According to the traditional view, midclavicular fractures are usually treated conservatively, but in view of the more frequent postoperative complications of conservative treatment of midclavicular comminuted fractures, such as nonunion, malunion, and clavicle shortening, the current academic community prefers a more aggressive surgical treatment for these patients. Although incisional internal fixation is the current gold standard for the treatment of clavicle fractures, postoperative complications such as nonunion of the fracture or infection are still not uncommon. In order to overcome these difficulties, some surgeons have applied the flexible intramedullary nailing technique to middle clavicle comminuted fractures, but the disadvantage of this technique is that the fixation effect is not exact, and there are possibilities of internal fixation displacement, shortening, and overlapping of the broken ends after surgery; the percutaneous plate internal fixation technique is respected by the majority of surgeons for its better fracture fixation and healing effect, but due to the special morphological structure of the clavicle, it is more difficult to reset and maintain the fracture during percutaneous plate internal fixation. However, due to the special morphology of the clavicle, it is difficult to reset and maintain the fracture during percutaneous plate internal fixation. Recently, a Korean orthopedic surgeon combined the flexible intramedullary nailing technique and percutaneous plate internal fixation technique to successfully treat 14 cases of comminuted fractures of the middle clavicle without significant postoperative complications, which were published in the journal INJURY. The investigators retrospectively analyzed patients hospitalized for midclavicular comminuted fractures from 2009 to 2010. A total of 15 patients met the study inclusion criteria, and all patients had fractures of clavicle B2.1 or higher. 14 of these patients received at least 12 months of postoperative follow-up, 11 were male and 3 were female, with a mean age of 42.9 years. The relevant demographic data are shown in Table 1. Table 1: Demographic data of patients included in the study Surgical technique: The required internal fixation material was prepared before anesthesia was reached. The required internal fixation material was a locking or non-locking reconstructive plate with a minimum of three distal and proximal plate screw holes for fixation. Pre-bending of the plate is performed through a clavicle model to allow the plate to fit. After general anesthesia, the patient is placed in the supine position with the patient’s shoulder elevated to obtain a better surgical field. Routine disinfection of the towel was performed. A skin incision was made 2 cm from the medial head of the clavicle, and a 2 or 2.5 mm titanium elastic intramedullary nail was inserted through the clavicle medullary cavity under C-arm machine fluoroscopy and entered through the fracture break to maintain the fracture repositioning situation, and if the repositioning was difficult, a 4.0 mm Schiff’s pin could be driven into the distal end of the fracture for prying to assist the fracture repositioning. Then, 2-3 cm skin openings are made on the proximal and distal clavicular surfaces of the clavicle fracture, and a subcutaneous tunnel is established between the two openings using instruments along the clavicle walking area, and the plate is placed through the subcutaneous tunnel without exposing the fracture end, and the plate is temporarily fixed in the proximal and distal ends using two Kirsch pins to maintain the plate and fracture repositioning position after determining that the plate is in the correct position. The temporary fixation of the elastic intramedullary nail is then followed by percutaneous placement of the remaining cortical bone or locking screws. Intraoperative bone grafting of the broken end is not required. This is shown in Figures 1,2,3,4. Figure 1:a, 48-year-old male with OTAB2.2 midclavicular fracture; b, imaging radiographs suggest overlapping midclavicular fracture ends and significant shortening of the clavicle Figure 2: Surgical procedure: A-C: A skin incision is made 2 cm from the medial head of the clavicle, and a 2 or 2.5-mm titanium elastic intramedullary nail is used to penetrate through the clavicular medullary cavity under C-arm machine fluoroscopy and enter the fracture break to maintain fracture repositioning, and if repositioning is If repositioning is difficult, a 4.0 mm Schiff’s pin may be driven distally into the fracture to pry and assist in fracture repositioning.D: elastic intramedullary nail to maintain fracture repositioning.E-F: percutaneous placement of a pre-shaped reconstructed plate, protected by a drill sleeve during drilling of the plate screw hole.G: transdermal incision or skin drilling of the screw.H: postoperative skin incision with the fracture end uncut. Figure 3: A-B, postoperative then X-ray, 3.5 mm preshaped clavicle reconstruction plate placed on the fractured clavicle surface. Figure 4: A-B: At 11 weeks postoperatively, the fracture end was crusted, bridging the two fracture ends, and the difference in clavicle length between the affected and healthy sides was slight. c, The patient had good shoulder motion. d, The postoperative scar was small. Postoperatively, the affected limb was suspended and functional exercises of the upper limb shoulder joint were feasible in the absence of pain. The postoperative X-ray was reviewed, and weight-bearing of the affected limb could be started if there were signs of fracture healing. The fracture healing and postoperative complications were assessed by comparing the clavicle on the healthy side with that on the affected side, and fracture healing and clavicle shortening were evaluated by imaging at 1,2,3,6 and 12 months after surgery. The mean postoperative follow-up was 17.6 months (15-31 months), the time from injury to undergoing surgery was 5.1 days (1-15 days), 11 patients used a locking reconstruction plate and 3 used a plain reconstruction plate, the mean operative fluoroscopy time was 109s and the operative time was 92min. The postoperative results showed: A Constant score of 97 for the shoulder joint and a mean DASH score of 5.5 at 6 months follow-up. At 12 months, the scores were 99 and 4.2, respectively. All patients had good postoperative shoulder motion and could return to their pre-injury level; the surgical incision healed well. Imaging showed a mean postoperative healing time of 15.6 weeks (11-18 weeks), and no patient had a nonunion or delayed healing of the fracture. Clavicle shortening ratio was 0.4% (-1.5%-2.4%), and no patient had postoperative protrusion of the plate at the fracture site. No patients were found to have postoperative complications, such as plate fracture, infection, screw loosening, and reoperation. In the discussion, the investigators concluded that the elastic intramedullary nail combined with percutaneous plate internal fixation technique has the following technical advantages: the elastic intramedullary nail does not need to expose the fracture end for fracture reduction, which can maximize the blood supply to the fracture end for later healing; the percutaneous plate internal fixation technique can maintain a better fracture end reduction with the assistance of the elastic intramedullary nail, and avoid the disadvantage of poor fixation by the elastic intramedullary nail. The disadvantages of the elastic intramedullary nail are avoided. The combination of the two techniques for the treatment of middle clavicle comminuted fractures is a technique worth promoting because of the ease of fracture repositioning, high postoperative fracture healing rate, no obvious incision infection, vascular nerve injury and other complications.