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Surgical Treatment of Adolescent Clavicle Fractures: Results and Complications

McIntosh, Amy L. MD

Journal of Pediatric Orthopaedics: June 2016 - Volume 36 - Issue - p S41–S43
doi: 10.1097/BPO.0000000000000757
Supplement

No level 1 evidence is available to guide the surgical treatment of adolescent clavicle fractures. Adult literature is not applicable as adolescent mid-diaphyseal clavicle fractures do not develop nonunions, and only a small percentage (10% to 20%) are symptomatic from malunions. Current indications for operative fixation are: (1) completely displaced midshaft fracture with shortening of >2 cm; (2) superior displacement with skin tenting and/or an impending open fracture; (3) associated neurovascular injury; (4) open clavicular fracture; and (5) floating shoulder with a completely displaced clavicular fracture. Future large prospective randomized studies will need to be performed to accurately define which adolescent patients will “truly” benefit from surgical intervention.

Texas Scottish Rite Hospital for Children, Dallas, TX

The author declares no conflicts of interest.

Reprints: Amy L. McIntosh, MD, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail: amy.mcintosh@tsrh.org.

Clavicle fractures are common. A total of 29 to 64 of 100,000 people will fracture their clavicle each year, and patients aged 13 to 20 years are the most likely to sustain this injury. Thus, clavicle fractures are synonymous with adolescence. Men are 2.6 times more likely to fracture their clavicle than women, and a sport-related injury is the most common mechanism.1

Over the last 10 years, the treatment of adult (above 18 y) clavicle fractures has changed dramatically. This changing treatment paradigm resulted from the prospective research that demonstrated a 4.5% rate of clavicular nonunion when diaphyseal fractures were treated nonoperatively. Risk factors for nonunion include increasing age, female sex, greater amounts of displacement, and comminution.2 Functional testing of displaced clavicle fractures treated nonoperatively also revealed 20% to 25% deficits in shoulder strength and lower outcomes scores compared with a group of normal controls.3

Shortly thereafter, a prospective, multicenter, randomized clinical trial was performed by the Canadian Orthopaedic Trauma Society. They compared open reduction internal fixation with sling for “completely displaced” diaphyseal clavicle fractures. The mean time to radiographic union was 28.4 weeks in the nonoperative group compared with 16.4 weeks in the operative group (P=0.001). There were 2 nonunions in the operative group compared with 7 in the nonoperative group (P=0.042). Symptomatic malunion developed in 9 patients in the nonoperative group and in none in the operative group (P=0.001). They concluded that operative fixation of a displaced fracture of the clavicular shaft results in improved functional outcome and a lower rate of malunion and nonunion compared with nonoperative treatment at 1 year of follow-up.4 This was the first level 1 evidence study to demonstrate superior outcomes with surgical treatment of clavicle fractures in adult patients.

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PRINCIPLES OF MANAGEMENT

Nonoperative Management: What are the Risks of Clavicular Nonunion and Malunion?

Should this adult literature be applied to adolescent patients? Do adolescent patients treated nonoperatively develop nonunions? Kubiak and Slongo reviewed 939 clavicle fractures in children over a 21-year period; no nonunions occurred.5 How much remodeling potential does a skeletally immature clavicle have? In a recent article by McGraw and colleagues, clavicular growth from birth to age 18 years was measured on 961 chest x-rays. They discovered that girls achieve 80% of their clavicle length by 9 years of age and boys by 12 years of age.6 Therefore, adolescent patients (aged, 12 to 18 y) with clavicle fractures have limited potential to remodel should a malunion occur.

Are clavicular malunions symptomatic in adolescent patients? Bae and colleagues examined 16 adolescent patients who were treated nonoperatively for mid-diaphyseal clavicle fractures. All fractures were displaced >2 cm and went onto a radiographic malunion. No clinically significant differences were demonstrated in range of motion or strength. However, at >2 years from injury, over 20% of patients reported pain and dissatisfaction as assessed by the visual analog scale≥3. Also, 1 patient underwent a corrective osteotomy for persistent thoracic outlet symptoms.7 Another study by Schulz et al8 demonstrated a 10% decrease in external rotation and abduction strength in adolescents treated nonoperatively with displaced (mean=12 mm) mid-diaphyseal clavicle fractures. At an average of 4.6 years postinjury, Randsborg et al9 correlated worse functional scores, cosmesis, and overall satisfaction with displaced clavicle fractures treated nonoperatively in adolescent patients aged 10 to 18 years.

We can then conclude that clavicular nonunions rarely occur, and only 10% to 20% of adolescent patients with clavicle malunions are symptomatic. To prevent a symptomatic clavicular malunion, which adolescent patient should undergo operative treatment?

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Operative Management: Are Outcomes Improved?

As a group, pediatric orthopaedic surgeons do not have any level 1 evidence to use as a guide. A few studies have reported good outcomes and minimal complications with operative treatment of displaced clavicle fractures.5,10,11 Vander Have et al12 compared operative with nonoperative treatment of midshaft clavicle fractures in adolescent patients. Operatively treated fractures were on average 27.5 mm displaced versus 12.5 mm in the nonoperative group. Time to union was 2.5 weeks shorter, and return to activity was 4 weeks faster in the operative cohort. Five patients (20%) in the nonoperative group developed a symptomatic malunion.12 Totally, 20% to 30% of the operatively treated patients underwent subsequent hardware removal.11,12 To truly understand the operative indications that will prevent symptomatic malunions in adolescent patients, large prospective randomized studies will need to be performed.

