A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members

Context factors in clinical decision-making: a scoping review

BACKGROUND

Clinical decision support systems (CDSS) frequently exhibit insufficient contextual adaptation, diminishing user engagement. To enhance the sensitivity of CDSS to contextual conditions, it is crucial first to develop a comprehensive understanding of the context factors influencing the clinical decision-making process. Therefore, this study aims to systematically identify and provide an extensive overview of contextual factors affecting clinical decision-making from the literature, enabling their consideration in the future implementation of CDSS.

METHODS

A scoping review was conducted following the PRISMA-ScR guidelines to identify context factors in the clinical decision-making process. Searches were performed across nine databases: PubMed, APA PsycInfo, APA PsyArticles, PSYINDEX, CINAHL, Scopus, Embase, Web of Science, and LIVIVO. The search strategy focused on combined terms related to contextual factors and clinical decision-making. Included articles were original research articles written in English or German that involved empirical investigations related to clinical decision-making. The identified context factors were categorized using the card sorting method to ensure accurate classification.

RESULTS

The data synthesis included 84 publications, from which 946 context factors were extracted. These factors were assigned to six primary entities through card sorting: patient, physician, patient's family, institution, colleagues, and disease treatment. The majority of the identified context factors pertained to individual characteristics of the patient, such as health status and demographic attributes, as well as individual characteristics of the physician, including demographic data, skills, and knowledge.

CONCLUSION

This study provides a comprehensive overview of context factors in clinical decision-making previously investigated in the literature, highlighting the complexity and diversity of contextual influences on the decision-making process. By offering a detailed foundation of identified context factors, this study paves the way for future research to develop more effective, context-sensitive CDSS, enhancing personalized medicine and optimizing clinical outcomes with implications for practice and policy.

Pediatric Orthopaedic Surgeons Manage Pediatric Diaphyseal Clavicle Fractures Differently Than Nonpediatric Orthopaedic Specialists

BACKGROUND

Pediatric clavicle fractures are often managed by physicians with and without pediatric subspecialty training. The aim of this study is to identify if variability of practice exists between pediatric orthopaedic surgeons versus nonpediatric orthopaedic specialists during management of pediatric diaphyseal clavicle fractures.

METHODS

Patients ≤18 years of age with an acute, closed diaphyseal clavicle fracture treated between January 2018 and July 2023 by a large hospital-employed multispecialty orthopaedic practice (in a regional and academic health network) were retrospectively reviewed. The study involved 26 orthopaedic surgeons (including 3 pediatric, 8 sports medicine, and 6 general) and 11 nonoperative sports medicine physicians, all of which accept patients ranging 0 to 18 years of age. Exclusion criteria included open or impending open fractures and insufficient data. Demographic, radiographic, and outpatient treatment parameters were recorded. Age groups were separated into <10 and ≥10 years old to control for age-associated differences.

RESULTS

Among 560 pediatric clavicle fractures, 385 met inclusion criteria (43.6% of which were treated by a pediatric orthopaedic surgeon), and 361 were treated nonoperatively. Follow-up averaged 48.8 days until orthopaedic discharge and 16.9 months until the most recent well-child visit (80% had a well-child visit after orthopaedic discharge). No patient <10 years of age had elective surgery, but pediatric orthopaedic surgeons demonstrated lower surgical rates in adolescent patients than nonpediatric specialties (4.3% vs. 14.4%, OR=3.8, P =0.027). Among the 169 nonoperative patients <10 years of age, pediatric orthopaedic surgeons completed fewer outpatient visits (2.1±0.8 vs. 2.4±0.8, P <0.037), shorter follow-up durations (28.5±18.9 vs. 41.8±22.6 d, P <0.001), less radiographic series (2.1±0.8 vs. 2.4±1.0, P <0.047), and less total radiographs (4.3±1.8 vs. 5.0±2.3, P <0.013) than nonpediatric specialists.

CONCLUSIONS

The surgical rate of acute, closed diaphyseal clavicle fractures is lower among pediatric versus nonpediatric orthopaedic surgeons in adolescents. During nonoperative management of pediatric clavicle fractures, pediatric orthopaedic surgeons treat young patients (but not adolescents) with less outpatient visits and radiographs than nonpediatric orthopaedic physicians.

LEVEL OF EVIDENCE

Level III.

5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers

BACKGROUND

Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes.

PURPOSE

To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data.

RESULTS

A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05).

CONCLUSION

Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

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.

Non-operative Management of a Rare Segmental Clavicle Fracture in an Adolescent Patient: A Case Report

A 12-year-old Caucasian male presented to the clinic with a displaced, segmental left clavicle fracture involving the distal clavicle after falling from a zip line. He was treated non-operatively in a sling and returned to normal activities without restrictions after three months. At one year, the patient was able to maintain his pre-injury baseline function without limitations of his left shoulder. While no clear guidelines for operative treatment of segmental clavicle fractures in the adolescent population exist in the current literature, this report illustrates an excellent patient outcome following conservative therapy of a segmental clavicle fracture involving the middle one-third and distal clavicle in a young adolescent with open physis.

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

BACKGROUND

Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood.

PURPOSE

To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction.

RESULTS

Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling.

CONCLUSION

Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Clavicular Fractures in the Adolescent

➤

Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively.

➤

Although rare, in certain patients or fracture patterns, nonoperative management may be associated with delayed healing, prolonged disability, and/or poor functional outcome requiring secondary reconstruction.

➤

When warranted, primary open reduction and internal fixation with plate and screw application has consistently good outcomes with a low complication rate, with the most common complication being implant-related symptoms requiring a secondary surgical procedure for implant removal.

