Midshaft Clavicle Fractures In Adolescents Research Articles

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

Shoulder & Elbow

The December 2022 Shoulder & 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.

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.

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.

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.

VARIATION IN TREATMENT APPROACHES TO ADOLESCENT MIDSHAFT CLAVICLE FRACTURES IN PEDIATRIC VERSUS ADULT HOSPITALS

Background:Optimal treatment of midshaft clavicle fractures in adolescents remains a topic of controversy. While adolescent midshaft clavicle fractures have historically been treated nonoperatively, recent randomized controlled trials of displaced midshaft clavicle fractures in the adult literature have raised the question of decreased symptomatic nonunion and malunion and improved functional outcomes with surgery. Consequently, the rates of surgical treatment of adolescent midshaft clavicle fractures, particularly in the older adolescent age group, has increased, despite a paucity of high-level evidence to justify this trend.Hypothesis/Purpose:To identify differences in treatment approach for isolated, displaced midshaft clavicle fractures in ‘older’ adolescent patients at adult versus pediatric hospitals. The secondary objective was to identify factors associated with surgery.Methods:Adolescents aged 15 to 18 years with isolated, displaced midshaft clavicle fractures treated at one of two adult tertiary care hospitals or one pediatric tertiary care hospital. Exclusion criteria included open fractures, skin tenting, nondisplaced fractures, medial third or distal third clavicle fractures, non-isolated injuries, and delay from injury to presentation of more than 2 weeks. Bivariate analysis and multivariable logistic regression analysis were used to identify factors associated with surgical treatment.Results:Two hundred and fourteen patients (median age: 16 years, mean BMI: 22.5, 85% male) were included. The cohort from the pediatric hospital was significantly younger, had lower BMI, had fewer comminuted fractures, and a higher proportion of angulated fractures (Table 1). One hundred six (50%) patients underwent surgical treatment. Bivariate analysis showed that older age (p = 0.004), higher BMI (p = 0.002), dominant upper extremity injury (p = 0.001), and treatment at an adult hospital (p < 0.0001) were associated with surgery. The fracture characteristics of comminution (p < 0.0001), greater displacement (p < 0.0001), and greater shortening (p < 0.0001) were associated with surgery. Multivariable logistic regression analysis showed superior-inferior fracture displacement (OR 1.13, 95% CI 1.06 to 1.20), dominant upper extremity injury (OR 2.60, 95% CI 1.19 to 5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28 to 12.2) to be independently associated with surgery.Conclusions:After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high quality prospective outcomes studies.

Adolescent mid-shaft clavicular fracture displacement does not predict nonunion or inferior functional outcome at long-term follow-up.

The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture. We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671). The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients' demography or functional outcomes between operative and nonoperative treatments. Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J2021;103-B(5):951-957.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents

Purpose: Treatment of midshaft clavicle fractures in adolescents remains controversial. The adult literature suggests more favorable outcomes with open reduction internal fixation (ORIF), and it is unknown how this has influenced the management in the adolescent population over the past decade. The purpose of this study was to longitudinally evaluate the rates of operative management of midshaft clavicle fractures in adolescent patients. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database were evaluated for the years 2005–2015. Patients 10–18 years-old with a midshaft clavicle fracture, who underwent operative or nonoperative management, were identified using diagnosis and procedure codes. Data regarding age, sex, race, insurance type, and income percentile were also collected. The overall number of fractures managed operatively and nonoperatively were compared. Throughout the study period, factors associated with operative and non-operative management were analyzed. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4,815 adolescent midshaft clavicle fractures identified between 2005 and 2015, and 375 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management from 4.26% (n = 62) between 2005 and 2008 to 12.13% (n=141) between 2012 and 2015 (p<0.001). This increase was seen across all racial groups (p<0.05). Patients undergoing operative management were significantly older [16.0±1.7 vs. 14.1±2.3 years-old, p<0.001], were more likely to have Medicaid insurance (p<0.001), and were more likely to be in the bottom 75th percentile for income. Conclusion: The rate of adolescent midshaft clavicle fractures treated operatively has significantly increased over the past decade, and there are several demographic and socioeconomic differences between patients treated with and without surgery. Additional outcomes research is needed to justify this trend in adolescent patients with midshaft clavicle fractures in the bottom 75th percentile income brackets. Additional studies are needed to understand and validate the increased rates in operative management of midshaft clavicle fractures in adolescents.