Regardless, across the nation, the volume of operative treatment of clavicle fractures in adolescent patients is rising. Heyworth et al13 reported this national trend in practice patterns at the 2014 American Orthopaedic Society for Sports Medicine.

Current indications supported by the existing literature for the surgical management of mid-diaphyseal clavicle fractures in adolescent patients include: (1) completely displaced midshaft fracture with shortening of >2 cm; (2) superior displacement with skin tenting and/or an impending open fracture; (3) associated neurovascular injury; (4) open clavicular fracture; and (5) floating shoulder with a completely displaced clavicular fracture (Figs. 1, 2).

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

Upright x-rays of the patient will help to determine the true displacement and shortening of the fracture.14 When positioning for surgery, the patient is placed in a beach chair position. Avoid placing an incision directly over clavicle, but instead, an incision slightly inferior to the clavicle is preferred. Create skin and subcutaneous flaps that allows for 2 layer closure including deltotrapezial fascia. Attempt a nerve sparring approach, but warn the patients that they will likely develop chest wall numbness. My preference for internal fixation is anteromedial precontoured plate fixation after an anatomic reduction is obtained and maintained with lag screws. Mulitple other implant options exist for the treatment of adolescent clavicle fractures. The lag screws are usually 2.7 or 3.5 mm in diameter. The wound is closed in layers with 2.0 and 3.0 monocryl. Patients wear a sling for 2 weeks postoperatively for pain control. Most patients are able to return to play at union, full motion, and strength. This usually occurs between 8 and 12 weeks postoperatively.

Surgical treatment of clavicle fractures is not free from complications. In a recent study by Luo et al,15 there was a 22% complication rate associated with operative fixation. Other studies also report that 20% to 30% of patients who undergo operative treatment of their clavicle fracture eventually require a subsequent hardware removal because of implant prominence in thin patients.11,12 The potential also exists for clavicular refracture after hardware removal.

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DISCUSSION

No level 1 evidence is available to guide the surgical treatment of adolescent clavicle fractures. Adult literature is not applicable because adolescent mid-diaphyseal clavicle fractures do not develop nonunions, and only a small percentage (10% to 20%) are symptomatic from malunions.

Current indications for operative fixation are: (1) completely displaced midshaft fracture with shortening of >2 cm; (2) superior displacement with skin tenting and/or an impending open fracture; (3) associated neurovascular injury; (4) open clavicular fracture; and (5) floating shoulder with a completely displaced clavicular fracture.

Future large prospective randomized studies will need to be performed to accurately define the adolescent patients who will “truly” benefit from surgical intervention.

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REFERENCES

1. Robinson CM. Fractures of the clavicle in the adult: epidemiology and classification. J Bone Joint Surg Br. 1998;80:476–484.
2. Robinson CM, Court-Brown CM, McQueen MM, et al.. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004;86:1359–1365.
3. McKee MD, Pedersen EM, Jones C, et al.. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88:35–40.
4. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89:1–10.
5. Kubiak R, Slongo T. Operative treatment of clavicle fractures in children: a review of 21 years. J Pediatr Orthop. 2002;22:736–739.
6. McGraw MA, Mehlman CT, Lindsell CJ, et al.. Postnatal growth of the clavicle: birth to 18 years of age. J Pediatr Orthop. 2009;29:937–943.
7. Bae DS, Shah AS, Kalish LA, et al.. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop. 2013;33:544–550.
8. Schulz J, Moor M, Roocroft J, et al.. Functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fractures. J Bone Joint Surg Am. 2013;95:1159–1165.
9. Randsborg PH, Fuglesang HF, Røtterud JH, et al.. Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years. J Pediatr Orthop. 2014;34:393–399.
10. Mehlman CT, Yihua G, Bochang C, et al.. Operative treatment of completely displaced clavicle shaft fractures in children. J Pediatr Orthop. 2009;29:851–855.
11. Namdari S, Ganley TJ, Baldwin K, et al.. Fixation of displaced midshaft clavicle fractures in skeletally immature patients. J Pediatr Orthop. 2011;31:507–511.
12. Vander Have KL, Perdue AM, Caird MS, et al.. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop. 2010;30:307–312.
13. Heyworth BE, Suppan CA, Kocher MS, et al.. Change in the volume of operative treatment of clavicle fractures in children and asolescents: National trends and practice patterns, AOSSM 2014, Seattle, OR.
14. Backus JD, Merriman DJ, McAndrew CM, et al.. Upright versus supine radiographs of clavicle fractures: does positioning matter? J Orthop Trauma. 2014;28:636–641.
15. Luo TD, Ashraf A, Larson AN, et al.. Complications in the treatment of adolescent clavicle fractures. Orthopedics. 2015;38:287–291.
Keywords:

adolescent; clavicle fracture; complications; surgery

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