Diaphyseal Clavicle Fractures 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.

New Generation Superior Single Plating versus Low-Profile Dual Mini-Fragment Plating of Diaphyseal Clavicle Fractures - A Biomechanical Study

Abstract Background Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model. Aims To compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates. Methods Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking. Results Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening, and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047. Conclusion From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations.

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.

NEW-GENERATION SUPERIOR SINGLE PLATING VERSUS LOW-PROFILE DUAL MINI-FRAGMENT PLATING OF DIAPHYSEAL CLAVICLE FRACTURES: A BIOMECHANICAL STUDY

Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model. Therefore, the aim of the current study was to compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates.Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking.Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047.From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations.

Single-plate versus double-plate comparison in the surgical treatment of comminuted clavicle fractures: Is the secondary plate reliable?

The objective of this study is to retrospectively assess the use of single-plate (SP) and double-plate (DP) fixation in the open reduction and internal fixation of comminuted clavicle fractures, focusing on fracture union and complications. We retrospectively evaluated comminuted diaphyseal clavicle fractures (Arbeitsgemeinschaft für Osteosynthesefragen type 15.B1-3) treated with open reduction and internal fixation and having a minimum 1-year follow-up. Two patient cohorts were identified: DP (utilizing a superiorly located clavicle-specific plate and an anteriorly located tubular plate) and SP (utilizing a superiorly located clavicle-specific plate). These groups were compared in terms of union time, peri-incisional numbness, implant irritation, return to work time, union rates, re-operation rates, Disabilities of Arm, Shoulder and Hand (DASH), and American Shoulder and Elbow Surgeons (ASES) scores. The study included 27 SP and 23 DP patients meeting the inclusion criteria. There was no significant difference between the 2 cohorts in terms of union time, peri-incisional numbness, implant irritation, return to work time, union rates, re-operation rates, DASH, and ASES scores at the end of the first year (P = .889, P = 1.00, P = .122, P = 1.00, P = 1.00, P = .493, P = .736, P = .762, P = .937 respectively). However, it was observed that the DP group showed a significantly earlier return to work time and better DASH scores at 3rd and 6th months, whereas the SP group exhibited significantly better ASES scores at 3rd and 6th months (P = .034, P = .016, P = .032, P = .036, P = .021, respectively). No significant difference was observed in terms of union and complications in acute clavicle fractures treated with SP and DP fixation. The DP group demonstrated an earlier return to work and superior early functional scores compared to the SP group. Our findings suggest that a secondary plate can be reliably used, particularly in situations where clavicle fracture fixation is insufficient or in cases of comminuted clavicle fractures.

An Evidence-Based Approach to Managing Adolescent (Ages 10 to 19 Years) Diaphyseal Clavicle Fractures.

Diaphyseal clavicle fractures occur most frequently in adolescents (defined as ages 10 to 19 years by the World Health Organization). Multiple prospective comparative studies exist in the adult literature, whereas studies focusing on adolescents are limited. Given the notable differences in healing potential between pediatric, adolescent, and adult diaphyseal clavicle fractures, treatment algorithms tailored specifically to children, adolescents, and adults are required. In the past two decades, there has been a dramatic rise in surgical fixation of adolescent diaphyseal clavicle fractures, largely influenced by adult literature. The remodeling potential of the clavicle throughout adolescence and into early adulthood exceeds that of the adult population. Furthermore, prospective outcomes studies of displaced diaphyseal clavicle fractures have demonstrated that, when compared with surgical management, nonsurgical management portends equivalent functional outcomes but a nearly four times greater rate of complications. Even those injuries with comminution and notable shortening, nonsurgical treatment yields good functional outcomes, high rates of return to sport, and low incidence of complications, such as nonunion, symptomatic malunion, and refracture. In rare cases of unsatisfactory nonsurgical treatment, secondary surgical fixation most often results in union and good functional outcomes.

New generation of superior single plating vs. low-profile dual minifragment plating in diaphyseal clavicle fractures: a biomechanical comparative study

Recently, a new generation of superior clavicle plates was developed featuring the variable angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, mini-fragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new generation plate versus dual plating using low-profile mini-fragment plates. Sixteen paired human cadaveric clavicles were pairwise assigned to two groups for instrumentation with either a superior 2.7 mm Variable Angle Locking Compression Plate (Group 1), or with one 2.5 mm anterior combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking. Initial construct stiffness was significantly higher in Group 2 (9.28 ± 4.40 N/mm) compared to Group 1 (3.68 ± 1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in Group 1 compared to Group 2, p≤0.038. Cycles to 2mm shear displacement were significantly lower in Group 1 (22792 ± 4346) compared to Group 2 (27437 ± 1877), p=0.047. From a biomechanical perspective, low-profile 2.5/2.0 dual plates can be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in less common unstable fracture configurations. 2.7 single superior variable angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in less common unstable fracture configurations.