➤

Prospective, comparative studies examining operative and nonoperative treatment, including measures of early return to function, injury burden, return to athletic activity, complication and reoperation rates, and shoulder-girdle-specific, long-term outcome measures are warranted to further elucidate which fractures may benefit from primary fixation.

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.

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).

Plating versus elastic stable intramedullary nailing for displaced pediatric midshaft clavicular fractures

Introduction

Traditionally, 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.

Methods

All 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.

Results

A 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.

Conclusion

A 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 evidence

III, retrospective observational study.

Nonunion of the Clavicle Among Children: A Review of the Literature and a Report of Three New Cases

Nonunion of the clavicle among children and adolescents is rare. A systematic review was conducted to identify published reports of nonunion of the clavicle among children after conservative treatment. A retrospective study was performed of 2096 children who were treated for clavicle fractures at our institution to identify cases of nonunion. Fourteen studies (27 children) from the literature met the inclusion criteria, and 3 new cases from our institution were identified. The mean age at injury was 11 years. Male sex, age younger than 12 years at the time of injury, and refracture of the clavicle are possible predisposing factors for nonunion. [Orthopedics. 2022;45(4):e190-e195.].

Increase in surgical fixation of pediatric midshaft clavicle fractures since 2008

BACKGROUND

Clavicle fractures in children have traditionally been treated non-operatively. In adults, a great increase in operative treatment has been reported. We aimed to analyze the respective trend and potential explanatory factors in children.

METHODS

This is a single-institution retrospective study in a subregion in Northern Finland. The ICD-code S42.0 was used to identify the cases in the hospital registry. Altogether, 214 children, aged < 16, with consecutive clavicle fractures were first enrolled in the area during 2008-2019. Hospital journals and radiographs were reviewed. After lateral and medial fractures and patients living outside the area were excluded, final study population was 172. The respective population at risk was extracted by Statistics Finland. Predictive factors and annual rates of operative treatment as adjusted for 100,000 children at risk were determined.

RESULTS

The rate of the surgical treatment of clavicle fractures increased from zero in 2008 to 10.8 in 2019 per 100,000 age-adjusted children (β = 0.864, 95% confidential intervals (CI) 0.4 to 1.4). There was a rise in the rate of surgery from 2.6% (2014-16) to 16.1% (2017-19) (diff. 13.5, 95% CI 1.7 to 23.3%). A displacement > 15 mm and a shortening of > 15 mm were associated with the increased risk of surgery but did not change during the study period. Age > 9 years increased the risk of surgery; the mean age increased from 5.5 years (2008-10) to 8.5 years (2017-19). There was a 3.6-fold increase in sports-related fractures (95% CI 7.4 to 26.4). The severity of the fractures did not change.

CONCLUSIONS

There has been an increasing trend in the surgical fixation of pediatric middle shaft clavicle fractures since 2008. The available literature does not support the trend.

Plate osteosynthesis of midshaft clavicle fractures in adolescent contact sports athletes - adolescent clavicle fracture

Surgical treatment of mid-shaft clavicle fractures via anatomical plates in adult athletes is documented to be safe and effective. Functional and cosmetic outcomes in adolescent contact sports athletes have not been well documented. Adolescent athletes (age 11-19) surgically treated for mid-shaft clavicle fractures between 1 May 2011 and 30 October 2017 were included in this study. Twenty-one adolescent athletes with a mean follow-up of 44 months were reviewed. Retrospective chart reviews were performed. Functional and cosmetic outcomes, return to sports time/rate were analyzed using Nottingham Clavicle Scores and a 'Custom Questionnaire'. Return of function and healing, evidenced on radiographs, was achieved in all 21 patients. All patients returned back to competitive sports. The mean time to return back to training was 45.9 ± 16 (24-76) days. Sixteen (76.1%) of the patients reported Nottingham Clavicle Scores with a mean score of 91.7 (85-98). In the Custom Questionnaire, 16 patients who participated in the phone interview were satisfied with the cosmetic outcomes. The most common complaint was implant prominence and irritation in 6 (40%) patients, subsequently requiring implant removal in 3 (18.8%). Surgical fixation of mid-shaft clavicle fractures can lead to excellent union and cosmetic outcomes and a rapid return to sports in adolescent contact sport athletes. However, one should consider the outcomes of implant-related complaints and the possibility of implant removal surgery in the future.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Factors influencing time to return to sport following clavicular fractures in adolescent athletes

BACKGROUND

There is a trend toward increased surgical treatment of displaced clavicle fractures in the adolescent population presumably because of extrapolation of adult-derived best practice guidelines. The purpose of this study was to compare return to sport between nonoperative and operative treatment of clavicle fractures in high school athletes.

METHODS

A retrospective review of clavicle fractures sustained in scholastic athletes participating in school-sponsored athletics in the upstate South Carolina was performed from 2015 to 2019. Injury circumstances, demographics, radiographs, treatment, and return to sport data were documented for all patients. Radiographs were evaluated for fracture location, comminution, displacement, shortening, and angulation. Patients were followed until complete return to sport, and results were compared based on sport participation, injury mechanism, fracture morphology, treatment type, and time to return to sport.

RESULTS

Forty-seven patients (44 were male; average age 15.6 years) were included who all returned to sport within the original or subsequent season. Thirty-six patients (73%) were managed conservatively (30 middle third fractures, 4 medial third fractures, 2 distal third fractures), whereas 11 were managed surgically (11 middle third fractures). Eighty-one percent of fractures occured in collision athletes (55% in football). There was no difference in time loss based on participating in collision vs. noncontact sports (P = .4). Conservatively managed fractures returned to sport faster (61 ± 38 days vs. 100 ± 49 days; P = .008) compared with surgically managed patients. Fracture displacement ≥100% (100 ± 51 days vs. 54 ± 27 days; P = .001), greater comminution (128 ± 50 days vs. 59 ± 31 days; P = .001), and angulation (86 ± 52 days vs. 54 ± 22 days; P = .001) all were statistically significant for slower return to sport. Athletes presenting with clavicular shortening <2 cm returned to sport within a similar time frame as athletes with ≥2 cm (P = 0.1).