Variation in Treatment Approaches to Adolescent Midshaft Clavicle Fractures in Pediatric Versus Adult Hospitals.

The primary objective of this study was to identify differences in the treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15-18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with the surgical treatment of these fractures in this age group. Retrospective cohort study. Two adult and one pediatric tertiary care referral hospitals. Adolescent patients 15-18 years of age with isolated, displaced midshaft clavicle fractures treated at 2 adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included. Nonoperative versus surgical treatment of clavicle fractures. Surgical treatment. A multivariable logistic regression analysis showed that superior-inferior fracture displacement [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06-1.20], dominant upper extremity injury (OR 2.60, 95% CI 1.19-5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28-12.2) were independently associated with the surgical treatment of adolescent displaced midshaft clavicle fractures. After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high-quality prospective outcome studies. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Radiological Outcomes after Various Treatments of Midshaft Clavicle Fractures in Adolescents.

BackgroudControversy exists about the optimal treatment of midshaft clavicle fractures in the presence of significant displacement, comminution, or shortening of the fracture in adolescents. The purpose of this study was to compare the clinical and radiological outcomes of 4 different treatments for midshaft clavicle fractures in adolescents: conservative treatment with a figure-of-8 (FO8) brace, open reduction and internal fixation with a plate (OPL), minimally invasive plate osteosynthesis (MIPO), and intramedullary nail fixation with a threaded Steinmann pin (TSP).MethodsA total of 94 teenagers with midshaft clavicle fractures were divided into the FO8, OPL, MIPO, and TSP groups (n = 24, 33, 16, and 21, respectively). We analyzed clinical and radiological outcomes and complications in each group and compared the results among the groups.ResultsAll groups showed satisfactory clinical and radiological outcomes, but each group showed different results for the assessment items. The Constant-Murley scores were higher in the operated groups than in the FO8 group. Recovery of joint motion was faster in the operated groups. The TSP group had the highest cosmetic satisfaction with respect to the satisfaction score and measured scar length. Fracture union was achieved in all patients. At the final follow-up, the bone length was closer to normal in the OPL and TSP groups than in the FO8 and MIPO groups, and angulation was less in the OPL and TSP groups than in the MIPO and FO8 groups. The TSP and MIPO groups obtained faster bone healing than the OPL and FO8 groups. In the operated groups, 9 patients had metal-induced irritating symptoms; 1, supraclavicular nerve injury symptoms; and 4, refractures after plate removal.ConclusionsThe nonoperatively treated group had no iatrogenic complications. The operated groups complained of various disadvantages induced by surgery; however, these groups achieved faster functional recovery and slightly better radiological and functional results than the nonoperative group.

Two-Year Functional Outcomes of Operative vs. Non-Operative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results from a Prospective, Multicenter, Level 2 Study

Purpose: To investigate the two-year functional outcomes and complications following operative versus non-operative treatment of completely displaced midshaft clavicle fractures in adolescents.&#x0D; Methods: All patients 10-18 years old treated for a midshaft clavicle fracture between August, 2013 and August, 2018 at one of 8 geographically diverse, high-volume, tertiary-care pediatric centers were enrolled, with independent treatment decisions determined by individual providers. The sub-population of patients with completely displaced fractures was prospectively followed for over 2 years. Clinical course, complications, validated patient-reported outcome measures (PROs), quality of life metrics, and satisfaction scores were analyzed. To address the ceiling effect of the PRO/satisfaction data following clavicle injuries, a priori thresholds for ‘suboptimal’ scores were established (ASES scores &lt;90, QuickDASH scores &gt;10, EQ-5D &lt;0.80). According to ‘intention to treat’ statistical principles, one post-operative complication (and a subsequent secondary operation) was analyzed within the non-operative cohort, given that the patient represented a ‘crossover’ from the non-operative to the operative treatment group.&#x0D; Results: Of the 909 patients enrolled in the prospective study, 417 patients (45.9%) demonstrated completely displaced fractures and maintained enrollment over the study period, 277 (66%) of whom had reached two year follow up, and 151 of whom provided adequate PRO data, representing a 55% response rate. Of these patients, 55 (36%) underwent operative treatment, while 96 (64%) were treated non-operatively. Those treated surgically showed no difference in gender distribution (76% males,p=0.43), athletic participation (p=0.76), or fracture pattern (p=0.18), but were older (mean age 15.3 vs. 13.5 years, p&lt;0.001) and had greater shortening (p&lt;0.001) than those treated non-operatively. Within the subset with adequate complication data, listed in Table 1, complications were less common in non-surgical than surgical patients (p=0.0003), but this difference did not reach significance when sensory deficits were excluded (p=0.17). There was no difference in secondary surgeries (p=0.43). While greater percentages of operative than non-operative patients reported suboptimal PRO/satisfaction scores (ASES: 15% vs. 5%, QuickDASH 11% vs. 5%, satisfaction 11% vs. 5%), these differences did not reach significance (p=0.07, 0.20, 0.06, respectively).&#x0D; Conclusion: At eight large pediatric centers with many surgeons making independent treatment decisions, non-operative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes.&#x0D; Significance: These data establish a comprehensive functional assessment of adolescents treated for clavicle fractures, which represents the epidemiological sub-population most affected by this condition. Unlike several adult studies demonstrating superiority in operative treatment, this adolescent study demonstrates equivalent function and fewer complications associated with non-operative treatment.

