From the Department of Orthopedics, Rafik Hariri University Hthe Weston Orthopedic and Sports Medicine Center, StonewaWeston, WV.

Received for publication September 15, 2014; accepted in2014.

No benefits in any form have been received or will beindirectly to the subject of this article.

Corresponding author: Shafic Sraj, MD, Weston OrthopedicStonewall Jackson Memorial Hospital, 29 Hospital Plaza, Se-mail: shaficsrajmd@gmail.com.

0363-5023/15/4001-0027$36.00/0http://dx.doi.org/10.1016/j.jhsa.2014.09.023

EVIDENCE-BASED MEDICINE

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Adolescent Displaced Midshaft Clavicle Fracture

edicin

Ibrahim Assafiri, MD, Shafic Sraj, MD

Evidence-Based

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THE PATIENTA 14-year-old girl presents with an injury to the leftshoulder 1 day after a motor vehicle accident. Shereports pain and deformity of the left clavicle. Shewas evaluated in the emergency department andgiven a sling. On examination, she has mild softtissue swelling and obvious deformity of the leftclavicle, mild bruising, no skin tenting, and no lac-erations. She is tender at the middle part of thediaphyseal clavicle. The radiograph reveals a 100%displaced mid-shaft clavicle fracture with nocomminution.

THE QUESTIONWhat are the advantages of operative treatment ofclosed displaced clavicle shaft fractures inadolescents?

CURRENT OPINIONThe clavicle is a commonly fractured bone in bothchildren and adults.1 Most are midshaft and one-halfof them are displaced.2 Traditional teaching hasemphasized the great potential of clavicle fracturesfor remodeling and union with consistent excellentresults after nonsurgical treatment in children. On theother hand, recent literature in adults emphasizes thepossibility of nonunion and malunion shortened anddisplaced midshaft clavicle fractures.3 Adolescence isa transitional period of physical and psychologicaldevelopment that occurs between puberty and adult-hood. The World Health Organization defines ado-lescents as aged 10 to 19 years.4 Clavicle fractures in

ospital, Beirut, Lebanon; andll Jackson Memorial Hospital,

revised form September 25,

received related directly or

and Sports Medicine Center,uite C, Weston, WV 26452;

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adolescents are included in the pediatric as well asadult literature, which makes specific recommenda-tions for this age group less clear.2,5

Plate fixation is increasingly offered to adolescentpatients with displaced and/or shortened midshaftclavicular fractures. Current opinion is that shorteningof the fractured clavicles tends to persist after union6

and remodeling of the fracture bump is less predict-able past age 10 years.7 Some surgeons offer operativetreatment to patients with comminution with asegmental butterfly fragment and high-demand ath-letes with fracture of the dominant arm. It also seemsthat patient and parent expectations may be driftingtoward reduction and fixation in select adolescentswith special skills and functional demands. Reportedbenefits to operative treatment include restoration oflength and alignment and more predictable union.

Carry et al8 surveyed the members of the PediatricSociety of North America regarding their preferredtreatment in 4 common midshaft clavicle fracturepatterns. The response rate was 32% (302 of 949members). Most physicians preferred nonsurgicaltreatment for all fracture patterns. Physicians weremore likely to operate on adolescents aged 16 yearsand older. Half of the respondents reported that theywere influenced by the recent adult literature. Patientsaged 16 or more years with angulated, displaced, andsegmental clavicle fractures would be offered surgeryin 8%, 25%, and 48% of cases, respectively.

THE EVIDENCEClavicle fracture potential for remodeling

The potential to remodel a diaphyseal clavicle frac-ture in children older than age 10 to 12 years may belimited.6,7,9 The clavicle reaches 80% of its length byage 9 years 3 months in girls and 12 years in boys.Above age 12 years, clavicles grow at a rate of 2.6mm/y in girls and 5.4 mm/y in boys.9

Nonsurgical treatment

Schulz et al6 described 16 patients aged 10 to 18 yearswith isolated, completely displaced, shortened, mid-shaft clavicle fracture treated with an arm sling. All ofthe fractures united, some with shortening, but there

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were no differences in range ofmotion, an 8%decreasein maximal shoulder external rotation strength, and an11% loss of shoulder abduction endurance strength.The researchers used Single Assessment NumericEvaluation, QuickeDisabilities of the Arm, Shoulder,and Hand (DASH) (shortened version of the DASHquestionnaire), and Constant scores to evaluate func-tional outcome 12 to 36months after the injury. Fifteenof the 16 patients were satisfied with the appearance ofthe clavicle, and all returned to full activity.

Bae et al10 evaluated 16 patients presenting to theoffice with radiographic malunion after nonsurgicaltreatment of midshaft clavicle fractures with more than2 cm of initial displacement. Compared with thecontralateral side, forward flexion and abduction werereduced 7.3� and 6.5�, respectively. Strength wassimilar on both sides. Although functional outcomesmeasured by DASH questionnaire and the PediatricOutcomes Data Collection Instrument were consistentwith excellent overall global and upper limb function,4 patients (20%)were unsatisfied and 4 (20%) reportedsubstantial pain 2 years after nonsurgical treatment.Only 1 patient requested an osteotomy.