Fractures around the shoulder in the skeletally immature: A scoping review.

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.

LOW-PROFILE DUAL MINI-FRAGMENT PLATING OF DIAPHYSEAL CLAVICLE FRACTURES: A BIOMECHANICAL STUDY

Implant removal after clavicle plating is common. Low-profile dual mini-fragment plate constructs are considered safe for fixation of diaphyseal clavicle fractures. The aim of this study was to investigate: (1) the biomechanical competence of different dual plate designs from stiffness and cycles to failure, and (2) to compare them against 3.5mm single superoanterior plating.Twelve artificial clavicles were assigned to 2 groups and instrumented with titanium matrix mandible plates as follows: group 1 (G1) (2.5mm anterior+2.0mm superior) and group 2 (G2) (2.0mm anterior+2.0mm superior). An unstable clavicle shaft fracture (AO/OTA15.2C) was simulated. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with torsion around the shaft axis and compared to previous published data of 6 locked superoanterior plates tested under the same conditions (G3).Displacement (mm) after 5000 cycles was highest in G3 (10.7±0.8) followed by G2 (8.5±1.0) and G1 (7.5±1.0), respectively. Both outcomes were significantly higher in G3 as compared to both G1 and G2 (p≤0.027). Cycles to failure were highest in G3 (19536±3586) followed by G1 (15834±3492) and G2 (11104±3177), being significantly higher in G3 compared to G2 (p=0.004). Failure was breakage of one or two plates at the level of the osteotomy in all specimens. One G1 specimen demonstrated failure of the anterior plate. Both plates in other G1 specimens. Majority of G2 had fractures in both plates. No screw pullout or additional clavicle fractures were observed among specimens.Low-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared to 3.5mm single plates, however, had significantly lower failure endurance. Low-profile 2.5/2.0 dual plates showed significant higher initial stiffness and similar resistance to failure compared to 3.5mm single locked plates and can be considered as a useful alternative for diaphyseal clavicle fracture fixation. These results complement the promising results of several clinical studies.

Anterior and superior plate positions in diaphyseal clavicle fractures produce similar patient outcomes.

While diaphyseal clavicle fractures can be treated with plate fixation on either the superior or anteroinferior aspect of the clavicle, the optimal plate position remains controversial. The purpose of this study was to determine if anteroinferior vs. superior plating for clavicle fracture fixation leads to better patient outcomes. A retrospective review of patients who sustained clavicle fractures (OTA/AO 15.2) treated with superior or anteroinferior plating at a tertiary Level I trauma center from 2015 to 2021 was performed. The clinical outcomes of clavicle fractures were compared between groups treated with an anterior versus a superior approach via Mann-Whitney U and Chi-squared tests as appropriate to evaluate for differences in outcomes between the two plate positions. A total of 315 diaphyseal clavicle fractures were identified. One hundred and forty patients were excluded due to inadequate follow-up. Of the remaining 175 patients, 25 were treated with an anteroinferior approach (14%) and 150 were treated with a superior approach (86%). There were no differences in age, BMI, tobacco use, or substance use between the two groups (p > 0.05 for all). On univariate analysis, there was no difference in rate of union (p = 0.60), nerve injury (p = 0.60), infection (p = 1.0), implant-related irritation (p = 0.42), implant removal (p = 0.26), or revision (p = 1.0) based on approach. Contoured plates had an association with risk of nerve injury (p = 0.04). There are no differences in union, nerve injury, infection, symptomatic implant, or revision rate between anteroinferior and superior clavicle approaches. Plate positioning during diaphyseal clavicle fracture fixation can reasonably be dictated based on surgeon preference and ideal reduction quality.

Coracoclavicular Ligament Reconstruction Using TightRope for Delayed Grade III Acromioclavicular Joint Injury After Ipsilateral Diaphyseal Clavicle Fracture Fixation: Surgical Technique and Review of Current Literature.

Athletes commonly sustain high-energy direct impact injuries to the shoulder, with acromioclavicular joint (ACJ) injuries accounting for over half. Ipsilateral ACJ injury and diaphyseal clavicle fracture occur nearly 7% of the time. There is limited literature offering treatment suggestions for this unique injury pattern and limited evidence providing guidance to suggest which injury patterns should be treated operatively or nonoperatively. Here, we present successful treatment of a high-level athlete utilizing a Knotless TightRope XP placed through a superior clavicle plate with successful return to full activity at 6 months postoperation. The TightRope technique offers the ability to augment through a preexisting superior clavicular plate in a low-profile manner and promote easy suture tensioning to obtain and maintain reduction of the injured ACJ.

