywords: Clavicular fracture, Elastic intramedullary nailing, Three-dimensional displacement

Subject terms: Medical research, Translational research

Introduction

Clavicle fractures are common fractures in orthopaedics. They account for approximately 5–10% of all fractures1,2, with midshaft clavicular fractures (MCFs) being the most common. Traditional treatment has predominantly involved conservative approaches, including figure-of-eight bandages and forearm sling fixation. However, there is increasing evidence showing that surgical treatment for such fractures with significant displacement can achieve better clinical results, so the trend of surgical treatment is increasing year by year3. Current surgical options include open reduction with plate fixation and minimally invasive intramedullary fixation, such as Kirschner wires, Push pins, titanium elastic nails, and hollow screws. The titanium elastic intramedullary nails (TENs) are commonly used intramedullary fixation devices with the advantages of being minimally invasive, improving the appearance, and shortening the healing time of the fracture, particularly when used for closed reduction with internal fixation. However, the effectiveness of TENs in improving the three-dimensional spatial displacement of MCFs remains unclear, especially when closed reduction is performed.

Therefore, the aim of the present study was to evaluate the improvement in three-dimensional spatial displacement of fractures following TEN fixation by conducting preoperative and postoperative CT scans and utilizing Mimics software for three-dimensional modeling and analysis.

Materials and methods

This study was approved by the Ethics Committee of Wendeng Orthopaedic Hospital, Shandong Province (NO. LL20190212). and followed the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants before conducting the study.

Inclusion and exclusion criteria

The inclusion criteria were as follows: ① presence of MCF; ② upright X-ray showing shortening ≥ 20 mm or displacement ≥ one diameter of the clavicle fracture; ③ within 14 days after injury; ④ MCF treatment with closed reduction with TEN fixation. The exclusion criteria were as follows: ① age ≤ 16 years; ② concurrent subclavian vascular or nerve injury; ③ poor patient compliance; ④ treatment with open reduction after failed closed reduction.

Patient data

From January 2019 to January 2023, a total of 74 patients meeting the inclusion criteria were treated surgically at Wendeng Orthopaedic Hospital in Shandong Province. Preoperative bilateral clavicle CT scans were performed, followed by closed reduction with TEN fixation and postoperative CT scans of the affected side. Patients were categorized into three groups according to the AO/OTA classification system: Group A (simple midshaft clavicle fractures), Group B (wedge-shaped midshaft clavicle fractures), and Group C (comminuted midshaft clavicle fractures). The CT scanning position was the supine position. General patient data are shown in Table 1.

Table 1.

General patient data.

Total number 74
Gender(cases)
 Male 47
 Female 27
Affected side(cases)
 Left 36
 Right 38
Age (years) 50.93 ± 11.71 (23–77)
Surgical method(cases)
 Closed reduction with antegrade fixation 13
 Closed reduction with retrograde fixation 61
AO/OTA classification (cases)
 A Simple shaft fracture 8
 B Wedge-shaped shaft fracture 27
 C Comminuted shaft fracture 39
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Surgical procedure

The patients were anaesthetised using brachial plexus block or general anaesthesia, positioned in the beach chair position.

Closed reduction and antegrade internal fixation: A hole was made in the expanded end of the proximal clavicle, and a 2–2.5-mm TEN (Synthes GmbH, Oberdorf, Switzerland) was inserted into the proximal medullary cavity of the clavicle. After reducing the fracture, the TEN was pushed until its head entered the distal medullary cavity of the clavicle.

Closed reduction and retrograde internal fixation: The lateral segment of the clavicle was clamped using a modified reduction clamp and lifted to a subcutaneous position. A Kirschner wire with a diameter between 2.0 and 2.5 mm was inserted into the medullary cavity of the lateral fragment. Then, we penetrated the posterolateral cortex of the lateral fragment using the Kirschner wire, and a same-side TEN was used to replace the original Kirschner wire. After repositioning the fracture, the TEN was driven from the distal medullary cavity of the clavicle into the proximal medullary cavity to complete the fixation.

The choice of the surgical plan was determined by the lead surgeon based on the type of fracture and intraoperative conditions.

