BACKGROUND: The complexity of the anatomic structure of proximal tibia made it difficult for treatment with intramedullary nailing and rate of complications was high. With the improved design and fixation technique of the intramedullary nails, the excellent and good rate of application of this technique is also increasing. Using intramedullary nailing to treat proximal tibial fractures is getting popular. OBJECTIVE: To summarize the latest techniques of intramedullary nailing for proximal tibial fractures. METHODS: 742 literatures were retrieved with keywords of "proximal tibial fracture" and "intramedullary nail" in English and Chinese respectively from PubMed, Web of science, WanFang and CNKI database. By analyzing their titles and summaries, based on the relevance to the subject, 57 articles were selected for this review after excluding 685 articles. RESULTS and CONCLUSION: (1) Due to the complexity of the anatomic structure of the proximal tibia and the limitations of both the fixation techniques and the structure of traditional intramedullary nails, rates of complications were high when intramedullary techniques were used to treat proximal tibial fractures. (2) With the development of intramedullary nail technique, newly designed intramedullary nails appeared, which increased proximal intramedullary nails, improved the position and direction of lock pin. Holding power was strong on the proximal fracture blocks. (3) The introduction of techniques such as combining with plates, Poller screws and improved approval increased the strength of the fixation of proximal tibial fractures. (4) Most of the biomechanical tests have proven that compared to other techniques, intramedullary nailing provides better stability. The intramedullary nailing has advantages of being minimal invasion, less blood transport damage, strong fixation, early postoperative activity and short healing time. It is especially effective for multi-level tibial fractures and proximal tibial fractures with severe soft tissue damages. (5) Deep knowledge of the anatomic structure of the proximal tibia and nailing procedure can help surgeons achieve satisfactory clinical results.

Objective: To compare the curative effect between Elastic Locking Intramedullary Nail (ELIN) and Anatomic Locking Plate (ALP) for the treatment of fracture in the mid-shaft of clavicle (Classification AO/OTA:2A/2B). Methods: Data of 47 cases of 2A/2B clavicular fractures who were treated with operation from January 2014 to December 2016 were retrospectively analyzed. The patients were divided into ELIN group and ALP group according to different fixation methods. There were 23 cases in ELIN group, 14 male and 9 female, aged from 19 to 85 years (average, 55.26 years). 14 cases on the left side and 9 cases on the right side. There were 6 cases of type 2A and 17 cases of type 2B. There were 24 cases in the ALP group, 18 male and 6 female, aged from 15 to 71 years (average, 51.25 years). 16 cases on the left side and 8 cases on the right side. There were 9 cases of type 2A and 15 cases of type 2B. The operation time, intraoperative blood loss, length of skin incision, fracture healing time, extraction time of internal fixation, Constant-Murley score of shoulder joint, disabilities of the arm, shoulder, and hand (DASH) score, and complication incidence were compared between the two groups. Results: All the operations were successfully performed. The mean follow-up for the patients in the ELIN group was 19.35 weeks (range, 14-23 weeks). The mean follow-up for the patients in the ALP group was 53.13 weeks (range, 28-76 weeks). In the ELIN group, the operative time was 20.78 ± 7.71 min, the intraoperative blood loss was 13.26±9.72 ml, the length of incision was 1.57±1.24 cm, the fracture healing time was 10.39±2.39 weeks, the extraction time of internal fixation was 13.17±2.37 weeks, the Constant-Murley score of shoulder joint was 99.09±1.86, and the DASH score was 1.20±2.47. In the ALP group, the operative time was 57.79±11.56 min, the intraoperative blood loss was 69.17±46.24 ml, the length of incision was 9.67±2.90 cm, the fracture healing time was 14.21±4.05 weeks, the extraction time of internal fixation was 47.38±10.46 weeks, the Constant-Murley score of shoulder joint was 98.00±2.17, and the DASH score was 0.89±1.65. The operation time (t=12.856, P=0.000), intraoperative blood loss (t=5.791, P=0.000) in the ELIN group were less than that of ALP group. The length of incision was significantly smaller in ELIN group than that of ALP group (t=12.549, P=0.000). The fracture healing time was earlier in ELIN group than that of ALP group (t=3.566, P=0.002). The extraction time of internal fixation was obviously earlier in ELIN group than that of ALP group (t=15.603, P=0.000). Constant-Murley score of shoulder joint and DASH score showed no significant difference. No delayed healing, no infection was found in the ELIN group, however skin irritation and tail bursitis were found in 6 cases, 3-6 weeks after the operation. The dressing was changed, kept clean. Skin irritation and tail bursitis disappeared, after the extraction of the internal fixation. There were 2 cases of delayed healing in the ALP group. After prolonged observation, the 2 cases healed. The healing time was extended to 24 and 27 weeks, respectively. There was 1 case of infection, 1 case of poor skin healing in the ALP group. The infected patient was treated with debridement and sensitive antibiotics, and the patient with poor skin healing was treated with dressing change. All the patients had wound healing about 4 weeks after surgery. 2 cases of skin irritation in the ALP group disappeared, after the extraction of the internal fixation. Conclusion Both ALP and ELIN are effective methods for the treatment of mid-shaft clavicular fracture. ELIN group has the advantages of more minimally invasive, faster union, shorter internal fixation time, better appearance, and lower medical cost. However, the ELIN group also had skin irritation and temporary bursitis.