Two-year Functional Outcomes Of Operative Vs. Non-operative Treatment Of Completely Displaced Midshaft Clavicle Fractures In Adolescents: Results From A Prospective, Multicenter, Level 2 Study

Objectives:To investigate the two-year functional outcomes and complications following operative versus non-operative treatment of completely displaced midshaft clavicle fractures in adolescents.Methods:All patients 10-18 years-old treated for a midshaft clavicle fracture between August, 2013 and August, 2018 at one of 8 geographically diverse, high-volume, tertiary-care pediatric centers were enrolled, with independent treatment decisions determined by individual providers. The sub-population of patients with completely displaced fractures was prospectively followed for over 2 years. Clinical course, complications, validated patient-reported outcome measures (PROs), quality of life metrics, and satisfaction scores were analyzed. To address the ceiling effect of the PRO/satisfaction data following clavicle injuries, a priori thresholds for ‘suboptimal’ scores were established (ASES scores <90, QuickDASH scores >10, EQ-5D <0.80). According to ‘intention to treat’ statistical principles, one post-operative complication (and a subsequent secondary operation) was analyzed within the non-operative cohort, given that the patient represented a ‘crossover’ from the non-operative to the operative treatment group.Results:Of the 909 patients enrolled in the prospective study, 417 patients (45.9%) demonstrated completely displaced fractures and maintained enrollment over the study period, 277 (66%) of whom had reached two year follow up, and 151 of whom provided adequate PRO data, representing a 55% response rate. Of these patients, 55 (36%) underwent operative treatment, while 96 (64%) were treated non-operatively. Those treated surgically showed no difference in gender distribution (76% males,p=0.43), athletic participation (p=0.76), or fracture pattern (p=0.18), but were older (mean age 15.3 vs. 13.5 years, p<0.001) and had greater shortening (p<0.001) than those treated non-operatively. Within the subset with adequate complication data, listed in Figure 1, complications were less common in non-surgical than surgical patients (p=0.0003), but this difference did not reach significance when sensory deficits were excluded (p=0.17). There was no difference in secondary surgeries (p=0.43). While greater percentages of operative than non-operative patients reported suboptimal PRO/satisfaction scores (ASES: 15% vs. 5%, QuickDASH 11% vs 5%, satisfaction 11% vs. 5%), these differences did not reach significance (p=0.07, 0.20, 0.06, respectively).Conclusion:At eight large pediatric centers with many surgeons making independent treatment decisions, non-operative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes.These data establish a comprehensive functional assessment of adolescents treated for clavicle fractures, which represents the epidemiological sub-population most affected by this condition. Unlike several adult studies demonstrating superiority in operative treatment, this adolescent study demonstrates equivalent function and fewer complications associated with non-operative treatment.Complications of Completely Displaced Midshaft Clavicle Fractures with 2-Year Follow-UpComplicationSurgical (N=53)Clinical OutcomeNon-Surgical (N=87)Clinical Outcome p-value n (%)n (%)Hardware pain/irritation5 (9.4%)2 out of 5 (40%;3.8% overall): ROH surgery (mean 21.5 months post-op)$1 (1.1%)‘Crossover’ patient: ORIF 2 months post-injury → ROH surgery 10 months post-op0.03Sensory symptoms13 (24.5%)Numbness distal to incision (resolution reported in 5 out of 13, 38%, mean 6 months post-op)1 (1.1%)Occasional paresthesias (6mo post-op) → spontaneous resolution<0.0001Superficial Infection0 (0.0%)0 (0.0%)n/aDeep Infection0 (0.0%)0 (0.0%)n/aDelayed Union2 (3.8%)Patient 1: bone stimulator (6 months post-op) → healing Patient 2: Revision ORIF → healed2 (2.3%)Both patients: non-operative treatment → healedn/aNon-union0 (0.0%)0 (0.0%)n/aSymptomatic Malunion0 (0.0%)2 (2.3%)Patient 1: PT → improvement Patient 2: operative exostosis for bony prominence → resolutionn/aRefracture1 (1.9%)2 wks following ROH → healed w/ non-operative tx2 (2.3%)Both patients: non-operative treatment → healedn/aOther described below)3 (5.7%)0 (0.0%)n/aAtlanto-axial rotatory subluxation (immediately postoperative)1 (1.9%)Unresponsive to halo traction → C1-2 fusion0 (0.0%)n/aIntra-operative blood loss (1 liter) —* urgent vascular surgery consultation1 (1.9%)Ligation of cephalic vein branch0 (0.0%)n/aDevelopment of acromioclavicular (AC) joint ganglion cyst (4 mo post-op)1 (1.9%)US-guided AC joint aspiration, injection (7 mo post-op)#0 (0.0%)n/aAny secondary operation4 (7.5%)3 (3.4%)0.43Any Complication19 (35.8%)8 (9.2%)0.0003Any Complication (excluding ‘Sensory’)9 (17.0%)7 (8.0%)0.17$ ROH = removal of hardware*PT = physical therapy#US = ultrasound