Measurement of Parameters2.4.1 image reconstruction

The patients’ CT data, including preoperative data of the affected and healthy sides, as well as postoperative data of the affected side, were reconstructed using an image processing program (Mimics Research 19, Materialise, Louvain, Belgique).

Establishment of coordinate axes

To be closer to the clinical reality, the original patient’s supine position CT data’s X/Y/Z axes were adopted as the coordinate axes for this study (Fig. 1).

Fig. 1.

Fig. 1

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The original CT data’s X/Y/Z axes used as the study’s coordinate axes. (a) The X and Y axes, and the XY plane (close to the anatomical coronal plane). (b) The X and Z axes, and the XZ plane (close to the anatomical transverse plane) (c) The Y and Z axes, and the YZ plane (close to the anatomical sagittal plane) (d) The X, Y, and Z axes, and the XY, XZ, and YZ planes.

Simulated repositioning

The healthy-side clavicle was inverted, and the preoperative three-dimensional model of the clavicle was surface-matched to the proximal end of the healthy-side clavicle using the global registration command in the Mimics software and then manually fine-tuned so that the two proximal ends of the clavicles completely overlapped. Using the healthy-side clavicle as a template, the fracture was repositioned progressively from the proximal end to the distal end (Fig. 2). The simulated resetting process was performed by two attending orthopaedic surgeons of the group, who were trained through the anatomical model of the clavicle before the study. If there was a controversy in the resetting, the decision was made by a higher level orthopaedic surgeon. Attention was paid to the anatomical resetting markers of the breaks as well as the alignment of the bony spines during the resetting process, so that the reset could be as precise as possible.

Fig. 2.

Fig. 2

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Simulated Repositioning. (a) Inversion of the healthy side and complete overlap of the clavicle’s medial ends. (b) During repositioning, from the proximal to the distal end of the clavicle fracture. (c) After simulated repositioning.

Parameter measurement

After repositioning, the preoperative three-dimensional clavicle model was overlapped completely with the postoperative and simulated repositioned models using the same method. Measurements of various parameters were performed as follows: ① Clavicle Length: In the three-dimensional view, the midpoint of the joint surfaces at both the proximal and distal ends of the clavicle was marked, and the length was determined by connecting these two points(Fig. 3-a). The clavicle length was measured preoperatively, postoperatively, and after simulated repositioning. ② Clavicle Shortening Displacement: The difference in the clavicle length after simulated repositioning minus the preoperative or postoperative length was considered the preoperative or postoperative clavicle shortening displacement. ③ Separation Displacement of the Clavicle: This represents the spatial distance between the centre points of the fracture ends at the distal and proximal segments of the clavicle. For comminuted fractures, the central point of the proximal fracture surface centroid preoperatively was defined as the central point of the section obtained after simulated repositioning of all comminuted bone fragments with the proximal end of the fractured clavicle and postoperatively as the image’s central point obtained after actual repositioning of the comminuted bone fragments with the proximal end of the fractured clavicle(Fig. 3-b). After marking the central points, their three-dimensional coordinates were obtained, and the spatial distance (d) between them was calculated using the Euclidean distance formula (d = sqrt [ (x1-x2)2 + (y1-y2)2 + (z1-z2)2]). The separation displacement was measured preoperatively and postoperatively.④ Measurement of Three-Dimensional Rotational Angles: In Mimics software, the preoperative, postoperative, and simulated reset distal clavicle axes were marked in the XZ/XY/YZ planes. The angle formed by the preoperative and simulated reset and the postoperative and simulated reset distal clavicle axes was measured, which was the angle of rotation of the distal clavicle along the Y/Z/X axes in the preoperative and postoperative periods (Fig. 4). Clockwise rotation along the axis of rotation was defined as (+) and counterclockwise rotation as (-).

Fig. 3.

Fig. 3

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Measurement of Clavicle Length and Separation Displacement. (a) Measurement of length. (b) Calculation of separation displacement.

Fig. 4.