A Cochrane review comparing figure-of-eightbandage with an arm sling for acute middle-thirdclavicle fractures in adolescents and adults found noimportant differences.5

Nonunion of the clavicle in the pediatric andadolescent population after nonsurgical treatment isuncommon. I found a total of 5 published case reports;patients were aged 7, 8, 10, 12, and 13 years.11e15 Allpatients underwent surgical intervention for persistentpain and healed uneventfully.

Operative treatment

Kubiak and Slongo16 described 15 children aged 9 to16 years who had open reduction internal fixation of afracture of the clavicle. They represented 1.6% of 939similar patients treated for clavicle fractures over 20years. Eight of those 15 fractures were displacedmidshaft fractures. Five were fixed using nonlockedintra-medullary nailing, 2 were fixed with an externalfixator, and 1 was fixed with a screw. Indications forsurgery included marked superior displacement of themedial fragment (6 patients), shortening (3 patients),concern for potential skin perforation/necrosis (4patients), and concern for potential neurovascular risk(1 patient). The fractures all healed but 13 of 15 pa-tients developed skin irritation and bursae formation atthe tip of the implant.

Grazy�nski et al17 studied 23 fractures of the clav-icle in children treated by K-wire stabilization (22open and 1 percutaneous) between 1999 and 2001.

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The only complication reported was irritation of skinat the protruding end of the pin. The pins wereremoved after 2 to 4 months.

Mehlman et al18 described 24 patients aged 7 to 16years with a displaced clavicle shaft fracture treatedbetween 2002 and 2007 with open reduction internalfixation. The authors reported no infections and nononunions. Twenty-one patients (87%) returned tounrestricted sports activities. Two patients had scarsensitivity and 1 experienced transient ulnar nerveneurapraxia. Implants were routinely removed.

Namdari et al19 retrospectively reviewed 14 skel-etally immature patients (mean age, 13 y) withclosed, displaced, midshaft clavicle fractures treatedwith open reduction internal fixation with a plate andscrew construct. Indications were defined as short-ening more than 2 cm, 100% displacement, and skintenting. Cosmetic concerns were taken into consid-eration. Eight patients reported numbness at the siteof surgery, 4 underwent a second surgical procedurefor removal of hardware, and 4 noted persistentdeformity. There were no nonunions. QuickeDASHscores averaged 7 (range, 0e37) and 93% of thepatients returned to sports with no limitation. Eightpatients were very satisfied, 4 were somewhat satis-fied, and 2 were neutral.

Vander Have et al2 retrospectively reviewed 42patients (aged 12e17 y) with 43 closed midshaftclavicle fractures. Surgery was offered to patients with20 mm or more of shortening. Twenty-five patientswere treated nonsurgically and 17 were treated withopen reduction plate fixation. Mean time to radio-graphic union for displaced fractures was 8.7 weeks inthe nonsurgical group and 7.4 weeks in the operativegroup (P ¼ .02). There were no nonunions in eithergroup. The operative group had 3 local hardwareprominences that required removal. The nonsurgicalgroup had 5 symptomaticmalunions; 4 patients electedto undergo corrective osteotomy. They definedsymptomatic malunion as pain with overhead activity,weakness, fatigability, and neurologic symptoms. Ofnote, the symptomatic malunions had 21 mm or moreof shortening, whereas all other patients in thenonsurgical group had 21 mm or less of shortening.Mean time to return to activities was 16 weeks in thenonsurgical group and 12weeks in the operative group.

SHORTCOMINGS OF THE EVIDENCEThe current evidence regarding treatment of displacedmidshaft clavicle fractures in adolescents is limited tosmall retrospective case series and one retrospectivecomparison. Available high-level data are from adult

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patients and it is not clear whether they apply to ado-lescents, particularly those who are skeletally imma-ture. Although studies try to group patients based onage, evaluation of the growth plate on radiographsmaybe more relevant to the determination of remodelingpotential of clavicle fractures than an age cutoff ordesignation of adolescence. Indications for surgery areimprecise, subjective, and not supported by evidence.

Evide

DIRECTIONS FOR FUTURE RESEARCHWe need to determine the degree to which age andskeletal maturity affect the risk of nonunion and thecapacity for remodeling with a displaced midshaftclavicle fracture. Malunions and nonunions do notcause much objective impairment (eg, stiffness,diminished sensation). It would be useful to observe alarge cohort of nonsurgically treated displaced mid-shaft clavicle fractures in children and adolescents todocument union and remodeling potential as well asfactors associated with symptom intensity andmagnitude of disability.

