review article displaced clavicle fractures in adolescents...

Displaced Clavicle Fractures inAdolescents: Facts,Controversies, and CurrentTrends

Abstract

There is an increasing trend toward stabilization and fixation ofmarkedly displaced midshaft clavicle fractures in adolescents.Recent studies in the adult literature have shown a greaterprevalence of symptomatic malunion, nonunion, and poorfunctional outcomes after nonsurgical management of displacedfractures. Fixation of displaced midshaft clavicle fractures canrestore length and alignment, resulting in shorter time to union.Symptomatic malunion after significantly displaced fractures inadolescents may be more common than previously thought.Adolescents often have high functional demands, and theirremodeling potential is limited. Knowledge of bone biology and theeffects of shortening, angulation, and rotation on shoulder girdlemechanics is critical in decision making in order to increase thelikelihood of optimal results at skeletal maturity. Selection of fixationis dependent on many factors, including fracture type, patient age,skeletal maturity, and surgeon comfort.

Few studies have specifically in-vestigated outcomes of surgical

and nonsurgical management ofclavicle fractures in children and ad-olescents; thus, most data are extrap-olated from the adult literature. Be-cause of a traditional belief thatclavicular nonunions are rare, mid-shaft clavicle fractures in adults haveroutinely been managed nonsurgi-cally, even in the setting of substan-tial displacement.1 More recently,however, higher rates of nonunionand unsatisfactory patient-derivedoutcomes have been reported incases of nonsurgically managed dis-placed midshaft clavicle fractures inadults.2,3 Additionally, two recentrandomized controlled studies dem-onstrated the superiority of surgicalmanagement of completely displaced

clavicle fractures in adults.4,5 Despitethis evidence, definite indications forfixation of clavicle fractures in adultpatients are not well-established. In-dications for fixation of clavicle frac-tures in children and adolescents areeven less clear.

Clavicle fractures in adolescentshave traditionally been managednonsurgically; however, the success-ful outcomes achieved from fixationof displaced clavicle fractures inadults have called into question thisclassic teaching. This shift in philoso-phy has led some pediatric orthopae-dic surgeons to search for and refineindications for fixation of claviclefractures in skeletally immature pa-tients, particularly in highly func-tional and active adolescents. Chil-dren have great potential for fracture

Nirav K. Pandya, MD

Surena Namdari, MD, Msc

Harish S. Hosalkar, MD

From the Department of PediatricOrthopaedic Surgery, RadyChildren’s Hospital–San Diego, SanDiego, CA (Dr. Pandya andDr. Hosalkar) and the Department ofOrthopaedic Surgery, Hospital of theUniversity of Pennsylvania,Philadelphia, PA (Dr. Namdari).

Dr. Pandya or an immediate familymember serves as a board member,owner, officer, or committee memberof the Pediatric Orthopaedic Societyof North America. Dr. Hosalkar or animmediate family member is amember of a speakers’ bureau orhas made paid presentations onbehalf of Synthes, serves as a paidconsultant to or is an employee ofAllergan and Synthes, and has stockor stock options held inGlaxoSmithKline, Johnson &Johnson, and Pfizer. NeitherDr. Namdari nor any immediatefamily member has receivedanything of value from or ownsstock in a commercial company orinstitution related directly orindirectly to the subject of thisarticle.

J Am Acad Orthop Surg 2012;20:498-505

http://dx.doi.org/10.5435/JAAOS-20-08-498

Copyright 2012 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

498 Journal of the American Academy of Orthopaedic Surgeons

healing and remodeling. However, asthey enter adolescence, children be-come more active than adult pa-tients, lose the ability to remodel,and theoretically may have greaterfunctional impairment resulting fromresidual disability.

Anatomy

The clavicle is an S-shaped bonewhose medial end is connected to theaxial skeleton via the sternoclavicu-lar joint and whose lateral end isconnected to the scapula via theacromioclavicular joint. Phylogeneti-cally, it has played a critical role inavian species, bipeds, and quadru-peds. As mammals evolved into anerect species, the clavicle continuedto be a critical bone, attaching andsuspending the entire upper extrem-ity and scapular blade to the thoracicgirdle. It is the first bone to ossify inthe fifth week in utero.6 Initialgrowth (<5 years) occurs from theossification center in the central por-tion of the clavicle, whereas contin-ued growth occurs at the medial andlateral epiphyseal plates.7,8 Duringchildhood, approximately 80% of

clavicular growth occurs at the me-dial physis.7 The medial growth plateis the last physis to close, generally atage 23 to 25 years.8