CONCLUSION

Our results show that adolescent athletes with clavicular fractures predictably return to athletics, including collision sports. Athletes conservatively managed returned 40% faster than those with surgery. However, this appears to be associated with the severity and complexity of fractures treated surgically. This study provides evidence to counsel adolescent athletes following clavicular fractures on return to sport expectations.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

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

OBJECTIVE

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.

DESIGN

Retrospective cohort study.

SETTING

Two adult and one pediatric tertiary care referral hospitals.

PATIENTS/PARTICIPANTS

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.

INTERVENTION

Nonoperative versus surgical treatment of clavicle fractures.

MAIN OUTCOME MEASUREMENT

Surgical treatment.

RESULTS

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.

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 outcome studies.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intermediate-Term Outcomes Following Operative and Nonoperative Management of Midshaft Clavicle Fractures in Children and Adolescents: Internal Fixation May Improve Outcomes

Although multiple prospective comparative studies exist for adults with midshaft clavicle fractures, few comparative studies exist in older children and adolescents. This study compares intermediate-term functional, pain, radiographic, and complication outcomes in children and adolescents with midshaft clavicle fractures treated operatively or nonoperatively.

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

Backgroud

Controversy 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).

Methods

A 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.

Results

All 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.

Conclusions

The 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.

Tendency towards operative treatment is increasing in children's fractures: results obtained from patient databases, causes, impact of evidence-based medicine

Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.

Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children’s fractures.

The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.

It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children’s fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.

Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012

Descriptive Epidemiology of Adolescent Clavicle Fractures: Results From the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study

Background:

The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased.

Purpose:

To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]).

Study Design:

Cross-sectional study; Level of evidence, 4.

Methods:

Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll.

Results:

A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation.

Conclusion:

Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.

Operative Versus Non-operative Management of Mid-diaphyseal Clavicle Fractures in the Skeletally Immature Population: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this study is to compare the outcomes and complications of operative vs non-operative management of mid-diaphyseal clavicle fractures in the skeletally immature population.

RECENT FINDINGS

Traditionally, skeletally immature clavicle fractures have been managed non-operatively. However, there has been an increasing trend towards operative management with a lack of evidence indicating its effectiveness.

METHODS

Two reviewers searched three online databases (MEDLINE, EMBASE and PubMed), independently and in duplicates, for literature comparing the outcomes and complications of operative versus non-operative management in skeletally-immature patients (defined as birth to 18 years of age) with a middiaphyseal clavicle fracture. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model.

RESULTS

Seven studies, containing 522 skeletally immature patients (with 528 mid-diaphyseal clavicle fractures) with an age range of 8 to 18 years, with 148 patients undergoing operative management and 380 patients undergoing non-operative management, were included. Across the 6 studies that reported gender (N = 444), there were 335 males and 109 females. Patients were followed up from 2 weeks to 3.7 years across five studies (N = 201 patients) that reported follow-up time. There was no significant difference in the time to achieve union (p = 0.1), the time to return to activity (p = 0.09), and the overall complication rate (p = 0.50) between the operative and the non-operative groups. There is no significant difference between operative and non-operative management of skeletally immature mid-diaphyseal clavicle fractures. Clinical equipoise exists to study this further by means of a prospective, randomized, blinded control trial.

LEVEL OF EVIDENCE

Level IV, systematic review and meta-analysis of level II, III, and IV.

Health-related Quality of Life After Fractures of the Lateral Third of the Clavicle in Children and Adolescents

INTRODUCTION

The health-related quality of life after pediatric fractures of the lateral third of the clavicle is unknown. Given the trend in the literature toward surgical management of clavicular fractures in adults, we frequently receive referrals for surgical management of lateral clavicular fractures in children.Therefore, we examined (1) the health-related quality of life of patients who sustained a fracture of the lateral third of the clavicle in childhood and who were treated at a large regional pediatric trauma center, (2) if the health-related quality of life was associated with the age at the time of the injury, and (3) whether fracture and displacement patterns were associated with health-related qualify of life.

METHODS

This is a retrospective case series. We were able to identify 69 patients (21 girls and 48 boys) who sustained a fracture of the lateral third of the clavicle between the period spanning from January 2004 to June 2015. These patients were asked to fill in a questionnaire that included the Quick version of the Disability of Arm, Shoulder, and Hand (DASH) (primary outcome) and the Pediatric Quality of Life Inventory (Peds-QL). Until July 2017, we were able to get a response from 56 of these patients, resulting in a follow-up of 81%.

RESULTS

Treatment was conservative in all cases but one. In these cases, after a mean follow-up of 6.5 years (range, 1 to 13.2 y), the mean Quick-DASH was 1.2 (SD, 4.4) at a scale of 0 to 100, with lower values representing better quality of life. The mean physical function score of the Peds-QL was 97.8 (SD, 4.4), and the mean psychosocial function score was 91.8 (SD, 10.8), both at a scale of 0 to 100, with higher values representing better quality of life.There was no statistically significant association of age at the time of injury on the primary outcome Quick-DASH.There were no statistically significant associations between fracture or displacement patterns with regard to health-related quality of life.