Fig. 4

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Measurement of Rotational Angles along the X/Y/Z Axes. (a) When the “Top” view is selected in the “View” of the Mimics software, image that can be seen was in the standard XZ plane, mark the axis of the distal clavicle and then measure the angle between the axis of the distal clavicle before surgery and simulated reset, and after surgery and simulated reset. The angle is the rotational angle of the distal clavicle in the Y-axis. (b) Using the same method, the rotational angle along the Z axis is measured in the “Back” view. (c) In the “Left” view, the rotational angle along the X axis is measured (for a patient with a left-side clavicle fracture).

Statistical analysis

Data were analyzed using SPSS Statistics 26.0.0.0 software (IBM Corp., Chicago, IL, USA). The Chi-square test was used to compare gender, affected side, fixation method, and injury mechanism, across the three groups. Age was compared using one-way analysis of variance (ANOVA). Repeated measures ANOVA was used to compare clavicular length changes after simulated reduction, as well as preoperatively and postoperatively, among the three groups. Within-group comparisons of preoperative and postoperative shortening, separation, and rotational displacements along the X/Y/Z axes were performed using paired sample t-tests. For B group patients, where postoperative shortening, separation displacement, and preoperative/postoperative rotational displacements along the Z-axis and X/Y/Z axes did not follow a normal distribution, the paired sample Wilcoxon signed-rank test was applied. Between-group comparisons of these variables were conducted using the Kruskal-Wallis test. A significance level of 0.05 was set for all statistical tests.

Results

No statistically significant differences were found in sex, affected limb, fixation method, injury mechanism, or age among the three groups (Table 2). The simulated reduction, preoperative, and postoperative clavicle lengths violated the assumption of sphericity; therefore, Wilks’ Lambda test was applied. The results showed that the main effect of measurement time on clavicle length was statistically significant (F = 125.034, p < 0.001), while the interaction effect between time and AO classification was not significant (F = 1.032, p = 0.393). These findings suggest that the surgery significantly improved the clavicle shortening displacement but did not completely restore it to normal, and these changes were not associated with the AO classification of the fracture (Fig. 5a).

Table 2.

Patient characteristics (Age, injury side, gender, mechanism of injury, and fixation Method) across three groups.

Variable Group A
(n = 8)		 Group B
(n = 28)		 Group C
(n = 38)		 Test Statistic P-value
Age (years) 45.5 ± 5.6 47.8 ± 6.3 46.9 ± 7.1 F = 0.049 0.712

Injury Side

Left:

Right:

5 (62.5%)

3 (37.5%)

16 (57.1%)

12 (42.9%)

20 (52.6%)

18 (47.4%)

 X2 = 0.695 0.707

Gender

Male

Female:

4(50.05%)

4 (50.0%)

17 (60.7%)

11 (39.3%)

24 (63.2%)

14 (36.8%)

 X2 = 1.057 0.589

Mechanism of Injury

Falls from height

Motor vehicle accidents

Bicycle accidents

Falls on level ground

4 (50.0%)

2 (25.0%)

1 (12.5%)

1 (12.5%)

8 (28.6%)

12 (42.9%)

3 (10.7%)

5 (17.9%)

8 (21.1%)

13 (34.2%)

9 (23.7%)

8 (21.1%)

 X2 = 11.540 0.073

Fixation method

Anterograde fixation

Retrograde fixation

2(25.0%)

6(75.0%)

3(10.7%)

25(89.3%)

8(21.1%)

30(78.9%)

 X2 = 1.532 0.465
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Fig. 5.

Fig. 5

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Within-group comparison of preoperative and postoperative three-dimensional clavicle displacements. All values are presented as mean ± SD. If the data did not follow a normal distribution, they are presented as median ± interquartile range (IQR). Statistical significance was analyzed using Wilks’ Lambda in panel (a), and paired t-tests or rank-sum tests in panels (b–f), *p > 0.05, **p < 0.05 (paired t-test), #p > 0.05, ##p < 0.05 (rank-sum test). (a) Comparison of simulated reduction, preoperative, and postoperative clavicle lengths. (b) Comparison of preoperative and postoperative clavicle shortening displacement. (c) Comparison of preoperative and postoperative clavicle separation displacement. (d) Comparison of preoperative and postoperative clavicle rotation displacement along the X-axis. (e) Comparison of preoperative and postoperative clavicle rotation displacement along the Y-axis. (f) Comparison of preoperative and postoperative clavicle rotation displacement along the Z-axis.