Several fascial layers and muscles at-tach to the clavicle and help to createthe predictable deformity seen withfractures. Midshaft fractures are themost common type (Figure 1). Thesefractures occur in the middle third ofthe clavicle and include all fractures lat-eral to the sternocleidomastoid muscleand medial to the coracoclavicular lig-aments. The medial fragment is pulledsuperiorly and posteriorly by the ster-nocleidomastoid muscle. The lateralsegment sags forward and rotates infe-riorly because of the weight of the up-per extremity and, to a lesser extent,the pull of the pectoralis muscle on thehumerus.9 More complex fracturepatterns can also occur, as seen inFigure 2.

Effect of Clavicle Malunionon Scapular Kinematics

The normal clavicle undergoes com-plex three-dimensional motion. Cla-vicular motion is linked directly to

the surrounding motion of the scap-ula via attachment to the acromio-clavicular joint and to the surround-ing motion of the sternum viaattachments to the sternoclavicularjoint.9 During elevation of the armand with respect to the thorax, theclavicle generally undergoes eleva-tion of 11° to 15°, retraction of 15°to 29°, and posterior long-axis rota-tion of 15° to 31°.10 The magnitudeof motion varies by subject andplane of motion.

Although nonsurgically managedclavicle fractures typically heal withsome degree of deformity, functionalresults have been considered to begenerally acceptable. However, morerecent studies have highlighted theimportance of clavicle shorteningand displacement in determininghealing potential and functional out-comes, which has created interest inthe role of clavicle malunion onshoulder girdle kinematics.11-13

Changes in the resting position of thescapula can lead to scapular dyskine-sis and pain on arm movement. Ad-ditionally, scapular malrotation maychange the orientation of the glenoidrelative to the humeral head, which

A, AP radiograph demonstrating a completely displaced (>100% displacement) midshaft fracture of the clavicle in anadolescent patient who presented with deformity, skin tenting, and neurapraxia in the form of a tingling sensation in theaffected upper extremity. B, AP radiograph obtained following open reduction and fracture fixation. The patient healeduneventfully and returned to full function 6 weeks postoperatively and to athletics 8 weeks postoperatively.

Figure 1

Nirav K. Pandya, MD, et al

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could lead to altered joint reactiveforces. In an experimental cadavermodel, Andermahr et al12 demon-strated that healing of clavicle frac-tures with bony shortening leads to aventromedial caudal shift in the posi-tion of the glenoid fossa. They hy-pothesized that this malposition canresult in functional deficits in abduc-tion, particularly overhead motion.Most recently, in a cadaver studyevaluating the effect of shorteningdeformity of the clavicle on scapularkinematics, Matsumura et al13 foundthat posterior tilting and external ro-tation of the scapula significantly de-creased with ≥10% shortening.

Although it is clear that clavicleshortening leads to alteration in thenormal scapular position, the clinical

influence of these changes has notbeen extensively studied. Ledgeret al11 evaluated the impact of clavi-cle malunion (ie, 15 mm of shorten-ing) on anatomic and functional out-comes in 10 patients. They noted areduction in muscular strength foradduction, extension, and internalrotation of the humerus as well as re-duced peak abduction velocity in theinjured shoulder. In a larger clinicalstudy of mostly adult patients, Laza-rides and Zafiropoulos14 reviewed132 patients with united fractures ofthe middle third of the clavicle afternonsurgical management at a mini-mum follow-up of 1 year. Of these,25.8% reported overall dissatisfac-tion with the result of their manage-ment. Final clavicular shortening of

>18 mm in male patients and >14mm in female patients was signifi-cantly associated with patient-reported overall dissatisfaction withnonsurgical treatment (P < 0.001 foreach). The study included 93 maleswith a mean age of 25.4 years(range, 16 to 72 years) and 39 fe-males with a mean age of 34.2 years(range, 15 to 77 years).