Low-profile dual mini-fragment plating of diaphyseal clavicle fractures. A biomechanical comparative analysis

Abstract Objective Implant removal rates after clavicle plating are high. Recently, low-profile dual mini-fragment plate constructs have proven safe for the fixation of diaphyseal clavicle fractures. Therefore, the aims of this study was to investigate: (1) the biomechanical competence of different dual plate designs in terms of stiffness and cycles to failure, and (2) to compare them against 3.5 mm single superoanterior plating. Methods 12 artificial clavicles were assigned to 2 groups and instrumented with titanium matrix mandible plates as follows: group 1 (2.5 mm anterior+2.0 mm superior) and group 2 (2.0 mm anterior+2.0 mm superior). An unstable clavicle shaft fracture (AO/OTA15.2C) was simulated. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with torsion around the shaft axis and compared to previous published data of 6 locked superoanterior plates tested under the same conditions (group 3) Results Displacement (mm) after 5000 cycles was highest in group 3 (10.7±0.8) followed by group 2 (8.5±1.0) and group 1 (7.5±1.0), respectively. Both outcomes were significantly higher in group 3 as compared to both groups 1 and 2 (p≤0.027). Cycles to failure were highest in group 3 (19536±3586) followed by group 1 (15834±3492) and group 2 (11104±3177), being significantly higher in group 3 as compared to group 2 (p=0.004). Conclusion Low-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared to 3.5 mm single plates, however, they revealed significantly lower endurance to failure. Moreover, low-profile 2.5/2.0 dual plates showed significant higher initial stiffness and similar resistance to failure compared to 3.5 mm single locked plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation. These results complement the promising results of several clinical studies.

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.

Low-profile dual mini-fragment plating of diaphyseal clavicle fractures. A biomechanical comparative testing

BackgroundImplant removal rates after clavicle plating are high. Recently, low-profile dual mini-fragment plate constructs have revealed lower implant removal rates following fixation of diaphyseal clavicle fractures. However, they have not been subject to a biomechanical investigation. AimsTo: (1) investigate thebiomechanical competence of different dual plate designs and (2) compare them against single superoanterior plating. MethodsTwelve artificial clavicles with a simulated AO/OTA 15.2C unstable diaphyseal clavicle fracture were assigned to 2 groups and instrumented with dual titanium mandible plates as follows: Group 1 – 2.5 mm anterior plus 2.0 mm superior (2.5/2.0); Group 2 – 2.0 mm anterior plus 2.0 mm superior (2.0/2.0). Specimens were cyclically tested to failure under craniocaudal cantilever bending superimposed with torsion around the shaft axis and compared to previous published data acquired using 6 locking superoanterior plates tested under the same conditions (Group 3). FindingsInitial stiffness was highest in Group 1 followed by Group 2 and Group 3, being significantly different between Group 1 and Group 3 (p = 0.020). Displacement after 5000 cycles was biggest in Group 3, followed by Group 2 and Group 1, with significant differences between Group 3 and both Group 1 and Group 2 (p ≤ 0.027). Cycles to failure were highest in Group 3 followed by Group 1 and Group 2, being significantly different between Group 2 and Group 3 (p = 0.004). InterpretationLow-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared with single 3.5 mm locking plates, however, they revealed significantly lower resistance to failure. Moreover, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness and similar resistance to failure compared with single 3.5 mm locking plates and can therefore be considered as their useful alternative for diaphyseal clavicle fracture fixation.

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.

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

Purpose: There has been a recent shift towards operative management of mid-shaft clavicle fractures in adults and adolescents. This has been largely based on studies in the adult population that showed reduced rates of nonunion, symptomatic malunion and better short-term functional outcomes. For injuries with a comminuted “Z-type” fracture pattern, characterized by vertical positioning of a segmental fragment, it is commonly accepted to treat surgically due to concerns about healing and bony prominence. The purpose of this study was to assess the clinical, radiographic, and patient-reported outcome measures (PROs) in adolescents with comminuted Z-type mid-shaft clavicle fractures by comparing an operative and nonoperative cohort.&#x0D; Methods: Patients aged 10 to 18 years treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at one of eight geographically diverse pediatric centers were screened and enrolled at the time of injury. Inclusion criteria were a comminuted Z-type fragment ≥1cm in size, with &gt;35 degrees of angulation relative to the long axis of the clavicle, and &gt;100% fracture displacement at time of presentation. Clinical course, complications, validated PROs, quality of life metrics, and satisfaction scores were analyzed and compared between the operative (Op) and nonoperative (NonOp) cohorts.&#x0D; Results: Eighty-two patients (37 NonOp, 45 Op) were included, 60 (73%) of whom provided 2-year PROs with similar response rates between treatment cohorts. There were no significant differences in demographics or fracture characteristics in the two cohorts other than fracture shortening being greater in the operative cohort (mean 29mm) compared to the nonoperative cohort (mean 23mm, p=0.01). This confounder was controlled for in both regression analysis and propensity score matching. There was no statistically significant difference in the rates of nonunion (none), delayed union (Op 2%, NonOp 0%, p=1.0), symptomatic malunion (Op 0%, NonOp 3%, p=0.4), refracture (Op 4%, NonOp 3%, p=1.0), unexpected surgery (Op 11% vs. NonOp 5%, p=0.45), or clinically significant complications (Op 16%, NonOp 5%, p=0.17) between cohorts. There were no differences in PROs (Table 1), even when controlling for fracture shortening.&#x0D; Conclusions: Z-type mid-shaft clavicle fractures are one of the most severe fracture patterns seen in adolescent shoulders. Yet, in this comparative investigation of 2-year PROs and complications, surgery appears to offer no benefit over nonoperative management. &#x0D; Significance: The comparable natural histories between this study’s operative and nonoperative cohorts are critical for surgeons and their adolescent patients to understand when deciding appropriate management, particularly when reviewing what are often very concerning appearing initial radiographs.

