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

[Treatment of clavicle fractures in children and adolescents : Conservative and surgical treatment options with a focus on the figure-of-eight style brace and intrafocal intramedullary nail osteosynthesis]

OBJECTIVE

Conservative treatment using a backpack bandage (RSV) for clavicle fractures in children and adolescents serves to restore anatomy and function. The technique used in adult patients with elastic stable intramedullary nailing (ESIN) from the medial end of the clavicle involves the risk of growth disturbance of the growth plate, which has been open for a very long time; in addition, a cosmetically disturbing scar usually forms there. Treatment with an intrafocal intramedullary nailless osteosynthesis allows length and axis to be restored within the age-specific correction limits using a soft tissue-sparing surgical method in adolescents with, among other things, severe shortening of the fracture. Sufficient stability ensures early functional follow-up treatment without weight-bearing.

INDICATIONS

Conservative therapy using a figure-of-eight style brace or an arm sling can be applied to nearly all clavicle fractures in children and adolescents. Displaced and significantly shortened fractures can be addressed with intramedullary nail osteosynthesis.

CONTRAINDICATIONS

Open injuries at the site of the figure-of-eight style brace application should be immobilized with the Gilchrist bandage. Multifragmentary or open fractures are not suitable for intramedullary nail osteosynthesis.

SURGICAL TECHNIQUE

The figure-of-eight style brace is applied in a figure-eight fashion around both shoulders or clavicles. A loop or knot is tied between the shoulder blades. For intrafocal intramedullary nailless osteosynthesis, an incision is made approximately 3-4 cm along the course of the clavicle directly above the fracture. After blunt dissection, the nail is first extracted laterally through the clavicle dorsally through the cortical bone. Here, the lateral clavicle may need to be reamed intramedullary and dorsolaterally through the opposite cortex using a 2.5-3.2 mm drill bit to facilitate insertion of the ESIN. A stab incision is made over the palpable end of the nail and the nail is removed. The ESIN is then grasped with the Jacob's reamer and advanced medially after reduction of the fracture. It may be useful to reduce the curvature at the tip of the ESIN. This is done as long as simple advancement is possible and until the clavicle stabilizes. The lateral end of the nail is pinched off subcutaneously and the wound is closed in several layers on all sides.

POSTOPERATIVE MANAGEMENT

Conservative treatment involves immobilization for 2-3 weeks, depending on age, until the patient is free of symptoms. Depending on age, the patient should refrain from sport for 4-8 weeks. The aim of osteosynthesis is early functional follow-up treatment without weight bearing. Rest is recommended for 8 weeks, which only applies to adolescents. Metal should be removed early after consolidation around the 8th-12th week.

RESULTS

Our own patients and the literature show excellent results for conservative treatment in children and adolescents. Clearly dislocated and, above all, shortened fractures can be very effectively reduced and treated using the technique described. The results show reconstruction of the length of the clavicle with very good functional results in adolescents using the described osteosynthesis technique. A flat learning curve was observed with regard to the remaining nail length, so that premature perforation occurred in a total of 4 cases at two centers. These cases healed without sequelae after premature metal removal (3 times) or reshortening. Pseudarthrosis, vascular/nerve damage or infections were not observed in either conservative or surgical procedures. Secondary dislocation of the fracture did not occur.

Adolescent Clavicle Fractures: A Management Dilemma?

Clavicle fractures are among the most common orthopaedic injuries in adolescents, particularly male athletes, arising primarily from sports-related trauma and vehicular accidents. While non-operative treatment remains the standard approach due to favourable recovery outcomes and lower complication rates, the trend toward surgical fixation has gained traction, driven by emerging studies suggesting potential benefits in certain cases. This review critically examines the indications, outcomes, and complications associated with both conservative and operative management of adolescent clavicle fractures. Non-operative treatment demonstrates high healing rates, minimal long-term functional deficits, and excellent patient satisfaction. Conversely, operative interventions, including plate fixation and intramedullary nailing, are associated with improved alignment in displaced fractures but carry risks of hardware-related complications, such as implant irritation, hardware failure, and the necessity for removal surgeries. The role of surgical intervention remains controversial, with no definitive consensus or Level 1 evidence favouring one approach over the other.

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.

[Clavicle shaft fractures in childhood and adolescence : Consensus report of the Pediatric Traumatology Section of the German Society for Trauma Surgery]

INTRODUCTION

Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist.

