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Displacement drives treatment of clavicle fractures

By Annie Hayashi

Nonsurgical treatment effective in most pediatric cases

Most clavicle fractures in pediatric and adolescent patients can be effectively treated without surgery—even if the fracture is displaced. But adolescents who sustain fracture displacements of more than 2 cm may require surgical treatment.

Those were the findings of two studies on the treatment of pediatric and adolescent clavicle fractures, one presented by Jeffrey I. Kessler, MD, and the other presented by Kelly L. Vanderhave, MD, at the Pediatric Orthopaedic Society of North America Annual Meeting.

Conservative management for youngsters
Dr. Kessler and his colleagues conducted a retrospective chart and radiographic review to assess nonsurgical treatment of closed pediatric clavicle fractures. Patients were grouped by age—birth to 5 years, 6 to 11 years, and 12 to 14 years.

“We assessed a number of variables, including the patient’s sex, the mode of injury, laterality, fracture site, fracture patterns, associated fractures, time to union, and complications that occurred within 1 year,” said Dr. Kessler.

Approximately 80 percent of patients had midshaft clavicle fractures; 58 percent of the fractures were on the left side and 42 percent were on the right side. A simple fall was the most common mechanism of injury.

Of the initial 791 patients, 118 were lost to follow-up. The remaining patients healed, based on both radiographic and clinical measures (full range of motion and an absence of any regular pain), with an average healing time of 6.4 weeks (Fig. 1).

Children younger than age 11 demonstrated excellent outcomes with no reports of symptomatic nonunions or delayed unions. (Malunions were not evaluated.)

Based on these results, Dr. Kessler concluded that younger patients may not require follow-up radiographs and appointments. “We may want to consider treating these clavicle fractures as we treat torus fractures. This could include giving the family a phone number for follow-up in the event that the child has a problem after the first 6 weeks,” he said.

Early adolescents also do well
Although several significant differences emerged in the older age group, these differences did not appear to adversely affect nonsurgical treatment outcomes. For example, the primary mechanism of injury shifted from a simple fall to a sports injury and the healing time was longer (average 10.1 weeks). In addition, the incidence of fracture displacement increased with age (Fig. 2).

“The recent literature on adult clavicle fractures indicates a higher incidence of pain, malunions, and nonunions than previously thought. Based on this data, I was expecting patients—particularly those returning to very active sports—to have some continued pain and difficulty. But they all returned to their pre-injury sports with apparently little to no symptoms,” noted Dr. Kessler.

Older adolescents may need surgery
“Midshaft clavicle fractures are common injuries and commonly displaced. In the 12- to 18-year-old age group, the fracture will invariably heal,” said Aaron M. Perdue, MD, one of Dr. Vanderhave’s coauthors.

“Adolescents do not possess the remodeling potential of younger children, however, and most midshaft clavicle fractures will heal with some degree of malunion, as seen with other extremity fractures,” he noted.

Dr. Vanderhave and her colleagues compared surgical and nonsurgical treatment of midshaft clavicle fractures in adolescents—looking specifically at time to union, complications, need for additional surgery, and return to activity.

Their retrospective review of 42 consecutive patients (age 12–18 years old) with 43 closed midshaft clavicle fractures included 25 patients treated nonsurgically and 17 patients treated surgically. Medical records were examined along with posteroanterior and cephalic radiographs to determine initial and interval fracture displacement and time to radiographic union.

“A symptomatic malunion was described as any fracture union with shortening and then residual sequelae. A complication was defined as any event requiring additional surgical treatment,” Dr. Vanderhave explained.

The patients in the nonsurgical group were treated with a sling or a figure-of-8 brace until their symptoms were resolved. Of the 25 patients, 13 had displaced fractures; the average displacement was 18.5 mm. The primary mechanism of injury was sports, and 11 patients in this group also sustained other injuries.

The surgical group—treated with open reduction and plating—had an average fracture displacement of 27.5 mm. The primary mechanism of injury was sports (58.8 percent), and 5 patients in this group had associated injuries.

Surgical patients had a shorter mean time to union than patients treated nonsurgically (7.5 weeks vs. 9.9 weeks for displaced fractures). Surgical patients also returned to activity earlier (mean 12 weeks vs. mean 16 weeks for nonsurgical treatment).

No nonunions were reported in either treatment group. The surgical group had no malunions; symptomatic malunion developed in five patients in the nonsurgical treatment group (four opted to have corrective osteotomy with internal fixation).

Based on these results, Dr. Vanderhave believes that adolescents with clavicle fractures and more than 2 cm of displacement may be at risk for symptomatic malunion. “The complication rates appear low with primary open reduction and internal fixation. Corrective osteotomy can be used to restore anatomy and resolve symptoms associated with mal-unions,” she concluded.

Fracture displacement is the decisive factor
Based on the findings of both studies, most pediatric patients with clavicle fractures responded well to conservative management—regardless of displacement.

Surgery may be an option, however, for older adolescents who have displaced fractures of 2 cm or more.

“We do not think all or even most displaced midshaft clavicle fractures need to be treated surgically,” said Dr. Perdue. “Conservative treatment of fractures with displacement of 2 cm or more, however, may result in a symptomatic malunion. Patients and their families should be counseled about that risk and the low complication risk associated with acute plate fixation, so that they can make an informed decision regarding which treatment is right for them.”

Dr. Kessler’s coauthors are Imani Gardner, MD, and Julia Corral, MD. No disclosures are available for Dr. Kessler or his coauthors.

Coauthors of Drs. Vanderhave and Perdue include Michelle S. Caird, MD, and Francis A. Farley, MD. The authors report the following disclosures: Dr. Caird— Arthrex, Inc; Medtronic; National Institutes of Health (NIAMS & NICHD); Stryker; Synthes; Wright Medical Technology, Inc., Department of Defense, Synvasive Inc; Dr. Farley—Medtronic; Drs. Vanderhave and Perdue—no disclosures available.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org

View the Presentation by Dr. Kessler

View the Presentation by Dr. Vanderhave

AAOS Now
August 2009 Issue
http://www.aaos.org/news/aaosnow/aug09/clinical1.asp