No study has evaluated kinematicsof the shoulder girdle in the settingof clavicular malunion in skeletallyimmature patients. Furthermore, it isnot clear which level of claviclemalunion leads to a clinically signifi-cantly altered scapular position anda poor functional result in this pa-tient population. To determine theextent of clavicle shortening, investi-

AP plain radiograph (A) and three-dimensional inferior oblique (B) and inferior transthoracic (C) CT reconstructions ofthe “Z” fracture in an athletic adolescent male patient. D, AP radiograph of the same patient following surgical fixation.The patient had full uneventful healing and recovery and returned to athletic participation 10 weeks postoperatively.

Figure 2

Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends


gators also must consider interindi-vidual variation in total claviclelength.11 For example, 2 cm of short-ening in a 10-cm pediatric claviclewill result in relative shortening of20%, whereas 2 cm of shortening ina 17-cm adult clavicle will result inrelative shortening of 12%. This isimportant because the same amountof shortening will result in differentdegrees of change in scapular posi-tion and sternoclavicular angula-tion.15 As a result, it may not be pos-sible to apply to skeletally immaturepatients established radiographicpredictors of poor outcome in skele-tally mature patients.

Radiography

Typically, a standard AP radiographand a 45° cephalic tilt view are ob-tained to assess clavicle fracture pat-tern, displacement, and angulation.9

Although shortening in clavicle frac-tures is considered to be an impor-tant parameter in selecting a treat-ment modality, no standardizedmethod of measurement exists. Con-siderable variability exists in mea-surement techniques. Shorteningmay be measured on a standardized15° tilted radiograph of the clavicle,a 15° uptilted AP panorama radio-graph of the shoulder girdle,16 a stan-dardized PA thorax radiograph,14 anabduction lordosis view,17 or clini-cally with a simple tape measure.18

Smekal et al15 assessed the differentmeasurement methods and foundthat the highest agreement with CTmeasurements was shown by PA tho-rax radiographs with the patientstanding erect and the clavicles posi-tioned close to the x-ray film. Re-gardless of technique, the authorsnoted a relatively low repeatability.They attributed this finding to thelimitation of two-dimensional radio-graphs, which can lead to misinter-pretation of overlapping fragments.

Advanced ImagingStudies

CT, which is less commonly usedthan plain radiography, allows three-dimensional reconstruction of theclavicle. This is important in measur-ing the true total length of the clavi-cle independent of its angle in refer-ence to the frontal and sagittalplanes15 and because of the interindi-vidual variability in total claviclelength. No study has evaluated theaccuracy of normal clavicular lengthmeasurement on plain radiographycompared with CT. However, giventhe variability in radiograph plateand beam angles and distance, it isunlikely that a true length measure-ment can be obtained in a reproduc-ible manner in two dimensions. Inour practice (H.S.H.), we commonlyutilize three-dimensional CT to eval-uate total length, shortening, andcomminution of clavicle fractures forwhich plain radiographs indicate theneed for surgical management.

Drawbacks of CT include cost andradiation exposure. Depending onthe machine settings, the organ beingstudied typically receives a radiationdose of 15 mSv in an adult and 30mSv in a neonate for a single CTscan, with an average of two or threeCT scans in a single evaluation.19

Children are at greater risk thanadults from a given dose of radiationbecause children are inherently moreradiosensitive and because they havemore remaining years of life duringwhich radiation-induced cancercould develop.20 CT is done with thepatient in the supine position; theo-retically, with the shoulder girdlemuscles relaxed and gravity acting asa tension mechanism, the fracturemay become reduced.15 However, thecorrelation between measurementsof clavicle fracture shortening on CTand standing plain radiographs hasnot been determined, and the clinical

significance of patient positioning isunclear.

Management

Historically, pediatric midshaft clavi-cle fractures have been managednonsurgically. Recent studies haveexpanded the surgical indications inthe adult population beyond injuriesthat are open or associated with neu-rovascular compromise to includefractures with >15 to 20 mm ofshortening, 100% displacement, andsignificant comminution.2,9,21 How-ever, the applicability of these find-ings to pediatric patients is unclear.

NonsurgicalTraditionally, excellent outcomeshave been achieved with nonsurgicalmanagement of pediatric claviclefractures. Treatment generally con-sists of 2 to 4 weeks of immobiliza-tion in either a figure-of-8 brace or ashoulder sling, followed by range ofmotion (ROM) activities and a re-turn to sports activities 6 to 8 weeksafter the date of injury, provided thefracture site is no longer tender.22 Ina review of 38 pediatric trauma pa-tients with head injury and concomi-tant clavicle fractures, Wilkes andHoffer23 found that all fractureshealed and exhibited excellent re-modeling. In addition, patients re-gained full shoulder ROM evenwithout immobilization.