CONCLUSIONS

Conservative treatment of lateral clavicular fractures in children and adolescents is associated with excellent health-related quality of life, as measured with the disease-specific Quick-DASH and the non-disease-specific Peds-QL at a mean follow-up of 6.5 years (range, 1 to 13.2 y). There was no effect of age at the time of injury, and we were unable to identify associations to commonly analyzed risk factors, such as displacement patterns.As the conservative treatment of this type of fracture in children and adolescents is associated with such a good health-related quality of life, it is unlikely that these results could be further improved by surgical interventions.

LEVEL OF EVIDENCE

Level IV-case series.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Midshaft Clavicle Fracture Pearls and Pitfalls

Pediatric diaphyseal clavicle fractures are a common injury, particularly in the adolescent athlete. There are no consensus guidelines for operative versus nonoperative management of these injuries; however, there has been a dramatic increase in operative treatment over the past 15 years, primarily guided by literature pertaining to the adult population. Despite this trend, current literature suggests that the majority of these injuries can be treated nonoperatively with good functional outcomes, high rates of return to sport, and low incidence of complications such as nonunion, symptomatic malunion, and refracture. For the rare patient treated nonoperatively who develops a symptomatic nonunion or malunion, delayed corrective surgery remains a viable treatment option. When surgical fixation is pursued, good outcomes have been universally reported, but the optimal indication for surgery remains elusive in this adolescent population.

Epidemiology of Clavicle Fractures Among US High School Athletes, 2008-2009 Through 2016-2017

Background

Little is known about the epidemiology of clavicle fractures in United States (US) high school athletes. Sports participation among high school students has increased steadily, placing increased numbers at risk of sports-related injury.

Purpose

To describe the epidemiology of clavicle fractures among high school athletes, including injury rates by sex, sport, and type of play and trends in operative versus nonoperative treatment.

Study Design

Descriptive epidemiology study.

Methods

The study data set included all athlete-exposure (AE) and clavicle fracture data collected from 2008-2009 through 2016-2017 from a large sample of US high schools as part of the National High School Sports-Related Injury Surveillance Study for students participating in boys' football, boys'/girls' soccer, boys'/girls' basketball, boys'/girls' volleyball, boys' wrestling, boys' baseball, girls' softball, girls' field hockey, boys' ice hockey, boys'/girls' lacrosse, boys'/girls' swimming and diving, boys'/girls' track and field, girls' gymnastics, girls' cheerleading, boys'/girls' tennis, and boys'/girls' cross-country.

Results

Overall, 567 clavicle fractures were reported during 31,520,765 AEs, an injury rate of 1.80 per 100,000 AEs. Injury rates varied by sport, with the highest rates in the boys' full-contact sports of ice hockey (5.27), lacrosse (5.26), football (4.98), and wrestling (2.21). Among girls' sports, the highest rates were in soccer (0.92), lacrosse (0.26), and basketball (0.25). In sex-comparable sports, injury rates were still significantly higher among boys (1.03) than girls (0.35) (rate ratio, 2.91; 95% CI, 1.97-4.30). Injury rates were significantly higher in competition (4.58) as compared with practice (0.87) (rate ratio, 5.27; 95% CI, 4.44-6.26). Most injuries were treated conservatively (82.7%) rather than operatively (17.3%). Time to return to sports varied, with a greater proportion of medical disqualifications among those treated operatively (40.0%) as compared with those treated conservatively (22.6%) (injury proportion ratio, 1.77; 95% CI, 1.31-2.39).

Conclusion

Although clavicle fracture rates are relatively low, they vary by sport, sex, and activity. Understanding such differences should drive more effective, targeted injury prevention efforts. Increased time loss from sports with surgical versus conservative treatment may have been influenced by factors including injury severity and its timing relative to the season's progress.

Adolescent Clavicle Fractures: Is There a Role for Open Reduction and Internal Fixation

PURPOSE OF REVIEW

Over the past ten years, there has been a change in the management of adolescent clavicle fractures. Utilizing data from the adult population, clinicians have become more aggressive in terms of surgical fixation. The purpose of this paper is to critically analyze the recent literature in regard to adolescent clavicle fractures, and to determine the role of open reduction and internal fixation.

RECENT FINDINGS

Although there have been many case series that demonstrate that open reduction and internal fixation can be done safely and with predictable healing, studies which compare operative versus non-operative intervention suggest there may not be functional outcome differences between the two treatment options. Further study is necessary to determine the specific indications for fixation of clavicle fractures in the adolescent population. Shared decision-making between patient, family, and clinicians is essential to determine the specific fracture patterns and patients who might benefit from fixation to improve functional outcome.

Management of Clubfoot Relapses With the Ponseti Method: Results of a Survey of the POSNA Members

BACKGROUND

Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet.

METHODS

We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members.

RESULTS

We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse.

CONCLUSION

This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method.

LEVEL OF EVIDENCE

Not applicable.

Incidence and mechanism of injury of clavicle fractures in the NEISS database: Athletic and non athletic injuries

BACKGROUND

Clavicle fractures are a very common injury due to accidental trauma, specifically during athletics. The purpose of this study was (1) to determine the incidence of clavicle fractures presenting to United States emergency departments; (2) to compare the rate of clavicle injuries from 2012 to 2015 to 2002-2005 (3) to determine the most common mechanisms of injury for clavicle fractures.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for the years 2002-2005 and 2012-2015. Examined variables included patient age, sex, and year of admission. Total annual case numbers were estimated using NEISS hospital weights. Annual injury incidence rates by age group and patient sex were calculated based on yearly U.S. Census estimates. Chi square test and logistic regression were used to compare injury rates by sex and age groups. Statistical significance was set at P < 0.05.