Within-group comparisons revealed significant differences in clavicle shortening displacement and separation displacement between the preoperative and postoperative measurements in all three groups. In Group A, a statistically significant difference in distal clavicle rotation displacement along the Z-axis was found between the preoperative and postoperative measurements. However, no significant differences were found in rotational displacement along the X, Y, or Z axes between the preoperative and postoperative measurements in the other groups (Fig. 5b-f). Between-group comparisons showed no statistically significant differences.in preoperative shortening displacement (H = 1.569, p = 0.456), or preoperative rotational displacements along the X/Y/Z axes (H = 0.957, p = 0.620; H = 1.534, p = 0.464; H = 4.999, p = 0.082). However, preoperative separation displacement (H = 6.427, p = 0.040) exhibited statistically significant differences, suggesting a correlation between preoperative separation displacement and AO/OTA classification. Postoperatively, there were no statistically significant differences in shortening displacement (H = 2.093, p = 0.351), separation displacement (H = 4.796, p = 0.091), or rotational displacements along the X/Y/Z axes (H = 0.359, p = 0.836; H = 0.332, p = 0.847; H = 1.550, p = 0.461).

Discussion

The clavicle, being the only bony structure connecting the upper limb to the trunk, plays a crucial role in the function of the shoulder and upper limb. MCFs have traditionally been managed conservatively, but there is increasing evidence suggesting that significantly displaced MCFs are prone to non-union and malunion, which can impair shoulder function4,5. Despite ongoing controversy6–8, there is a growing consensus advocating surgical intervention for markedly displaced MCFs3,9–13. Surgical options include open reduction and internal fixation with plates and minimally invasive intramedullary nailing11. TENs are among the most commonly used minimally invasive internal fixation methods due to their advantages of being minimally invasive, elastic fixation, leading to shorter operative times, less intraoperative bleeding, and faster fracture healing compared with plate fixation14–18.

Three-dimensional displacement of fractures, including length displacement, separation displacement, and rotational displacement along the X, Y, and Z axes, is closely associated with postoperative functional outcomes. Previous analyses of displacement in MCFs have primarily relied on traditional radiographs. Given the S shape of the clavicle, its appearance varies with different views, making it challenging for two-dimensional radiographs to accurately reflect three-dimensional displacement, thereby limiting measurements to length and separation displacement and single-plane angular displacement, with significant error19–22. Utilising CT to analyse spatial displacement in clavicle fractures is considered the optimal method23. Researchers such as Mehmet Öztürk, Kim JH, Oki S, and Chao Y have conducted relevant studies, but their subjects were all non-surgically treated patients2,24–26. The effectiveness of titanium elastic nails as non-locking intramedullary fixation devices in correcting and controlling three-dimensional displacement remains unclear, with no reports found in the literature reviewed.

Clavicle shortening and separation displacements following fractures are closely associated with scapular motion and can result in shoulder dysfunction, leading to unsatisfactory clinical outcomes27. These displacements are currently considered the most strongly correlated imaging indicators for subsequent functional outcomes. Pradel et al. found that the percentage of clavicle shortening significantly correlated with the DASH score, with a higher incidence of shoulder dysfunction in non-surgically treated patients, and identified a threshold of 1.3 cm shortening20. Biz et al. identified clavicle shortening as an independent predictor of shoulder function, while separation displacement affected fracture healing7,28. Tagliapietra et al. also confirmed that relative displacement was a likely predictor of delayed union and non-union29. Our within-group analysis indicated that the use of TENs for closed reduction of MCFs effectively corrected fracture shortening and separation displacements, significantly restoring clavicular length, with statistically significant differences between preoperative and postoperative measurements. Between-group analysis indicated that the original separation displacement of MCFs correlated with the AO/OTA classification, suggesting that more attention should be paid to separation displacements in complex clavicle fractures. Postoperative between-group analysis showed that TENs effectively addressed shortening and separation displacements in all three groups, with no statistically significant differences in the repositioning outcomes.