There is room for the development of adolescent-specific outcome measures that address upper ex-tremity function, modeled after already establishedadult questionnaires. Adolescents are not little adults.They may have different outlook toward pain, func-tion, and cosmesis. They also may have differenttolerance to deformity or functional limitation withrespect to future academic, athletic, and career plans,factors that may have less weight in adults who alreadyhave well-defined roles.

Studies can also evaluate patients’ attitude towardinitial nonsurgical treatment, taking a chance of futuresurgery for symptomatic nonunion or malunioncompared with immediate operative treatment withattendant operative risks and the possible need toremove a symptomatic or unsightly implant. In addition,studies may evaluate satisfaction with aesthetics,comparing fracture site prominence (bump) versusexposed surgical scar and implant prominence.

OUR CURRENT CONCEPTS FOR THIS PATIENTWe discuss scar or implant prominence versus frac-ture deformity and the risks of anesthesia and surgeryversus the risks of nonunion and symptomatic mal-union with each patient and his or her parents. Afteroperative or nonsurgical treatment, I advise 2 to 4weeks of sling immobilization. Contact sports and

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heavy lifting should be avoided for 6 to 12 weeks.We check radiographs periodically until union isdocumented. Implant removal is discretionary.

REFERENCES

1. Nordqvist A, Petersson C. The incidence of fractures of the clavicle.Clin Orthop Relat Res. 1994;(300):127e132.

2. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operativeversus nonoperative treatment of midshaft clavicle fractures in ado-lescents. J Pediatr Orthop. 2010;30(4):307e312.

3. Canadian Orthoapedic Trauma Society. Nonoperative treatmentcompared with plate fixation of displaced midshaft clavicular frac-tures: a multicenter, randomized clinical trial. J Bone Joint Surg Am.2007;89(1):1e10.

4. World Health Organization. Adolescent health. Available at: http://www.who.int/topics/adolescent_health/en/. Accessed May 11, 2014.

5. Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB,Faloppa F. Conservative interventions for treating middle thirdclavicle fractures in adolescents and adults. Cochrane Database SystRev. 2009;(2):CD007121.

6. Schulz J,MoorM,Roocroft J, BastromTP, PennockAT. Functional andradiographic outcomes of nonoperative treatment of displaced adoles-cent clavicle fractures. J Bone Joint Surg Am. 2013;95(13):1159e1165.

7. Calder JDF, Solan M, Gidwani S, Allen S, Ricketts DM. Manage-ment of paediatric clavicle fractures—is follow-up necessary? Anaudit of 346 cases. Ann R Coll Surg Engl. 2002;84(5):331e333.

8. Carry PM, Koonce R, Pan Z, Polousky JD. A survey of physicianopinion: adolescent midshaft clavicle fracture treatment preferencesamong POSNA members. J Pediatr Orthop. 2011;31(1):44e49.

9. McGraw MA, Mehlman CT, Lindsell CJ, Kirby CL. Postnatalgrowth of the clavicle: birth to 18 years of age. J Pediatr Orthop.2009;29(8):937e943.

10. Bae DS, Shah AS, Kalish LA, Kwon JY, Waters PM. Shouldermotion, strength, and functional outcomes in children with estab-lished malunion of the clavicle. J Pediatr Orthop. 2013;33(5):544e550.

11. Pourtaheri N, Strongwater AM. Clavicle nonunion in a 10-year-oldboy. Orthopedics. 2012;35(3):e442ee443.

12. Caterini R, Farsetti P, Barletta V. Posttraumatic nonunion of theclavicle in a 7-year-old girl. Arch Orthop Trauma Surg. 1998;117(8):475e476.

13. Ropars M, Bey M, Bouin M, Chapuis M, Bracq H, Violas P.[Posttraumatic nonunion of the clavicle in a child: case report]. RevChir Orthop Reparatrice Appar Motil. 2004;90(7):666e669.

14. Spapens N, Degreef I, Debeer P. Posttraumatic pseudarthrosis of theclavicle in an 8-year-old girl. J Pediatr Orthop B. 2010;19(2):188e190.

15. Wilkins RM, Johnston RM. Ununited fractures of the clavicle. J BoneJoint Surg Am. 1983;65(6):773e778.

16. Kubiak R, Slongo T. Operative treatment of clavicle fractures inchildren: a review of 21 years. J Pediatr Orthop. 2002;22(6):736e739.

17. Grazy�nski J, Wawrzaszek P, Sobczy�nski S, Adamczak M. [Operativetreatment of clavicle fractures in children]. Chir Narzadow RuchuOrtop Pol. 2003;68(1):19e21.

18. Mehlman CT, Yihua G, Bochang C, Zhigang W. Operative treatmentof completely displaced clavicle shaft fractures in children. J PediatrOrthop. 2009;29(8):851e855.

19. Namdari S, Ganley TJ, Baldwin K, et al. Fixation of displacedmidshaft clavicle fractures in skeletally immature patients. J PediatrOrthop. 2011;31(5):507e511.

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