RESULTS

During the 8 years studied, the participating emergency departments (EDs) coded 14,795 fracture exposures. Using weighted estimates, this represent 545,663 injuries nationally (95% CL 425,986-665,339). This resulted in an incidence of 22.4 injuries per 100,000 person years (95% CL 17.5-27.3). The most common causes of injury were bicycles (15.1%), football (10.7%), beds/bedframes (6.8%), stairs (5.4%), and floors (4.0%). Fifty percent of clavicle fractures were due to an athletic activity. There was no significant change in injuries from 2002 to 2005 compared to 2012-2015 (23.1 per 100,000, 95% CL 18.5-27.7, and 22.4 per 100,000 person years (95% CL 17.5-27.3), respectively).

CONCLUSION

Clavicle fractures continue to occur at similar rates, with athletics accounting for 50% of injuries. Patients most at risk for clavicle fracture was bimodal in nature, with males aged 0-19 being the most common. Females were most at risk between 0 and 9 years old. We found that clavicle fracture continued to occur at similar rates as compared to 10 years prior, especially in active populations participating in collision sports (bicycle, football, and soccer).

Do All Clavicle Fractures in Children Need To Be Managed by Orthopedic Surgeons?

OBJECTIVES

Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatric fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system.

METHODS

A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed.

RESULTS

Three hundred forty patients (227 males, 113 females) with an average age of 8.1 years (range, 0.1-17.8) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.1 (1.3). The mean number of radiology department appointments was 1.8 (1.3), where patients received a mean number of 4.2 (3.0) radiographs. Complications were minimal: 2 refractures in our series and no known cases of nonunion. All patients achieved clinical and radiographic union and returned to sport after fracture healing.

CONCLUSIONS

Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary care physician, then routine clinical or radiographic follow-up is unnecessary. Our pediatric clavicle fracture pathway will reduce patient radiation exposure and reduce costs incurred by the health care system and patients' families without jeopardizing patient outcomes.

Flexible intramedullary nailing versus nonoperative treatment for paediatric displaced midshaft clavicle fractures

PURPOSE

The treatment of displaced midshaft clavicle fractures in children remains controversial. The purpose of our study was to compare the outcome of displaced midshaft clavicle fractures in children who were managed operatively by flexible intramedullary nailing (FIN) with nonoperative treatment.

METHODS

A prospective review of 31 children (mean age 10.5 years) with displaced midshaft clavicle fractures treated either by FIN or nonoperatively and with at least a six-month follow-up was undertaken. In all, 24 children underwent FIN and seven underwent nonoperative treatment. The patient outcomes included the Constant-Murley score, Customer Satisfaction Questionnaire (CSQ-8), numeric pain rating scale, time to union and time to return to activity. Surgical complications were recorded.

RESULTS

The two groups were comparable with regards to age, gender and mechanism of injury. At six months of follow-up, the Constant-Murley (97.8 versus 94.7, p < 0.001) and CSQ-8 (29.1 versus 19.1, p < 0.001) scores were higher in the FIN group. Time to union and return to activity were significantly shorter in the FIN group (7.3 and 9.2 weeks versus 10.4 and 16.6 weeks respectively, p < 0.01). The only surgical complication was a FIN exchange for skin irritation due to nail prominence.

CONCLUSION

FIN is a minimally invasive procedure for children with displaced midshaft clavicle fractures associated with shorter time to union, quicker return to activity and higher Constant-Murley and CSQ-8 scores when compared with nonoperative treatment. However, the difference in Constant-Murley scores was not clinically significant. Furthermore, the advantages of FIN are at the expense of an increased complication rate of 12.5% (upper 95% confidence interval 33.3%).

LEVEL OF EVIDENCE

Therapeutic, II.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series

INTRODUCTION

Clavicle fractures are common injuries in adolescent patients. In this study we present our technique and results for treating non-comminuted displaced midshaft clavicle fractures using flexible intra medullary nails.

METHODS

A retrospective review of prospectively collected data using the electronic medical record was performed. Adolescent patients presenting to a level one pediatric trauma center with acute displaced non comminuted clavicular shaft fractures who were treated with intra medullary flexible nails were included in this study.

RESULTS

Seven adolescent patients with non-comminuted displaced mid shaft clavicle fractures were treated with flexible nails over a period of five and half years with an average follow up time of 10 months. The average age was 14.6 years (range 14-16), and a 2 mm nail was used in all cases. Closed reduction was obtained in five cases with only two cases needing open reduction to pass the nail. One patient had skin breakdown over the nail entry and had the nail removed in clinic two months after surgery, all other patients healed with no complication. Sports and full shoulder activity were allowed when radiographic healing was seen at an average 8 weeks. Implant removal was performed four of the seven patients.

CONCLUSION

Flexible intramedullary nailing is an effective minimally invasive method for the treatment of displaced midshaft clavicle fractures in the adolescent population. The surgeon should be aware that a 2 mm nail is likely the optimal diameter, and the nail is difficult to pass beyond the lateral 2-3 cm of the distal segment due to canal narrowing, but passage further than this is not necessary to achieve stability and union. Following these pearls will allow the surgeon to successfully perform the procedure.

Preferences of orthopedic surgeons for treating midshaft clavicle fracture in adults

Objective

To determine the current clinical practice in Latin America for treating midshaft clavicle fractures, including surgical and non-surgical approaches.

Methods

A cross-sectional study using a descriptive questionnaire. Shoulder and elbow surgeons from the Brazilian Society of Shoulder and Elbow Surgery and from the Latin American Society of Shoulder and Elbow were contacted and asked to complete a short questionnaire (SurveyMonkey^®) on the management of midshaft fractures of the clavicle. Incomplete or inconsistent answers were excluded.

