Clavicle Fractures In Adolescents Research Articles

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. Prospective observational cohort. Eight tertiary care pediatric centers. Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures.

Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3mm, and 69% of patients demonstrating > 20mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4mm. Forty-one percentage of patients had >5mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20mm, 18 patients (41%) with <20mm EES increased to ≥20mm EES, and 19 patients (19%) with ≥20mm EES decreased to <20mm EES at 2-week follow-up. Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. Level IV-case series.

Do We Ever Need to Fix Clavicle Fractures in Adolescents?

Clavicle fractures in adults are increasingly being treated by surgical fixation following reports of symptomatic non-union, malunion and poor functional outcome with conservative treatment. This has led to a similar trend in the management of clavicle fractures in adolescents. This study aims to evaluate the outcome and complications of non-operatively treated clavicle fractures in adolescents. This is a retrospective, single institution study on adolescents aged 13-17 years who sustained a closed, isolated clavicle fracture, between 19972015. Clinical records were reviewed for demographic information, injury mode, time to radiographic fracture union, time to re-attainment of full shoulder range of motion (ROM), and time to return to full activities and sports. Complications and fracture-related issues were recorded. Radiographs were analysed for fracture location, displacement and shortening. A total of 115 patients (98 males, 17 females; mean age:13.9 ± 0.89 years) were included for study. 101 (88%) sustained a middle-third fracture while the remainder sustained a lateral-third fracture. A total of 96 (95%) of the middle-third fractures were displaced, and 12 (86%) of the lateral-third fractures were displaced. All displaced fractures in this study had shortening. Sports-related injuries and falls accounted for 68 (59%) and 34 (30%) of the cases respectively. Overall, the mean time to radiographic fracture union was 7.8 ± 4.35 weeks; there were no cases of non-union. Full shoulder ROM was re-attained in 6.6 ± 3.61 weeks, and full activities and sports was resumed in 11.4 ± 4.69 weeks. There were 5 cases of re-fracture and a single case of intermittent fracture site pain. Clavicle fractures in adolescents can and should be treated non-operatively in the first instance with the expectation of good outcomes in terms of time for fracture union, reattainment of shoulder full range of motion, and return to activities. Surgical stabilisation should be reserved for cases for which there is an absolute indication.

Paper 15: 5 Year Radiographic and Functional Outcomes of Non-Operative Treatment of Completely Displaced Clavicle Fractures in Teenagers, A Prospective Study

Objectives: Optimal treatment for displaced clavicle fractures in adolescents remains controversial, with many surgeons favoring operative reduction and fixation. To prospectively assess patient reported outcomes (PROs) in teenagers undergoing non-operative treatment of a completely displaced clavicle fracture ≥ 5 years post-injury. Furthermore, bilateral clavicle imaging was used to determine the association between these outcomes and the presence or absence of bony remodeling. Methods: This study used a subset of patients previously enrolled in a multicenter study looking at adolescent clavicle fractures. Patients from a single institution and ≥ 13 years at the time of injury, with non-operatively treated completely displaced clavicle fractures who were ≥5 years out from their initial injury were able to participate in the study. Patients were clinically evaluated for evidence of scapular dyskinesia, strength deficits, and cosmetic concerns. Bilateral clavicle imaging was used to assess residual shortening, displacement, and angulation. PROs included: ASES, QuickDASH, Marx Shoulder Activity Scale, and return to sport data. Results: Twenty-four patients were available for follow-up, of whom 17 (71%) consented to the additional imaging. The mean age at the time of injury was 14.5±1.1 years with 89% being male. At a mean follow-up of 6.1 years, all fractures healed and no interventions were necessary (Figure 1). Significant remodeling was observed across all measurements with improvements of 70% in mean shortening (22.8 mm to 6.8 mm, p&lt;0.001), 73% in superior displacement (13.4 mm to 3.6 mm, p&lt;0.001), and 83% in angulation (10.4˚ to 1.8˚, p&lt;0.001) (Figure 2). Thirteen patients (72%) had initial shortening &gt; 2 cm and all remodeled to &lt; 2 cm. PROs were almost universally excellent with no patients reporting shoulder pain and mean ASES, quickDASH, and Marx activity scores of99±3, 1±3, and 20±1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Majority (58%) were completely satisfied with the appearance of their shoulder, 38% were more satisfied than not, one patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 returned to sporting activities if interested. No PROs were associated with bony remodeling (p&gt;0.05). Conclusions: Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. This study further supports the role of non-operative treatment for teenagers, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs.

