Abstract
BACKGROUND: Literature on the functional outcomes following the treatment of closed, displaced midshaft clavicle fractures in adolescents is fairly limited. These fractures have traditionally been treated non-operatively; however, recent literature in adults shows improved outcomes with operative treatment, and it has been suggested that these results may translate to adolescents. STUDY OBJECTIVE: To assess the effectiveness of titanium elastic nailing in the treatment of displaced midshaft clavicle fractures in adolescents. METHODS: Adolescent patients (age 13 to 17 years) with closed, displaced midshaft clavicle fractures sustained between 2008 and 2015, were treated operatively with a titanium elastic nail inserted in an unreamed fashion from the sternal end of the clavicle by a single surgeon. Post-operatively, patients were immobilised in a sling for six weeks and attended scheduled follow-up visits at two, six and 12 weeks. The nail was removed from 12 weeks onwards in all cases. All patients were assessed by the surgeon with regard to the radiological outcome, Constant shoulder score, scar quality and complications RESULTS: Fifteen patients, 12 males and three females with a mean age of 14.9 years, were assessed. Fourteen patients went on to complete union by 12 weeks and the remaining one united by 20 weeks post-surgery. The difference in Constant shoulder scores between the affected and unaffected shoulders for 14 patients was below 11 at 12 weeks' follow-up and all patients were satisfied with their scar after 12 weeks. Two patients developed complications - one an iatrogenic perforation of the posterior cortex of the lateral fragment and one a haematoma after re-injury. CONCLUSION: Operative treatment with a titanium elastic nail is a safe, minimally invasive and reliable treatment method for displaced, uncomminuted midshaft clavicle fractures in adolescents. Level of evidence: Case series; Level IV evidence.
Highlights
Clavicle fractures occur commonly, comprising 2.6–5% of adult fractures[1] and 10–15% of paediatric fractures seen.[2]
A 2003 study by Jubel et al evaluating the use of titanium elastic nails in 58 displaced midshaft clavicle fractures, reported marked pain reduction and early restoration of shoulder function with excellent cosmetic results compared to plate fixation or conservative management.[23]
Radiological assessment of the affected clavicle was done by the surgeon using a standard anterior-posterior, and 15° cranial oblique view taken day one post-operatively to assess nail placement and fracture reduction, and again at six and 12 weeks to assess the rate of progression to union
Summary
Clavicle fractures occur commonly, comprising 2.6–5% of adult fractures[1] and 10–15% of paediatric fractures seen.[2]. Complications.[5,6] Recent literature has challenged this belief and numerous studies in adults have revealed unacceptably high non-union rates (15.1%) as well as associated pain, loss of strength and rapid fatigability when these fractures were managed conservatively.[7,8,9,10]. Van der Have et al retrospectively reviewed 42 adolescents with significantly displaced clavicle fractures and showed that symptomatic malunion was more common than initially thought They found that operative management of displaced midshaft clavicle fractures reliably restored length and alignment, and resulted in a shorter time to union, with lower complication rates than fractures treated nonoperatively.[2]. A 2003 study by Jubel et al evaluating the use of titanium elastic nails in 58 displaced midshaft clavicle fractures, reported marked pain reduction and early restoration of shoulder function with excellent cosmetic results compared to plate fixation or conservative management.[23]. The functional and patientorientated outcomes of management of these fractures in skeletally immature patients, remain to be adequately investigated.[26]
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