MATERIAL AND METHODS

Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion.

RESULTS

Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment.

CONCLUSION

In addition to X‑rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment.

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.

Are there any differences between the shoulder-arm sling and figure-of-eight bandage in the conservative treatment of paediatric clavicle fractures?

PURPOSE

Clavicle fractures are treated conservatively in the paediatric age group, except in rare types of fractures. We investigated whether there was a difference between using shoulder-arm sling and figure-of-eight bandage in this age group.

METHODS

This study was designed as a retrospective study. In all, 41 children among 53 who underwent conservative treatment with a shoulder-arm sling or figure-of-eight bandage between 2014 and 2019 were included in the study and divided into two groups. Treatment results were compared clinically with respect to pain intensity, muscle strength and radiological examinations.

RESULTS

Group A comprised 20 children with a figure-of-eight bandage and group B comprised 21 children with shoulder sling. According to the Robinson classification, ten fractures were displaced in group A and 12 in group B (p = 0.647). The mean time until the first appointment after the index visit that started the management course was 25.5 days (21 to 31) in group A and 24 days (20 to 30) in group B (p = 0.129). Fracture healing was observed in all patients at the first follow-up and the treatment was discontinued. There was no difference between the groups in the muscle strength examination and shoulder joint range of movement examination at the first-year follow-up (p = 1.00).

CONCLUSION

In the paediatric age group, there was no significant difference between shoulder-arm sling and figure-of-eight bandage in the conservative treatment of clavicle fractures. Since the shoulder-arm sling is more suitable for treatment, it may be the primary preference.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

Long-term Functional Outcomes and Complications in Operative Versus Nonoperative Treatment for Displaced Midshaft Clavicle Fractures in Adolescents: A Retrospective Comparative Study

INTRODUCTION

Traditionally, midshaft clavicular fractures in adolescents are treated nonoperatively. In later years, a trend toward operative treatment can be observed. Documentation of the benefit of surgery in this group is scarce. The purpose of this study is to evaluate the long-term patient reported functional outcomes and complications for patients treated operatively and nonoperatively for displaced midshaft clavicular fractures. Using the same outcomes we also compared the operative methods.

METHODS

One hundred nine adolescents aged 12 to 18 years sustaining displaced midshaft clavicular fractures in the period 2010 to 2016 were identified in our computerized files. Sixty-one were treated nonoperatively, 48 operatively (22 plate and 26 intramedullary nail). Their radiographs and patient journals were examined for fracture classification, wound infection, sensory affection, surgery duration, hardware removal, and nonunion (n=109). Long-term function, pain, and satisfaction were measured with Quick Disability of Arm, Shoulder, and Hand (QuickDASH), Oxford Shoulder Score and Visual Analogue Scale (n=87).

RESULTS

Operative treatment: We could find no difference in functional score outcomes. The main outcome QuickDASH was excellent in both groups (median 0 nail vs. 2.26 plate). Surgery duration was shorter with intramedullary nail. We found 2 infections and 2 sensory affections in the plate group, and 1 infection and 1 sensory affection in the intramedullary nail group. There were 2 refractures in the nail group. Operative versus nonoperative treatment: there were no differences in functional outcomes between the operative and nonoperative groups. For the main outcome QuickDASH both groups scored excellently (median 1.12 operative vs. 0 nonoperative). The nonoperative group was more satisfied with the cosmetic result. There was 1 nonunion in the nonoperative group that later was operated.

CONCLUSIONS

Adolescents aged 12 to 18 years with displaced midshaft clavicular fractures show good long-term functional results after plate fixation, intramedullary nail, and nonoperative treatment. No additional benefit is demonstrated for surgery in our material. Nonoperatively treated patients are more satisfied with the cosmetic results. Little difference is seen between the operative methods in our study. We conclude that surgery should rarely be the choice of treatment for displaced midshaft clavicular fractures in adolescents.

LEVEL OF EVIDENCE

Level III study-retrospective comparative study.

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.

Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this study was to systematically review and quantitatively analyze outcomes in operative versus nonoperative management of displaced midshaft clavicle fractures in pediatric and adolescent patients.

DATA SOURCES

Using the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic searches of PubMed and EMBASE were conducted to identify English-language studies reporting outcomes in displaced pediatric midshaft clavicle fractures from 1997 to 2018.

STUDY SELECTION

Studies that reported on outcomes of operative and/or nonoperative treatment of displaced midshaft clavicle fractures in patients younger than 19 years were included.