CHANGES IN SUPERIOR DISPLACEMENT, ANGULATION, AND SHORTENING IN THE EARLY PHASE OF HEALING FOR COMPLETELY DISPLACED MIDSHAFT CLAVICLE FRACTURES IN ADOLESCENTS: RESULTS FROM A PROSPECTIVE, MULTICENTER STUDY

Background:Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from non-operative to operative treatment. Whether this occurs in adolescent patients has not been well investigated.Purpose:The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing.Methods:This was an IRB approved multi-center study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients age 10-18 years treated at one of three tertiary care pediatric trauma centers were included; all of which had standardized imaging within 2 weeks of the date of injury and throughout the course of healing (5-20 weeks post-injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment were noted, as well as the subsequent need for surgical intervention. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement.Results:One hundred patients met the inclusion criteria. The mean shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks post-injury, the fracture alignment improved across all three measurements for the overall cohort, with mean improvements in shortening of 15%, superior displacement of 15%, and angulation of 21% (Figures 1,2,3) Using a clinical threshold of a change in shortening or displacement of 10 mm or angulation of 10 degrees, 21% of fractures improved, 4% worsened, and 75% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than less displaced fractures (p<0.001). No patient underwent surgical intervention for progressive displacement.Conclusions:Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, a 20% improvement in shortening and 50% improvement in angulation was identified. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.Figures:Figure 1.Figure 2.Figure 3.

Prospective study of clavicle fractures treated with pre-contoured locking compression plate

Introduction: We surgically treated acute displaced mid-third diaphyseal clavicle fractures with plate osteosynthesis using a precontoured locking compression plate, to evaluate the functional and radiological outcome and enumerate the complications associated with this modality of treatment. Materials and Methods: This prospective observational clinical study involving 50 adult patients was conducted in hospital over a period of 2 years. Fractures were classified based on Allman and Robinson classification system. Patients underwent ORIF with 3.5mm precontoured locking compression plate. Regular follow up for a minimum period of 6 months was done clinically and radiologically. Duration required for fracture union was studied, functional outcome was measured using Constant Murley score and complications if any were noted. Results: The functional outcome is assessed at the end of 6 months by the Constant and Murley scoring system. The mean constant score was 93.32% with a standard deviation of 6.67% and a range of 71% to 100%. In our study, 36 cases had excellent functional outcome, 10 cases had good functional outcome and 4 cases had fair functional outcome. None of the patients had a poor outcome. Conclusion: Bony union could be achieved with pre-contoured locking compression plate by reducing the complication rates in midshaft comminuted displaced clavicle fractures and functional outcome were satisfactory. Overall operative treatment using precontoured LCP is effective in the treatment of displaced mid-third clavicle fractures. All the fractures achieved union and there were no cases of non-union. Keywords: Clavicle, Fracture, Midshaft, Precontoured locking compression plate.

Can Upstream Patient Education Improve Fracture Care in a Digital World? Use of a Decision Aid for the Treatment of Displaced Diaphyseal Clavicle Fractures.

The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist. Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance. A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid. Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcome of absolute fixation by 3.5mm superior locking plate for displaced diaphyseal fractures of clavicle

The current study is a multi centre study done by both the surgeons in different tertiary care hospitals on thirty four patients, both the orthopedic surgeons followed the same operative protocols. It’s a prospective observational study of outcome of diaphyseal fractures managed by absolute fixation by 3.5 mm superiorly placed anatomically contoured locking plate. In case of comminuted fractures lag screws were also used in antero superior plane of clavicle. DASH (Disability of the Arm, Shoulder and Hand) Score was used to quantify the outcome. Regular follow-ups were done and our study showed a mean outcome of DASH score of 3.3 at 2 yrs.