Bioabsorbable plating in the treatment of pediatric clavicle fractures: A biomechanical and clinical analysis

BackgroundClassic implants for operative intervention of mid-shaft clavicle fractures in adolescents can become symptomatic, requiring removal. This study compares 1) biomechanical properties and 2) clinical outcomes in adolescents of mid-shaft clavicle fracture fixation with bioabsorbable versus metal implants. MethodsSix synthetic clavicles with mid-shaft fractures underwent bioabsorbable plating. A testing frame applied 10 non-destructive torsion and 10 axial compression cycles, followed by cantilever bending to failure. Stiffness was calculated; maximum failure load and failure mode were recorded. Results were compared to previous data for locked metal constructs.Retrospective review of surgically treated clavicle fractures over three years included functional and radiographic outcomes. FindingsBioabsorbable plates had lower torsional stiffness (P < 0.001) and maximum cantilever load (P < 0.0001) than locked metal plates. There was no significant difference in compression stiffness (P = 0.2) or cantilever bending stiffness (P = 0.4). Primary failure of metal plates was screw pull-out compared to plate bending in bioabsorbable constructs.Seven patients with bioabsorbable implants were included. All patients with bioabsorbable constructs achieved radiographic union, but 71% lost reduction. Despite fracture angulation, all achieved normal shoulder function after one year determined by QuickDASH evaluation. None required a second surgery. InterpretationBioabsorbable implants had lower torsional stiffness and cantilever failure load, but comparable compression stiffness to metal implants. Bioabsorbable implants failed via gradual bending versus the catastrophic failure seen in metal implants. The clinical review allows understanding of the sequelae of this lower failure load of bioabsorbable plates where their use allowed in fracture displacement, yet achievement of ultimate radiographic union and acceptable functional outcomes.

Reliability of Radiographic Assessments of Adolescent Midshaft Clavicle Fractures by the FACTS Multicenter Study Group.

There is a recent trend toward increased surgical treatment of displaced midshaft clavicle fractures in adolescents. The primary purpose of this study was to evaluate the intrarater and interrater reliability of clavicle fracture classification systems and measurements of displacement, shortening, and angulation in adolescents. The secondary purpose was to compare 2 different measurement methods for fracture shortening. This study was performed by a multicenter study group conducting a prospective, comparative, observational cohort study of adolescent clavicle fractures. Eight raters evaluated 24 deidentified anteroposterior clavicle radiographs selected from patients 10-18 years of age with midshaft clavicle fractures. Two clavicle fracture classification systems were used, and 2 measurements for shortening, 1 measurement for superior-inferior displacement, and 2 measurements for fracture angulation were performed. A minimum of 2 weeks after the first round, the process was repeated. Intraclass correlation coefficients were calculated. Good to excellent intrarater and interrater agreement was achieved for the descriptive classification system of fracture displacement, direction of angulation, presence of comminution, and all continuous variables, including both measurements of shortening, superior-inferior displacement, and degrees of angulation. Moderate agreement was achieved for the Arbeitsgemeinschaft für Osteosynthesefragen classification system overall. Mean shortening by 2 different methods were significantly different from each other (P < 0.0001). Most radiographic measurements performed by investigators in a multicenter, prospective cohort study of adolescent clavicle fractures demonstrated good-to-excellent intrarater and interrater reliability. Future consensus on the most accurate and clinically appropriate measurement method for fracture shortening is critical.