DATA EXTRACTION

Patient and treatment characteristics, union rates, time to union, time to return to activity, patient-reported outcome measures, and complications were extracted.

DATA SYNTHESIS

All extracted data were recorded and qualitatively compared. QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand) scores and Constant scores were pooled using random-effects modeling and compared among studies, which adequately reported data for hypothesis testing.

CONCLUSIONS

Three thousand eight hundred ten articles were identified, and 12 met inclusion criteria. These studies encompassed 497 patients with an average age of 14.1 years (8-18 years, range). Both operative and nonoperative management of displaced midshaft clavicle fractures in this population provide excellent rates of union and patient-reported outcome measures. Compared with nonoperative management, operative management yielded faster return to activity, superior Constant scores, and equal QuickDASH scores. Operative management had higher complication rates and complications that required secondary operative treatment (mostly related to implant prominence).

LEVEL OF EVIDENCE

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

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.

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.

Operative Versus Nonoperative Treatment of Pediatric and Adolescent Clavicular Fractures: A Systematic Review and Critical Analysis

BACKGROUND

The optimal treatment of displaced middle-third clavicular fractures in pediatric and adolescent patients remains controversial. Furthermore, risk factors for the failure of nonoperative treatment have not been clearly defined. Therefore, we designed a systematic review and critical analysis to assess appropriate Grades of Recommendation for evidence-based treatment of middle-third clavicular fractures in the pediatric and adolescent populations.

METHODS

We performed a systematic review following a search of the PubMed, Embase, and Cochrane databases that was conducted in May 2017. The search terms were clavicle, clavic*, and fracture. Our specific PubMed search was ("clavicle"[MeSH] OR clavic*) AND ("fracture"[MeSH] OR fracture*). The results were filtered for English language and subjects ≤18 years of age. There was no chronological limit on the results. The results were then assessed for relevance via a stepwise approach by first screening titles, then abstracts, and, finally, full text. The levels of evidence were determined for studies that met the inclusion criteria. The findings were summarized, and Grades of Recommendation were assigned by consensus.

RESULTS

Our search returned 3,615 studies. Of these, 215 were potentially relevant. Studies that did not meet our inclusion criteria were removed by consensus. One hundred and nineteen full-text articles were then assessed. Of these, 19 met the inclusion criteria. Overall, patients with both operative and nonoperative treatment of displaced middle-third clavicular fractures have good functional outcomes, with Grade-B supporting evidence. There is Grade-B evidence that operative treatment results in a high complication rate. Both plating and nailing have a high likelihood of requiring implant removal, with Grade-B evidence. There is conflicting evidence regarding the effect of both nonoperative and operative treatment on patient cosmesis following displaced fractures. There is Grade-B evidence that nonunions of pediatric clavicular fractures are exceptionally rare, regardless of treatment strategy. Nonoperatively treated displaced fractures have conflicting evidence regarding any adverse effect displacement may have on functional status.

CONCLUSIONS

Existing literature does not clearly delineate appropriate indications for nonoperative care or relative indications for operative intervention. Further studies are needed to guide treatment and promote better informed consent.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

Clavicle fracture nonunion in the paediatric population: a systematic review of the literature

AIMS

Clavicle fracture nonunions are extremely rare in children. The aim of this systematic review was to assess what factors may predispose children to form clavicle fracture nonunions and evaluate the treatment methods and outcomes.

METHODS

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming to find papers reporting clavicle fracture nonunion in children under the age of 18 years. Data was collected on patient demographics, fracture type, mechanism of injury (MOI), surgical intervention and reported outcome. Two independent reviewers evaluated all the data.

RESULTS

A total of 13 articles reporting 21 cases of clavicle fracture nonunion were identified. The mean age at time of injury was 11.4 years (4 to 17). Falls were the most common MOI. The majority of nonunions occurred after displaced fractures on the right side. Six were refractures. Mean time of presentation following injury was 13.5 months (4 to 60). In all, 16 were treated surgically. Radiographic union was eventually achieved in 12 cases, with functional outcome satisfactory in all cases.

CONCLUSION

Clavicle nonunion is an extremely rare but possible complication in children. The majority occur after displaced right-sided fractures or refractures and present around one year after injury. Surgical fixation provides good radiographic healing and functional outcomes.

LEVEL OF EVIDENCE

IV.