Questions remain regarding theideal type of immobilization. In aCochrane review, Lenza et al24 evalu-ated the available evidence from twotrials comparing the figure-of-8 ban-dage with an arm sling. The only sta-tistically significant difference inclinical outcome between the twogroups was that the patients treatedwith figure-of-8 bracing had signifi-cantly higher pain scores at 15-dayfollow-up in one trial (mean differ-ence, 0.80; 95% confidence interval,


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0.34 to 1.26; visual analog scale, 0[no pain] to 10 [worst pain]). In theother study, neither healing nor re-duction was affected by eithermethod of immobilization. However,9 of 34 patients treated with thefigure-of-8 bandage were dissatisfied(26%), whereas only 2 of 27 patientstreated with a sling were dissatisfied(7%) (relative chance of satisfactionfor sling treatment, 1.3 [95% confi-dence interval, 1 to 1.6]; P = 0.09).The difference appeared to be associ-ated with discomfort caused by thefigure-of-8 brace, including impair-ment of agility and personal care,sleep disturbance, edema of the arm,and paresthesia.

The available evidence is not suffi-cient to allow definitive conclusionsregarding which intervention is bet-ter. Given the ease with which a slingcan be placed on pediatric patients aswell as the minimal cost, we preferslings when nonsurgical managementis selected.

SurgicalIt is important to understand thestudies behind the expanded indica-tions for surgical management ofmidshaft clavicle fractures in adultsand their potential applicability tothe pediatric population. In a multi-center study, the Canadian Ortho-paedic Trauma Society prospectivelycompared nonsurgical managementwith plate fixation to manage dis-placed midshaft clavicle fractures inadults.4 Surgically managed fractureshad significantly improved Constantand Disability of the Arm, Shoulderand Hand (DASH) scores (P = 0.001and P < 0.01, respectively), fastertime to radiographic union (16.4weeks with surgery versus 28.4weeks without; P = 0.001), decreasedrate of nonunion and malunion (P =0.042 and P = 0.001, respectively),and improved patient satisfaction(appearance of the shoulder [P =

0.001]; shoulder in general [P =0.002]). In a systematic review of2,144 acute midshaft clavicle frac-tures, Zlowodzki et al25 found thatcomminuted displaced fractures hada higher rate of nonunion and long-term negative sequela with nonsurgi-cal management, with a relative riskreduction of 57% for nonunionwhen plate fixation was applied.

Participation of pediatric patientsin higher-demand activities thatplace adult-type demands on theshoulder girdle, with resultant frac-ture patterns that resemble high-energy adult trauma, begs the ques-tions whether surgeons should bemore aggressive in the surgical fixa-tion of displaced clavicle fractures inchildren and whether midshaft clavi-cle fractures should be surgicallyfixed in the presence of >15 mm ofshortening, 100% displacement,and/or significant comminution.2,9,21

There is a dearth of studies on surgi-cal management of pediatric claviclefractures. A review of several studiesexamining surgical interventionsmay provide a basis on which pre-liminary recommendations can bemade and further studies developed.

Kubiak and Slongo26 provided oneof the first reports on the surgicalmanagement of clavicle fractures inthe pediatric population. The au-thors reviewed the outcomes of 939children who presented with claviclefracture over a period of 21 years;924 of these patients were treatednonsurgically. The 15 children whounderwent surgical treatment weremanaged with a variety of techniques(eg, Kirschner wires [K-wires], osse-ous suture, elastic stable intramedul-lary nailing [ESIN], screw fixation,external fixation). Seven of the eightpatients with midshaft clavicle frac-ture underwent surgery to addressconsiderable displacement, shorten-ing, and soft-tissue impingement.The authors found complete healingand return of full shoulder ROM

with surgical intervention with fewminor complications (eg, hardwareirritation, scar cosmesis) in the sevenpatients with midshaft fracture. Theauthors concluded that indicationsfor the management of pediatricclavicle fractures should be ex-panded from the traditional indica-tions of open injury and neurovascu-lar compromise to include fractureswith severe shortening and displace-ment. A strong recommendation wasalso made for the use of ESIN as op-posed to other techniques.