Outcomes of treatment of displaced midshaft clavicle fractures in adolescents using titanium elastic nails

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.

Sports participation and radiographic findings of adolescents treated nonoperatively for displaced clavicle fractures

BackgroundThere is a relative paucity of high-level evidence that guides the treatment of displaced midshaft clavicle fractures in adolescents. Some use overhead sports or significant shortening as relative indications for surgical treatment, while others rarely consider operative intervention for these patients. The purpose of this study is to determine the effect of overhead sports participation and fracture shortening on subjective and objective outcomes after nonoperative treatment of displaced midshaft clavicle fractures in those aged 10–17 years. MethodsUsing a radiographic database, adolescents with displaced clavicle fractures were identified and contacted over the phone. These subjects were invited to take part in the study in return for compensation. Radiographic measurements of dedicated clavicle films around the time of injury were performed, and a custom survey aimed at elucidating participation in overhead or contact sports was given. The Nottingham Clavicle Score (NCS) and the Constant Shoulder Score were obtained for each patient to provide both subjective and objective outcome data. Statistical Package for Social Science (SPSS) software (version 22, IBM) was used to compare radiographic and sports data to the outcome measures. ResultsGender, age at the time of fracture, time since fracture, relative and absolute radiographic shortening, and hand dominance were all not significantly correlated with subjective or objective outcomes. Five patients (23%) reported not feeling happy with the appearance of their shoulder at the beach or at the pool. This group had statistically lower NCS results. Eleven of 22 participated in ≥6 months per year of overhead or contact sports; they did not have worse subjective or objective outcomes. ConclusionsFracture shortening and sports participation do not have a significant impact in adolescents on outcomes after displaced midshaft clavicle fracture.

Reliability of Measurements of Clavicle Shaft Fracture Shortening in Adolescents

A relative indication for surgical treatment of midshaft clavicle fractures is shortening ≥2.0 cm. A standard method for determining shortening with routine clavicle radiographs has not been established. This study evaluated the interobserver and intraobserver reliability when measuring shortening of midshaft clavicle fractures in adolescents. We identified all clavicle radiographs of simple midshaft clavicle fractures in adolescents from 2006 to 2010. Thirty-two radiographs were chosen following a power analysis for 7 observers. Each film was measured twice by each evaluator using 2 separate methods. Method 1 was the evaluator's method of choice to determine shortening on the digital radiographs. Method 2 was standardized. Intraclass correlation coefficient and confidence intervals (CI) were calculated to determine interrater reliability, and average differences between the 2 time points with 95% CI were calculated to determine intrarater reliability. Interrater reliability for method 1 was 0.771 (95% CI, 0.655-0.865) and 0.743 (95% CI, 0.604-0.851) at the 2 time points for fair agreement. Interrater reliability for method 2 was 0.741 (95% CI, 0.629-0.842) and 0.685 (95% CI, 0.554-0.805) at the 2 time points, for fair and poor agreement, respectively. Neither method was statistically superior to the other. For method 1, the SD for the measurements averaged 3.1 mm. For method 2, the average SD was 3.0 mm. Intrarater reliability for method 1 was 2.62 mm average difference between the 2 time points (95% CI, 2.24-3.00), and for method 2 it was 3.34 mm average (95% CI, 2.88-3.80). Method 2 had a significantly greater difference at the 2 time points than method 1 (P=0.027). There is only fair agreement among observers when measuring the shortening of clavicle fractures in adolescents on digital clavicle radiographs by either method described. However, as the average difference among measurers was only 3 mm, this is unlikely to influence clinical decision making. A lack of standardization of measurement in previous studies on clavicle fracture treatment may not represent a significant problem. Level III diagnostic study.