Skin Tenting Associated with Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results from the FACTS Multi-Center Prospective Cohort Study

Skin Tenting Associated with Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results from the FACTS Multi-Center Prospective Cohort Study

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

Background: Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood. Purpose: To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process. Study Design: Case series; Level of evidence, 4. Methods: Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction. Results: Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling. Conclusion: Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Trends in the Treatment of Adolescent Clavicle Fractures: Are We Listening to the Evidence?

From 1999 to 2011, studies demonstrated an increasing trend toward surgical management of adolescent clavicle fractures. The purpose of this study was to examine more recent trends of surgical management of closed clavicle fractures in adolescent patients over the past decade. A retrospective cohort study was conducted using the PearlDiver database. Patients with clavicle fractures from 2011 to 2021 were identified and stratified by age, sex, and year of their fracture. Categorical variables were compared with a chi square test, and continuous variables were compared with the Welch t test or Mann-Whitney U test. Overall, there was a significant increase in the percentage of patients surgically treated by open reduction and internal fixation from 2016 to 2021 compared with 2011 to 2015 (8.58% vs. 7.34%, P < 0.001). When stratified by age, both the 10 to 14-year group (3.80% vs. 3.10%, P < 0.001) and the 15 to 18-year group (15.41% vs. 12.84%, P < 0.001) demonstrated significant increases in the percentage of patients surgically treated. Despite increasing literature demonstrating high revision surgery rates for surgical treatment of adolescent clavicle fractures with no difference in functional outcomes, this study demonstrated a notable increase in the rate of surgical treatment of adolescent clavicle fractures from 2011 to 2021 in the United States.

Shoulder &amp; Elbow

The December 2022 Shoulder &amp; Elbow Roundup360 looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Adolescent displaced lateral-end clavicle fractures are not comparable to the adult variant. Epidemiology, fracture patterns and outcome of non-operative management.

The primary aim of this study was to determine the epidemiology of lateral-end clavicle fractures in adolescents. The secondary aim was to assess the outcome following non-operative management. A retrospective review of all adolescent clavicle fractures over a 10-year period was undertaken. Fracture classification, demographics, management, and complications were analysed. Functional outcomes were undertaken with the Quick Disabilities of Arm, Shoulder and Hand and EuroQol five-dimension at mean 8.8 years post-injury. In total, 677 clavicle fractures were analysed, 8.7% were lateral-end fractures (n = 59/677). The median age was 14.6 (range: 13-17) and 92% were male (n = 54/59). The incidence was 0.17 per 100,000 per year. All displaced physeal fractures (Neer IV n = 14) were managed non-operatively and of the six followed-up, all united with good outcomes. The adult type displaced fracture (Neer II) occurred in fifteen fractures, five underwent operative fixation and ten were managed non-operatively with one subsequent nonunion (n = 1/10). Those patients that underwent non-operative management (response n = 5/10, 50%) reported a median Quick Disabilities of Arm, Shoulder and Hand of 2.3 but approximately 40% reported cosmetic and outcome dissatisfaction at long-term follow-up. Displaced Neer II lateral-end clavicle fractures are rare in the adolescent population. Although nonunion is rare, some dissatisfaction with cosmesis persists at long-term follow-up despite good functional outcomes with non-operative management.

Plating versus elastic stable intramedullary nailing for displaced pediatric midshaft clavicular fractures

IntroductionTraditionally, operative treatment for displaced midshaft clavicle fractures in adolescents has been achieved by using a plate and screws. However, a minimally invasive trend has led surgeons to use the elastic stable intramedullary nail (ESIN) for displaced midshaft clavicle fractures. This study aims to compare the clinical outcomes of adolescent patients who were operated on with an ESIN vs. a plate.MethodsAll patients aged between 10 and 14 years with displaced midshaft clavicle fractures who were operated on at our institute between January 2014 and January 2018 were reviewed retrospectively. The preoperative data, including baseline information on the patients, and types of surgical procedure were collected from the hospital database. The postoperative data, including clinical outcome and complications, were collected during the follow-up visits. Clinical outcome was evaluated during outpatient visits using the American Shoulder and Elbow Surgeons (ASES) score. The scar problem was evaluated according to the Scar Cosmesis Assessment and Rating (SCAR) scale.ResultsA total of 73 patients were included. Patients were categorized into two groups: ESIN (n = 45; 27 males, 18 females) and plate (n = 28; 17 males, 11 females), according to surgical technique. The average age of the patients in the ESIN group was 12.2 ± 1.5 years, and that in the plate group was 12.2 ± 1.4 years. The ESIN group presented significantly less operative time (31.1 vs. 59.8 min), a shorter hospital stay (1.5 vs. 2.5 days), and a smaller incision (2.4 vs. 5.4 cm) as compared to the plate group (P < .001). The rate of scar concern was much higher in the plate group (71.4%) than the ESIN group (22.2%) (P < .001). There was no statistically significant difference in shoulder function between the ESIN group and the plate group at different time points.ConclusionA conservative approach remains the first choice for a pediatric clavicle fracture. Both the ESIN and the plate are safe and effective treatment methods for displaced midshaft clavicle fractures in adolescents. The ESIN is superior to the plate given its shorter operative time, shorter hospital stay, lower rate of scar concern, and easier implant removal.Level of evidenceIII, retrospective observational study.

Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group

Background: The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. Purpose/Hypothesis: The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity–based confounders for creation of comparable subgroups for analysis. Results: Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of “suboptimal” scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ–5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. Conclusion: Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. Registration: NCT04250415 (ClinicalTrials.gov identifier).

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

The present letter to the editor is a commentary on the study titled “Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents”. There is a debate over whether surgical treatment of clavicle shaft fractures improves clinical outcomes in adolescents. The readmission and reoperation rates following surgery should be identified.

Paper 63: Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

Objectives:The phenomenon of bony remodeling of healed displaced clavicle midshaft fractures in adolescents remains poorly understood. The purpose of the current study was to evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures treated non-operatively to understand the factors that may influence this process.Methods:Patients were identified from the database(s) of a multi-center study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced mid-diaphyseal clavicle fractures that were treated non-operatively who had further imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Radiographic measurements were performed on the injury and final follow-up films. Fracture remodeling was subjectively classified as ‘complete/near-complete’, ‘moderate’, or ‘minimal’ (Figure 1) and subsequently analyzed quantitively and qualitatively to determine factors associated with deformity correction.Results:Ninety-eight patients (mean age of 14.4±2.2 years) were analyzed at a mean radiographic follow-up of 3.4± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 59%, 61%, and 30% respectively (p<0.001). Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrate more remodeling (p<0.001). Ninety-two percent of patients <14 years and 79% of patients ³14 years-old at time of injury with a minimum follow-up of four years underwent complete/near-complete remodeling.Conclusions:Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. This finding may help explain why symptomatic malunions are so infrequently observed in adolescent patients, even in severely displaced fractures.

Short-term Recovery After Displaced Adolescent Clavicle Fractures: Do Differences an Exist Between Surgical and Non-Surgical Treatments?

Introduction:Clavicle fractures are common in the young, active adolescent population. It is increasingly recognized that displaced clavicle fractures treated either conservatively or surgically have good outcomes at 1 year. Currently, it is not well established whether any differences in the short-term recovery (<3 months) exist. Patient-Reported Outcomes Measurements Information System (PROMIS) computer adaptive testing (CAT) has been shown to be a valid and reliable means to assess PROs.Purpose:To compare short-term recovery between surgical and non-surgical treatment of displaced clavicle fractures in adolescents utilizing PROMIS.Methods:Patients with displaced clavicle fractures were assessed prospectively utilizing PROMIS at each clinic visit. Patients completed the Pediatric PROMIS CAT domains Upper Extremity Function and Pain Interference. Inclusion criteria included patients <18 years old, treatment either surgically or conservatively, and at least two follow up time points within 2 months post-op. Time points were calculated as <10 days, 7-21 days, 6 weeks (22-52 days), and 3 month (70-110 days) post-injury. Time points were compared utilizing a mixed-linear regression model. Ceiling or Floor Effects were present when ≥15% of study cohort had reached the maximum or minimum possible score.Results:A total of 52 patients with displaced clavicle fractures were identified (26 surgically treated and 26 conservatively treated). Mean age was similar (15.4 v. 14.1, respectively). No differences in mean PROMIS scores between treatment modalities were present at baseline (p>0.05). For Pain Interference and Upper Extremity Function, significant improvement by 6 weeks was seen in both surgically and conservatively treated patients (Figure 1). For Pain Interference, significant improvement by 6 weeks was seen in both surgically (Δ=-6.8, p=0.03) and conservatively treated patients (Δ=-8.3, p=0.003). More surgically treated patients reached a floor effect for Pain Interference at 6 weeks (24%), compared to conservatively treated patients (4%). For the Upper Extremity function, significant improvement was seen by 6 weeks in both surgically (Δ=7.2, p=0.042) and conservatively (Δ=11.9, p=0.003) treated patients. For UE Function, 21% of surgically treated patients reached a ceiling effect at 6 weeks, compared to 13% for conservative treatment (p>0.05). No differences were present at 3 months post-injury.Conclusions:While both surgical and conservative treatment of adolescent displaced clavicle fractures demonstrate similar trends of PROMIS recovery, surgical treatment may allow for rapid recovery at 6 weeks compared to conservative treatment in some patients.