Prinz et al27 also reported on theuse of K-wires and ESIN in the surgi-cal management of pediatric claviclefractures and examined the role ofpatient age in surgical decision mak-ing. All patients aged <10 years weretreated nonsurgically. Ten of the pa-tients aged ≥10 years and with dis-placed clavicle fractures were treatedsurgically and achieved good func-tional and cosmetic results as mea-sured by the Constant score and apatient satisfaction questionnaire.The authors concluded that, in pa-tients aged ≥10 years, surgical treat-ment with ESIN can lead to im-proved pain relief and patientsatisfaction, largely resulting from ashorter immobilization time. To ourknowledge, no other studies havespecifically assessed wire fixation orESIN in a pediatric population.

Several reports in the adult litera-ture indicate that smooth pins are as-sociated with risk of migration inupper extremity surgery.28-31 In addi-tion, intramedullary nailing of cla-vicular midshaft fractures is techni-cally demanding, with risk of highfluoroscopy and surgical times, corti-cal perforations, nail breakage, andhardware irritation.32 For these rea-sons, we do not currently performwire or ESIN fixation of pediatricclavicle fractures.

An examination of adult type im-plants in the surgical management ofpediatric clavicle fractures is also im-



perative, particularly the role of plat-ing. Vander Have et al33 retrospec-tively compared the results of 42adolescent patients who were treatedfor midshaft clavicle fractures (meanage, 15.4 years). Twenty-five patientswere treated nonsurgically with asling or figure-of-8 brace; the other17 were treated with nonlocking an-terosuperior compression plating.The surgical group had greater short-ening at the time of injury (27.5 ver-sus 12.5 mm), a quicker time to ra-diographic union (7.4 versus 8.7weeks), and a faster return to full ac-tivities (12 versus 16 weeks). Al-though the quicker time to radio-graphic union was statisticallysignificant (P = 0.02), we do not be-lieve that this small time difference isclinically relevant. In addition, al-though the authors do not providestatistical analysis to determinewhether the 4-week faster return toactivity of the surgical group is sta-tistically significant, we believe thatit is clinically relevant. No patient ineither group developed nonunion.However, symptomatic malunion de-veloped in five of the nonsurgicallytreated patients (mean fracture short-ening, 26 mm). Four of these five pa-tients elected to undergo correctiveosteotomy. In this study, symptom-atic malunion was defined as frac-ture union with shortening or angu-lation and asymmetry, as comparedwith the uninvolved shoulder, andsubjective complaints, including painwith overhead use, weakness, fatiga-bility, and neurologic symptoms. Weare unaware of any other reportsthat specifically address the need forcorrective osteotomy to manage cla-vicular malunion in the pediatricpopulation.

Mehlman et al34 retrospectively ex-amined the outcomes of 24 adoles-cent patients who underwent surgi-cal fixation of their displacedclavicular shaft fractures. Twenty-two patients underwent plate fixa-

tion. The patients achieved a 100%rate of union, a 100% rate of satis-faction, and an 87% rate of return tounrestricted sports activities. All pa-tients returned for hardware removalafter healing.

Most recently, Namdari et al35 ret-rospectively reviewed 14 skeletallyimmature patients (mean age, 12.9years) with closed, displaced, mid-shaft clavicle fractures that weremanaged with open reduction andinternal fixation (ie, plate fixation).Total quickDASH and simple shoul-der test (SST) scores were determinedat a minimum follow-up of 24months. In this study, the mean post-operative total quickDASH scorewas 7.0, and a mean of 11 questionswere answered “yes” on the SST. Allfractures healed. However, four pa-tients from the surgical group re-quired a second surgical procedureto remove hardware, and eight pa-tients complained of numbness at thesite of injury/surgery.

Hosalkar et al36 reviewed a seriesof surgical fixations performed attheir institution to address displacedunilateral clavicle fracture in 19 ado-lescent patients (mean age, 14.6years). Baseline demographic and ra-diographic data were collected pre-operatively, and patients were evalu-ated postoperatively with functionaloutcomes measures such as thequickDASH and SST as well as addi-tional binary questions. The meanquickDASH score was 4.0 at a meanfollow-up of 16 months (range, zeroto 35.5 months), and the mean num-ber of “yes” responses on the SSTfor all surgical patients was 11(range, 9 to 12). Complete radiologicunion was noted in all cases at3-month follow-up, and all patientsreturned to full sports participationat a mean of 14 weeks (range, 12 to17 weeks). Minimal hypertrophicscarring was noted in two patients,and no keloid formation or neuro-vascular deficit was noted. At 15-

month follow-up, one patient re-ported implant prominence andcomplained of occasional discom-fort. This patient elected to undergoimplant removal and experienced acomplete and uneventful recovery.All patients were satisfied with theirdecision to undergo surgical treat-ment. These results led the authorsto conclude that anatomic reductionwith internal fixation and early mo-bilization of displaced clavicle frac-tures in adolescent patients remains aviable treatment option with predict-able results and no major complica-tions when performed by experi-enced surgeons.