The three-dimensional rotational displacement of clavicle fractures postoperatively remains unclear due to the lack of feasible measurement methods, and relevant literature is scarce. Hung et al. noted that after open reduction and internal fixation of clavicle fractures, the length of the clavicle was restored, and shoulder range of motion and function returned to normal, but scapular motion trajectory remained altered1. Although the possible reasons were not mentioned, we believe that rotational displacement of the fracture ends may be a contributing factor. This study employed spatial matching techniques to overlap the proximal ends of the clavicle and then measured the rotational angles of the distal clavicle in different planes. For instance, the rotational displacement of the fracture in the X-axis could be measured as the rotation in the YZ-plane, and similarly, the rotational displacements along the Y- and Z-axis could be measured as the rotations in the XZ- and XY-planes, respectively. This method significantly reduces technical difficulty by simplifying the three-dimensional problem into a two-dimensional problem, especially compared to using complex rotation matrices and three-dimensional Euler angles24,26. Since the X/Y/Z axis is the original X/Y/Z axis of supine CT, the corresponding YZ/XZ/XY planes correspond to the sagittal, transverse, and frontal planes of normal human anatomy, respectively, which is more in line with clinical reality. Our findings showed that, apart from a significant difference in the distal clavicle's rotational displacement along the Z-axis before and after TENs fixation in Group A, no significant differences were observed in rotational displacement along the X/Y/Z axes in the other groups. This suggests that TENs can effectively improve rotational displacement in the XY-plane  (frontal plane) only for simple midshaft clavicle fractures, wheras their effect on other types of rotational displacement is limited. These findings appear to contradict previous reports of favorable clincial outcomes with TENs.16–18,30,31. Possible reasons are as follows: ① CT data were acquired in the supine position, which may reduce displacement compared with standing32,33; ② the shoulder joint is a multi-joint conformer. Specifically, the glenoid joint has a large range of motion, and a certain degree of spatial rotational displacement is compensated for by other joints; ③ most literature reporting favourable outcomes of TEN treatment involves short- to medium-term follow-up, and the long-term effects of uncorrected rotational displacement remain unclear. Therefore, although we obtained this finding in our study, the extent of its relevance to clinical efficacy needs to be evaluated in further studies.

There are some limitations to this study: ① The study only observed the spatial three-dimensional displacement of the broken end after surgery but failed to observe the data related to the broken end after the fracture healed. It is not clear whether the broken end of the fracture would be displaced secondary to the fracture and whether the rotational displacement would be spontaneously reset with the movement of the shoulder joint. ② Due to the asymmetrical nature of clavicle length, with the lengths of the right and left clavicles differing by over 5 mm in about 30% of individuals34–36, we did not simply use the contralateral mirror image as the preoperative three-dimensional imaging data of the affected clavicle. Instead, we used the healthy side as the template, and the bone blocks were sequentially spliced together to simulate the reset, hoping to maximise the recovery of the preoperative three-dimensional imaging data of the clavicle. However, even with the adoption of various measures, we found it challenging to avoid reset errors during the actual reset process, especially in cases involving rotational displacement. ③ The number of participants in this study was small. These are the problems that need to be addressed and solved in our follow-up study.We received the trail registration para to changed as ethical approval as per house style. Kindly check and confirm.Thank you for making the changes. I confirm that this modification is appropriate . If further revisions are needed, please let me know.

Conclusion

This study demonstrates that closed reduction with TENs is effective for MCFs, particularly in correcting shortening and separation displacement and restoring clavicle length. However, the results also highlight the limited effectiveness of TENs in correcting rotational deformities along the X/Y/Z axes, necessitating further research to evaluate the clinical significance of these findings.

Author contributions

J. Zhang (Conceptualization, Investigation, Methodology, Project administration, Writing – original draft)H. Jiang (Conceptualization, Writing – review & editing)Z. Li (Investigation)J. Hou (Project administration, Supervision)H. Bi (Project administration, Supervision)W. Nie (Supervision)Z. Ma (Validation)L. Duan (Validation)L. Chen (Visualization)Z. Peng (Writing – review & editing).

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors, and no material support of any kind was received.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

This study was approved by the Ethics Committee of Wendeng Orthopaedic Hospital, Shandong Province (NO. LL20190212).

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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