Results

The type of radiographic classification preferably used was related to description of fracture morphology, according to 41% of participants. Allman classification ranked second and was used by 24.1% of participants. As to indications for surgical treatment, only the indications with shortening and imminence of skin exposure were statistically significant. Conservative treatment was chosen in cortical contact. Regarding immobilization method, the simple sling was preferred, and treatment lasted from 4 to 6 weeks. Although the result was not statistically significant, the blocked plate was the preferred option in surgical cases.

Conclusion

The treatment of midshaft clavicle fractures in Latin America is in accordance with the current literature.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents

PURPOSE

Superiority of non-operative versus operative treatment of clavicle shaft fractures remains unclear. We aimed to assess shoulder function in adolescents following shortened clavicle fracture and compare operative versus non-operative treatment.

METHODS

Patients aged 12 to 18 years at the time of fracture and minimum 1.5 years post injury were identified for this institutional review board (IRB)-approved study. For this retrospective cohort study, patients were frequency-matched for age, gender, shortening of the clavicle fracture and activity level. The dominant arm was controlled in the statistical model. Initial radiographs were used to measure clavicle shortening. At follow-up, isokinetic testing of both shoulders was performed in flexion, external rotation and the plane of scapular motion. Maximum number of isotonic repetitions and average isometric torque were recorded, as were ASES and DASH scores. Data were analysed comparing non-operative and operative groups and involved and uninvolved shoulders.

RESULTS

Twenty patients were recruited (18 male, 2 female), with ten in each group. Median clavicle shortening was 17.5 mm (11.4 to 23.6). There was no statistical difference in average ASES (100 vs 99; p = 0.84) or DASH (0.0 vs 1.7; p = 0.08) between non-operative and operative groups, respectively. Results of isokinetic testing comparison between non-operative and operative groups showed no statistical difference for any individual association, controlling for the dominant arm. Among the non-operative group, the involved arm had decreased functional measures compared with the uninvolved arm on all measures, when controlling for dominant arm, and there was increased variability of the functional estimate.

CONCLUSIONS

The increased variability in functional measures for the non-operative group suggests some patients may have dysfunction.

Is There a Deficit After Nonoperative Versus Operative Treatment of Shortened Midshaft Clavicular Fractures in Adolescents?

BACKGROUND

Recent clinical studies in adults have reported a higher incidence of symptomatic malunions and functional deficits in nonoperatively treated shortened midshaft clavicular fractures. We sought to determine whether functional or subjective deficits are found in adolescents after operative versus nonoperative treatment of clavicle fractures.

METHODS

Adolescents with displaced midshaft clavicle fractures, >15 mm of shortening, and a minimum of 9 months of follow-up were recruited. Exclusion criteria included concomitant upper extremity injuries or abnormalities that would affect biomechanical strength testing. Sixteen patients, equally divided between nonoperative and operative plate fixation, met inclusion criteria and consented to testing. The average age (±SD) at the time of injury was 14±2 years (range, 10 to 16 y), time from injury was 22±10 months (range, 10 to 41 mo), and shortening was 24±6 mm (range, 16 to 35 mm). Consenting subjects completed a QuickDASH Score, Constant Shoulder Score, and questions regarding satisfaction with treatment. Quantitative isometric strength, range of motion, and abduction fatigue testing was performed on the involved and uninvolved sides for comparison.

RESULTS

Treatment groups did not differ in age, time from injury, or fracture shortening. QuickDASH and Constant Shoulder Scores were perfect in all but 1 patient in the operative group who actively complained of persistent symptomatic hardware. This patient and one other in the operative group underwent symptomatic hardware removal. There were no cases of symptomatic malunions in the nonoperative group. All patients expressed satisfaction with their treatment. Two in each treatment group were unsatisfied with the appearance of the clavicle. With the exception of a 3% decrease in abduction strength in the operative group (P=0.03) there were no differences in range of motion, isometric strength, or abduction fatigue of the involved shoulder in either treatment group.

CONCLUSIONS

Shortened midshaft clavicular fractures had excellent outcomes after both operative and nonoperative treatments. No subjective or objective differences were observed between treatment groups.

LEVEL OF EVIDENCE

Level III-therapeutic, retrospective comparative study.

Trends in the volume of operative treatment of midshaft clavicle fractures in children and adolescents: a retrospective, 12-year, single-institution analysis

The purpose of this study was to examine institutional trends in the volume of clavicle fractures in children and adolescents. Medical records were retrospectively reviewed to identify patients aged 10-18 years treated for a clavicle fracture between 1999 and 2011 at a single tertiary-care pediatric hospital. There were significant increases in the number of clavicle fractures seen annually, of midshaft clavicle fractures, and of midshaft clavicle fractures treated operatively. The percentage of midshaft clavicle fractures treated with fixation also increased significantly. The volumes of clavicle fractures and midshaft clavicle fractures treated operatively appear to be increasing. Despite a lack of evidence-based support, the frequency of fixation of midshaft clavicle fractures appear to be increasing in the pediatric population.

Treatment trends in adolescent clavicle fractures

BACKGROUND

Controversy continues with regard to decision making for operative treatment of adolescent clavicle fractures, while the literature continues to support operative treatment for select middle third fractures in adults. The purpose of our study was to evaluate the recent trends in nonoperative and operative management of adolescent clavicle fractures in the United States.