Excellent outcomes can be achievedwith surgical management. However,patients and families must be counseledregarding the known risks of hardwarefailure, incisional numbness, and thepotential need for a second surgery toremove hardware.

The Authors’ PreferredMethodAt our institution (H.S.H.), adoles-cents with clavicle fractures that arecompletely displaced (ie, no corticalcontact between the fracture ends) orcomminuted, or that contain a trans-verse Z-shaped fragment, are treatedsurgically. In addition, using as aguide the average length of the clavi-cle and the amount of shorteningconsidered to be a relative indicationfor surgical intervention in adults(138 and 20 mm, respectively),4,37 weconsider clavicle shortening of 14%to 15% (20/138) to be another rela-tive indication for surgical interven-tion in adolescent patients. Relativeshortening by itself is insufficient towarrant surgical intervention. Itmust be accompanied by comminu-tion, marked displacement, or skintenting. Fractures that are open orpresent with neurovascular compro-mise require surgical management, aswell.


August 2012, Vol 20, No 8 503

The patient is placed supine on aJackson table, and a bump is placedunder the scapula. A nonlockingcompression plate is affixed to thesuperior surface of the clavicle. Inthe patient with severe comminutionor osteopenia, a locking plate is usedinstead. In general, bone quality isexcellent in pediatric patients, andnonlocking screws are preferred. In-terfragmentary compression screwsare used when the fracture patternallows.

Postoperatively, the patient is keptin a sling and swath for 3 weeks, af-ter which ROM exercises are begun.Following a progressive ROM andstrengthening program and in thepresence of clinical and radiographicsigns of healing, the patient is al-lowed to return to sport at 12 weeksafter the injury. Patients who aretreated nonsurgically are typicallyplaced in a simple shoulder sling for3 to 4 weeks. A sling and swath isused acutely for 2 weeks in the pa-tient with significant swelling andpain, after which ROM exercises andprogressive strengthening are begun.Return to sport is allowed once thepatient shows clinical (ie, no tender-ness about the fracture site) and ra-diographic signs of healing.

Summary

The current literature in the adultpopulation has clearly shown thatthe indications for surgical fixationof midshaft clavicle fractures are ex-panding. Patient shoulder function,biomechanics, and risk of nonunionor malunion can be significantly af-fected based on the treatment course(ie, nonsurgical, surgical). The ques-tion persists whether markedlydisplaced fractures in the pediatricpopulation should be managed surgi-cally. The limited literature on surgi-cal treatment in the pediatric popula-tion demonstrates that positive

outcomes can be achieved with re-gard to shoulder function, patientsatisfaction, and union. However,there is no specific criterion that canbe universally and consistently ap-plied to guide clinicians as to whattype of fractures (ie, shortening, dis-placed, comminuted) should be sur-gically managed in this young popu-lation and in which manner.

Issues that remain unresolved in-clude the degree of shortening that isacceptable, the degree of displace-ment that can be tolerated while stillachieving union, the level of commi-nution that will heal without impair-ment in shoulder function, and theappropriate fixation method. Pro-spective comparative studies oflarger numbers of pediatric patientsmay help guide future managementof displaced clavicle fractures by de-termining indications for nonsurgicaland surgical management in this ac-tive patient population.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references 4,5, 21, and 24 are level I studies.References 10 and 15 are level IIstudies. References 27 and 33 are levelIII studies. References 2, 3, 11, 14, 16,18, 22, 23, 25, 26, 28-32, 34, and 35are level IV studies. References 1, 6-9,12, 13, 17, 19, 20, and 37 are level Vexpert opinion.

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Conservative interventions for treatingmiddle third clavicle fractures inadolescents and adults. CochraneDatabase Syst Rev 2009;2:CD007121.

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review article displaced clavicle fractures in adolescents...

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