Does Shortening Change in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures?

Background:Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment in clavicle fractures. However, the degree to which shortening may actually change in the weeks following injury has not been well studied.Purpose:The purpose of this study was to evaluate the potential change in shortening of adolescent clavicle fractures in the first 2 weeks following injury.Methods:This was an IRB-approved multi-center study of prospectively collected data which was acquired as a part of a larger cohort study evaluating functional outcomes of adolescent clavicle fractures. A consecutive series of patients ages 10 – 18 years of age with completely displaced diaphyseal clavicle fractures with a baseline AP clavicle radiograph (0-6 days from date of injury) and a follow-up AP clavicle radiograph (7 – 21 days from date of injury) were included. Measurements of end-to-end clavicle shortening were performed with validated techniques.Results:142 patients met inclusion criteria. Baseline radiographs were obtained at a mean of 1 day +/- 1.7 days following injury. Mean baseline shortening was 22.3mm +/- 0.6mm. 69% of patients had >/= 20mm of shortening. Follow-up radiographs were obtained at a mean of 13.8 days +/- 3.8 days post-injury and demonstrated a mean change in shortening of 5.4mm, compared to baseline films. 41% of patients had >5mm of change in shortening and 15% of patients had >10mm change in shortening. Using a threshold shortening of 20mm, 26% of patients had a change from baseline to follow-up from either above to below 20mm or below to above 20mm. This includes 28% of patients with 20-25mm of shortening at baseline that were less than 20mm at follow-up.Conclusion:Significant changes in fracture shortening occur in many adolescents with completely displaced clavicle fracture in the first 3 weeks. More than a quarter of patients demonstrated a drop from above to below 20mm, a commonly used threshold for surgical decision making. While there is minimal evidence to suggest that shortening influences outcomes following this fracture in adolescent sub-populations, the findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions.

Remodeling of Adolescent Displaced Clavicle Fractures: A Facts Study

Background:The phenomenon of bony remodeling of healed displaced clavicle midshaft fractures in adolescents remains poorly understood.Hypothesis/Purpose:The purpose of the current study was to evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures treated non-operatively to understand the factors that may influence this process.Methods:Patients were identified from the database(s) of a multi-center study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced mid-diaphyseal clavicle fractures that were treated non-operatively who had further imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Radiographic measurements were performed on the injury and final follow-up films. Fracture remodeling was subjectively classified as ‘complete/near-complete’, ‘moderate’, or ‘minimal’ (Figure 1) and subsequently analyzed quantitively and qualitatively to determine factors associated with deformity correction.Results:Eighty-one patients (mean age of 14.4±2.2 years) were analyzed at a mean radiographic follow-up of 34.8±24.3 months. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 60%, 57%, and 38% respectively. Fracture remodeling was found to be associated with patient age and follow-up time, with younger patients and those with longer follow-up undergoing more remodeling. All patients <14 years and 83% of patients ≥14 years-old at time of injury with a minimum follow-up of four years underwent complete/near-complete remodeling.Conclusion:Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. This finding may help explain why symptomatic malunions are so infrequently observed in adolescent patients, even in severely displaced fractures.Figure 1.

Medial clavicle shaft fractures in children and adolescents: differences from adults and management.

Clavicle fractures are a common injury in the pediatric and adolescent population. Most fractures are located in the middle third of the clavicle. There has been no information in the literature regarding the management of extra-physeal medial clavicle shaft fractures in this population. The objective of this study is to evaluate demographic and injury characteristics, management options and clinical outcomes of medial clavicle fractures in children and adolescents and differentiate them from those in adults. A retrospective review was performed at a single institution to identify patients with medial clavicle shaft fractures. Radiographs, clinical features and patient-reported outcomes (QuickDASH) were analyzed. Eight patients were identified with medial clavicle fractures. Two fractures could not be diagnosed on anteroposterior radiographs. Both operative (four patients) and nonoperative (four patients) treatment had excellent radiographic and clinical outcomes, irrespective of initial displacement. Compared to high-energy and life-threatening injuries in adults, these fractures in children and adolescents were sports-related and isolated fractures. Conservative treatment should be considered for medial clavicle fractures in children and adolescents. These fractures are distinct from their adult counterparts and do not lead to increased morbidity or mortality.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

BACKGROUNDThe national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown.AIMTo determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.METHODSThis retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses.RESULTSIn total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02).CONCLUSIONThere is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014.

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.