METHODS

Data were derived from a publicly available database of patients, PearlDiver Patient Records Database. The database was queried for ICD-9 810.02 (closed fracture of shaft of clavicle), with the age restriction of either 10 to 14 or 15 to 19 years old, along with CPT-23500 (closed treatment of clavicular fracture) and CPT-23515 (open treatment of clavicular fracture) from 2007 to 2011. The χ analysis was used to determine statistical significance with regard to procedural volumes, sex, and region. The Student t test was used to compare average charges between groups.

RESULTS

A significant increase in the number of adolescent clavicle fractures managed operatively (CPT-23510, ages 10 to 19 y) from 309 in 2007 to 530 in 2011 was observed (P<0.0001). There was a significantly greater increase in operative management of clavicle fractures in the age 15 to 19 subgroup compared with the age 10 to 14 subgroup (P<0.0001). In the operative group, there was a trend toward a higher number of males being managed with operative intervention. The overall average monetary charge for both nonoperatively and operatively managed adolescent clavicle fractures increased significantly in the study period. A statistically significant increase in normalized incidence of operatively managed adolescent clavicle fractures was noted in the midwest, south, and west regions with the greatest increase in west region where the incidence increased over 2-fold (P<0.0001).

CONCLUSIONS

Adolescent clavicle fractures seem to be being treated increasingly with open reduction and internal fixation recently, especially in the 15 to 19 age group. Nevertheless, there remains of lack of high-level studies comparing outcomes of operative and conservative treatment specifically for the adolescent population to justify this recent trend.

LEVEL OF EVIDENCE

Level IV-retrospective database analysis.

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

BACKGROUND

There 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.

METHODS

Using 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.

RESULTS

Gender, 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.

CONCLUSIONS

Fracture shortening and sports participation do not have a significant impact in adolescents on outcomes after displaced midshaft clavicle fracture.

Surgical treatment of clavicle fractures in the adolescent athlete

CONTEXT

Current literature has clearly shown that the indications for surgical treatment of clavicle fractures in adults are expanding. Although clavicle fractures in children and adolescents have traditionally been treated nonoperatively, surgical treatment of displaced clavicle fractures may be indicated for adolescent athletes.

EVIDENCE ACQUISITION

A review of relevant articles published between 1970 and 2013 was completed using MEDLINE and the terms clavicle fracture and adolescent athlete.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Excellent outcomes and rapid return to competition can be achieved with surgical management of displaced clavicle fractures in the adolescent athlete with high functional demands similar to those of their adult counterparts. Complications include hardware irritation, screw loosening, pin migration, peri-incisional numbness, and refracture. Athletes and families must be counseled regarding complications and potential need for secondary surgery to remove hardware.

CONCLUSION

The adolescent athlete with a displaced, shortened, or comminuted clavicle fracture presents a unique, controversial dilemma for the surgeon. Earlier return to competition can be achieved with surgical management to restore length and alignment and may prevent malunion, nonunion, and poor outcomes.

Complications in the treatment of adolescent clavicle fractures

This study evaluated the complications associated with the treatment of clavicle fractures in adolescents. All cases of clavicle fractures were identified during an 8-year period between January 2005 and January 2013. During the study period, 153 clavicle fractures occurred in patients between the ages of 14 and 17 years who were treated at the authors' center. Medical records and radiographs were reviewed to determine injury mechanism, fracture pattern, treatment, and complications. Injury severity was assessed as high, medium, and low. Patients with medial or distal metaphyseal fractures and intra-articular fractures were excluded. Of the 153 clavicle fractures, 23 (15.0%) were treated surgically. Compared with the fractures treated nonsurgically, the surgical fractures had greater shortening (mean, 2.0 vs 0.9 cm; P<.001) and were more likely to be comminuted (65.2% vs 23.1%; P<.001). Complications occurred in 21.7% of fractures treated surgically, including refracture (n=2), implant removal for prominence (n=2), and nonunion with implant failure (n=1). One complication was associated with intramedullary nailing, whereas the other 4 complications occurred in clavicles treated with plate fixation. In the non-surgical group, no patients sustained a refracture or malunion who required delayed surgical intervention. Pediatric fellowship-trained orthopedic surgeons treated 78 displaced fractures, resulting in 8 (10.3%) surgeries. Nonpediatric orthopedic specialists treated 46 displaced fractures, 15 (32.6%) of which were treated surgically (P=.0035).

Venous thromboembolism in children: preliminary results of a survey of POSNA members

BACKGROUND

The term venous thromboembolism (VTE) includes deep venous thrombosis of the extremity and pulmonary embolism, a potentially fatal clinical entity. Although the prevalence of VTE may be lower in children compared with adults, recent reports suggest a possible rise in this diagnosis among pediatric patients, especially in association with certain risk factors. We assessed the clinical experience and practice of members of the Pediatric Orthopaedic Society of North America (POSNA) related to VTE among their pediatric patients.

METHODS

A 36-question online survey was sent to all 636 active POSNA members. The proportion of surgeons who had encountered at least 1 child with VTE and the respondents' practice of using thromboprophylaxis in children (<18 y old) was assessed. The relationship of responders' experience with VTE among pediatric patients with various practice characteristics was evaluated.

RESULTS

The response rate was 56% (354/636). More than half (55%) [95% confidence interval (CI), 50%-60%] of the respondents could recall at least 1 (median, 2 cases/member) pediatric patient with deep venous thrombosis and 29% (95% CI, 24%-34%) could recall ≥1 child with pulmonary embolism. Approximately one quarter (23%) (95% CI, 18%-27%) of all respondents reported never using mechanical prophylaxis and almost one half (45%) (95% CI, 40%-50%) of respondents reported never using pharmacologic prophylaxis against VTE in children. Only 16% (95% CI, 12%-20%) of the respondents had a thromboprophylaxis protocol for pediatric patients. Respondent characteristics such as being in clinical practice <5 years (P=0.01) and having a surgical volume of <100 cases/y (P=0.03) were associated with a lower likelihood of encountering a pediatric patient with VTE.

