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Fig. 1 AP radiographs showing a clavicle shaft fracture. A, The fracture before fixation. B, Fixation of the fracture with a plate contoured to the clavicle. This type of plate is acceptable for adolescents but probably is not useful or necessary for younger children. Reproduced from Pring ME and Wallace CD: Shoulder and Elbow Trauma, in Song K (ed): Orthopaedic Knowledge Update: Pediatrics 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2011, p. 330.

AAOS Now

Published 8/1/2014
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Terry Stanton

Study Finds Low Complication Rates for Adolescent Clavicle Fractures

Authors call for additional studies to identify optimal treatment strategies

A study of treatment outcomes for clavicle fractures in adolescents found that although refracture is more common in patients who receive nonsurgical treatment, overall complication rates are higher in those who undergo surgery, with the most common complication being implant-related symptoms.

These findings were presented at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), by Benton E. Heyworth, MD, who conducted the study along with colleagues from Boston Children’s Hospital.

According to the authors, the question of whether to surgically treat the adolescent with a middiaphyseal clavicle fracture is “an area of significant controversy.” The issue has gained attention as greater numbers of clavicle fractures are being seen in the adolescent population, with more than 60 percent of cases occurring during sports activities. In recent years, the trend has been toward increasing use of surgical treatment, Dr. Heyworth said.

In conducting this study, he and his colleagues sought to better understand the issue by reviewing the demographic characteristics, treatment approaches, and complications in a large series of adolescent clavicle fractures receiving surgical or nonsurgical treatment.

Demographics and outcomes
The investigators reviewed radiographic and medical records for 641 patients aged 10 to 18 years with middiaphyseal clavicle fractures who were seen between 2003 and 2012. Demographic data, radiographic features such as fracture pattern, operative details when applicable, and posttreatment clinical course were analyzed, including the reported time to healing and any known complications.

Of the cases reviewed, 79 percent of the injuries were sustained by males; the mean age was 14.3 years. Nearly two-thirds (64 percent) of the fractures were sustained during sports, most frequently football (25 percent), hockey (18 percent), soccer (12 percent), snowboarding (12 percent) and skiing (9 percent). Other common mechanisms of injury were falls sustained outside of athletic activity (19 percent) and motor vehicle accidents (5 percent). Surgical and nonsurgical treatment groups had similar distribution of mechanisms of injury and similar rates of associated injuries (5 percent in the surgical group and 6 percent in the nonsurgical group).

Greater numbers of clavicle fractures were seen annually as the study period progressed. Among the overall cohort, 82 percent were treated nonsurgically, while 18 percent were treated surgically; the percentage of patients undergoing surgery increased during the study period.

The mean age was higher in the surgically treated group (15.5 years) than the nonsurgically treated group (14.1 years) (P < 0.001). There were 58 documented complications in 46 patients (7.2 percent); such complications were more common in older patients and significantly more common (P < 0.001), in the surgical group than in the nonsurgical group. Just one case of nonunion occurred in each treatment group.

The rate of symptomatic implants was 13 percent in the surgical group (leading to plate removal in 9 percent of cases), while the rate of symptomatic malunion was 2 percent in the nonsurgical group. Refracture was significantly more common in the nonsurgical group (3 percent) than in the surgical group (2 percent). No infections were reported in either group.

Key takeaways
“One of the key takeaways of the study is that complication rates are relatively low, overall, for both types of treatment,” Dr. Heyworth said. “Notably, nonunion and symptomatic malunion rates after nonsurgical treatment are extremely low in this age group. This is quite different from previous studies on adult populations that, to date, have had substantial influence on treatment decisions in adolescents.

“Our most important takeaway,” he continued, “may be that future prospective research is needed with more comparable matched cohort studies that are followed for longer periods with functional outcome measures. Until this subject is better studied, we hope our results on this relatively larger population can facilitate discussions with families about approximate rates of events related to each type of treatment, either of which may be reasonable for a given patient. We believe a shared decision-making approach should be pursued with patients and families.”

Dr. Heyworth’s coauthors are Collin J. May, MD; Sasha Carsen, MD; Kyna Donohue, BS; Patricia Miller, MS; Dennis E. Kramer, MD; Mininder S. Kocher, MD, MPH; and Donald S. Bae, MD.

Disclosure information: Dr. Heyworth—AOSSM, Pediatric Orthopaedic Society of North America (POSNA); Dr. Kocher—Best Doctors, Biomet, Gerson, Lehrman Group, OrthoPediatrics, Smith & Nephew, Fixes 4 Kids, Pivot Medical, Saunders/Mosby-Elsevier, AAOS, ACL Study Group, AOSSM, Harvard Medical School, Harvard School of Public Health, Herodicus Society, POSNA, PRISM, Steadman Philippon Research Institute; Dr. Bae—DTRX, Johnson & Johnson, VVUS, Lippincott Williams & Wilkins, American Society for Surgery of the Hand, POSNA; Dr. May, Dr. Carsen, Dr. Kramer, Ms. Donohue, and Ms. Miller reported no conflicts.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Incidence of clavicle fractures is increasing in adolescents; more than 60 percent of injuries occur during sports participation.
  • The surgical approach has been increasingly favored for management of the injury.
  • This study of 641 patients reviewed outcomes for both surgical and nonsurgical management.
  • Although overall complication rates were higher in the surgical group, complication rates were low for both groups of patients.