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

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.

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

Background

The primary aim of this study was to determine the epidemiology of lateral-end clavicle fractures in adolescents. The secondary aim was to assess the outcome following non-operative management.

Methods

A retrospective review of all adolescent clavicle fractures over a 10-year period was undertaken. Fracture classification, demographics, management, and complications were analysed. Functional outcomes were undertaken with the Quick Disabilities of Arm, Shoulder and Hand and EuroQol five-dimension at mean 8.8 years post-injury.

Results

In total, 677 clavicle fractures were analysed, 8.7% were lateral-end fractures (n = 59/677). The median age was 14.6 (range: 13-17) and 92% were male (n = 54/59). The incidence was 0.17 per 100,000 per year. All displaced physeal fractures (Neer IV n = 14) were managed non-operatively and of the six followed-up, all united with good outcomes. The adult type displaced fracture (Neer II) occurred in fifteen fractures, five underwent operative fixation and ten were managed non-operatively with one subsequent nonunion (n = 1/10). Those patients that underwent non-operative management (response n = 5/10, 50%) reported a median Quick Disabilities of Arm, Shoulder and Hand of 2.3 but approximately 40% reported cosmetic and outcome dissatisfaction at long-term follow-up.

Conclusion

Displaced Neer II lateral-end clavicle fractures are rare in the adolescent population. Although nonunion is rare, some dissatisfaction with cosmesis persists at long-term follow-up despite good functional outcomes with non-operative management.

How common are refractures in childhood?

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Methods

All patients aged under 16 years with a fracture that had occurred in a bone with ongoing growth (open physis) from 1 May 2015 to 31 December 2020 were retrieved from the Swedish Fracture Register. A new fracture in the same segment within one year of the primary fracture was regarded as a refracture. Fracture localization, sex, lateral distribution, and time from primary fracture to refracture were analyzed for all long bones.

Results

Of 40,090 primary fractures, 348 children (0.88%) sustained a refracture in the same long bone segment. The diaphyseal forearm was the long bone segment most commonly affected by refractures (n = 140; 3.4%). The median time to refracture was 147 days (interquartile range 82 to 253) in all segments of the long bones combined. The majority of the refractures occurred in boys (n = 236; 67%), and the left side was the most common side to refracture (n = 220; 62%). The data in this study suggest that the risk of refracture decreases after 180 days in the diaphyseal forearm, after 90 days in the distal forearm, and after 135 days in the diaphyseal tibia.

Conclusion

Refractures in children are rare. However, different fractured segments run a different threat of refracture, with the highest risk associated with diaphyseal forearm fractures. The data in this study imply that children who have sustained a distal forearm fracture should avoid hazardous activities for three months, while children with a diaphyseal forearm fracture should avoid these activities for six months, and for four and a half months if they have sustained a diaphyseal tibia fracture.

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

BACKGROUND

From 1999 to 2011, studies demonstrated an increasing trend toward surgical management of adolescent clavicle fractures. The purpose of this study was to examine more recent trends of surgical management of closed clavicle fractures in adolescent patients over the past decade.

METHODS

A retrospective cohort study was conducted using the PearlDiver database. Patients with clavicle fractures from 2011 to 2021 were identified and stratified by age, sex, and year of their fracture. Categorical variables were compared with a chi square test, and continuous variables were compared with the Welch t test or Mann-Whitney U test.

RESULTS

Overall, there was a significant increase in the percentage of patients surgically treated by open reduction and internal fixation from 2016 to 2021 compared with 2011 to 2015 (8.58% vs. 7.34%, P < 0.001). When stratified by age, both the 10 to 14-year group (3.80% vs. 3.10%, P < 0.001) and the 15 to 18-year group (15.41% vs. 12.84%, P < 0.001) demonstrated significant increases in the percentage of patients surgically treated.

CONCLUSION

Despite increasing literature demonstrating high revision surgery rates for surgical treatment of adolescent clavicle fractures with no difference in functional outcomes, this study demonstrated a notable increase in the rate of surgical treatment of adolescent clavicle fractures from 2011 to 2021 in the United States.