CONCLUSIONS

More than half of responding active POSNA members reported having come across at least 1 case of VTE among pediatric patients during their practice. The routine use of VTE prophylaxis for children is uncommon among pediatric orthopaedists. Further studies aimed at determining the prevalence of VTE and developing specific guidelines for prophylaxis among pediatric patients seeking orthopaedic care are warranted.

LEVEL OF EVIDENCE

IV.

Elastic stable intramedullary nailing for displaced pediatric clavicle midshaft fractures: a prospective study of the results and patient satisfaction in 24 children and adolescents aged 10 to 15 years

BACKGROUND

Whereas displaced clavicle fractures in young children are treated nonoperatively, older children are more likely to suffer persistent pain and misalignments during a longer period of treatment. This study presents the outcomes of elastic stable intramedullary nailing for displaced clavicle fractures in children over the age of 10.

METHODS

Prospectively, this study evaluates elastic stable intramedullary nailing for displaced clavicle midshaft fractures in children and adolescents, aged 10 to 15 years, from July 2004 to June 2010. We analyzed all complications, patient pain and long-term results, measured using the Constant & Murley Shoulder Score, the Client Satisfaction Questionnaire-8, and ultrasound.

RESULTS

Eight girls and 16 boys (aged 10 to 15 y), 1 with bilateral fracture, were recruited. Sixteen mini-open reductions were necessary. All adolescents reported full mobilization from the first postoperative day, full activity after 1 week, and sporting activity after 1 month. Self-reported pain was very low. Five complications occurred: 1 implant breakage (kick-boxing); 2 nail deformations (fall during football, collision in ice-hockey); and 2 imminent skin perforations. The mean Constant & Murley Shoulder Score at follow-up after 1 year was 99.5 of 100 points; the mean patient satisfaction in the Client Satisfaction Questionnaire-8 was 30.6 of 32 points. Axial deviation of the clavicle was always <10 degrees; shortening <0.5 cm.

CONCLUSIONS

Elastic stable intramedullary nailing can be offered for displaced midshaft clavicle fractures in children older than 10 years. They benefit from little pain, early mobilization, and fast full range of motion. To avoid complications the maximum projection of the ends of the nails must be 5 mm; no sports should be allowed for 4 weeks, contact sports for 8 weeks.

Variation in management of intra-abdominal abscesses in children with Crohn's disease

BACKGROUND

Complications of Crohn's disease may include intra-abdominal abscesses, which often result in hospitalization, surgery, and increased cost. There is a paucity of primary research and practice guidelines regarding optimal management in children. The study objective was to assess the current standard of care in an effort to define best practices and identify priority areas for additional research.

METHODS

The web-based survey was approved by the Institutional Review Board and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. We examined preferences in imaging, drainage, anti-tumor necrosis factor-α therapy, and antibiotic use. We assessed for associations between provider level of experience and management strategies.

RESULTS

A total of 248 of 1608 North American Society for Pediatric Gastroenterology, Hepatology and Nutrition members responded. Of them, 64% were male, 87% practiced in the United States, and 74% practiced in an academic setting. Approximately 26% cared for >50 patients with Crohn's disease and 25% were in practice for >20 years. For initial imaging, computed tomography was chosen by 52%, followed by magnetic resonance imaging (26%) and ultrasound (21%), and upon reassessment computed tomography was chosen by 13%, magnetic resonance imaging by 33%, and ultrasound by 47%. About 77% recommended percutaneous drainage, whereas 21% would only do so if antibiotics were unsuccessful, and 2% proceed to immediate surgery. If a fistula was demonstrated, 70% planned medical therapy followed by surgical resection; only 30% planned surgical resection if no fistula was present. Approximately 55% would consider infliximab before surgery. There were no clinically significant associations between treatment strategies and practitioner experience.

CONCLUSIONS

There is considerable variation in diagnostic and therapeutic interventions in the management of intra-abdominal abscesses, which was not explained by practitioner experience.

The current management of idiopathic clubfoot revisited: results of a survey of the POSNA membership

BACKGROUND

In 2001, the members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding their approach to treating idiopathic clubfoot deformity. Since that time, several studies have advocated a change in the approach to treating this deformity, moving away from surgical release and toward less invasive methods. The purpose of this study was to assess the recent approach to treating clubfoot among the POSNA membership.

METHODS

A survey was emailed to all POSNA members to define their current treatment of idiopathic clubfoot deformity.

RESULTS

We received 323 responses. Ninety-three percent of participants were fellowship trained and were in practice for an average of 17.2 years. On an average, physicians reported each treating 23.5 new clubfoot patients during the year of survey. Nearly all (96.7%) of those surveyed stated that they use the Ponseti treatment method. The average time to initial correction was estimated at 7.1 weeks. Eighty-one percent of patients were estimated to require a tenotomy; 52.7% were performed under general anesthesia or conscious sedation, whereas 39.4% were done under local. Those surveyed estimated that 22% of clubfeet relapsed and 7% required a comprehensive release. Seventy-five percent of the respondents stated that their current treatment approach differed from how they were trained, and 82.7% were trained in the Ponseti method in the last few years.

CONCLUSIONS

Our study provides convincing evidence that a large majority of pediatric orthopaedic surgeons now prefer the Ponseti method to treat idiopathic clubfoot and indicates that the move away from extensive release surgery occurred during the past decade.

LEVEL OF EVIDENCE

Not applicable.