Clavicle Fractures in Children and Adolescents

John A. Schlechter, DO Children’s Hospital Orange County Orange, CA Objectives • The Bone

• The Fracture

• The Treatment

• The Controversies The Bone The Clavicle • S Shaped

• First bone to ossify in the 5th week in utero

Ogden JA, et al. Radiology of postnatal skeletal development: The clavicle. Skeletal Radiol 1979;4(4):196-203. The Clavicle • Initial growth (<5 years)  central ossification center

• Continued growth occurs at the medial & lateral epiphyseal plates

Secondary Ossification Centers

Primary Ossification Center The Clavicle

• Secondary center at the sternal end of the clavicle does not appear before the 18th year and may not unite until the 25th year

Secondary Ossification Centers

Primary Ossification Center

• Incomplete ossification up to age 24-26 The Fracture Clavicle Fractures in Children Anatomic Considerations

AT RISK: • Subclavian vessels • Brachial plexus

• Mediastinal Structures − posterior displacement in medial injuries

Clavicle Fractures in Children Epidemiology & Mechanism of Injury

• 8-15% of all pediatric fractures • Fall onto shoulder • 87% of cases (Stanley et al. JBJS Br. 1988) • Direct blow to clavicle • FOOSH • Child abuse Pediatric Clavicle Fractures Chronologic Division CHILD ADOLESCENT

< 10 years > 10 years FRACTURES

MEDIAL 80% 15% MIDSHAFT 5% DISTAL

ANATOMIC CLASSIFICATION Imaging Clavicle Fractures

• A/P X-ray • “Serendipity” view XR − 40° cephalic tilt • CT Scan The Treatment Clavicle Fractures in Children NONOPERATIVE TREATMENT “Don’t worry, it will heal.”

• Low Nonunion Rate

• Reported 0.1-5.9%

Beatty JH & Kasser JR, Eds. Rockwood and Wilkens’ Fractures in Children 6th Ed. 2006 Clavicle Fractures Historical Treatment • “All clavicle fractures heal.”

• “The best way to prevent a clavicle fracture from healing is to operate on it.”

• “With surgery, you trade a bump for a scar.”

• “Malunion is of radiographic interest only, and doesn’t affect function.” “They all heal in a sling”

Neer 3 nonunions in 2235 middle-third clavicle fracture (.1%)

#1 cause of nonunion was surgery

Recommend ORIF for outer third, neuro or vascular compromise or soft tissue interposition

Neer CS: Non-union of the Clavicle. Journal of the American Medical Association. 1960;172:1006. “They all heal in a sling”

Rowe 690 clavicle fractures(566 midshaft) MGH - Non op 0.8% nonunion - Surgery 3.7% nonunion

Fix with K-wire Included pediatrics

Rowe CR: An Atlas of Anatomy and Treatment of Midclavicular Injuries. Clinical Orthopedics and Related Research. 1968;58:29-42. “It Will Remodel”

Excellent remodeling potential Wilkes & Hoffer, JOT 1987 • 35 clavicle fractures treated without immobilization (age 2-17) • All fractures healed •Observed remodeling up to 90° & 4 cm overlap • All patients recovered full ROM

Recommended all clavicle fractures in children be treated non-operatively Non Op Treatment Options Option 1 Sling Pros • Alerts others that the child is injured. • Typically readily available in most primary and urgent care settings. • Does not cross at the fracture site therefore it tends to provide immediate comfort to the injured shoulder. Option 1 Sling Cons • May allow unwanted shortening at the fracture site secondary to allowing the extremity to rest in an adducted internally rotated position. • Disallows use of the hand/wrist/elbow of the injured extremity and potentially can lead to stiffness of those joints. Option 2 Figure-of-Eight brace Pros • This brace will tend to retract the scapula and shoulders in turn holding the bone out to length in a more anatomic position. • Allows full free use of both hands. • Can be hidden under a shirt quite easily. Option 2 Figure-of-Eight brace Cons • May cross at or over the fracture site and may prove to be quite uncomfortable.

• On average is twice the monetary cost when compared to an arm sling. Clavicle Fractures in Children Traditional Operative Indications • Open fractures • Neurovascular compromise • Skin at risk “tenting”

• Severely displaced??? Operative treatment of clavicle fractures in children: a review of 21 years • 15 patients treated with ORIF of clavicle fractures − 8 midshaft (age 9.5-15.6) • Indications: − impingement of soft tissue − potential skin perforation − displaced/shortening/cosmesis/pain • Technique: Elastic Nails (5), Ex-Fix (2), screw (1)

Kubiak R, Slongo T. J Pediatr Orthop. 2002 Nov-Dec;22(6):736-9. Operative treatment of clavicle fractures in children: a review of 21 years Results • All patients regained full ROM & function • No major complications (Infection, Instability) • Minor complications: − Discomfort/local hypoesthesia at surgical site (4) − Unsatisfactory scar (3) − Pseudobursa at tip of ESIN (3) − Skin perforation by ESIN (2) − Refracture after repeated fall (1) Kubiak R, Slongo T. JPO 2002. Operative treatment of clavicle fractures in children: a review of 21 years CONCLUSION  Surgical Indications • Open fractures • Impingement of soft tissue/potential risk for skin perforation • Severe “shortening” of the shoulder girdle • Displaced fractures with risk to neurovascular or mediastinal structures

Kubiak R, Slongo T. J Pediatr Orthop. 2002 Nov-Dec;22(6):736-9. Severely Displaced??

• Reviewed 66 COMPLETELY DISPLACED midshaft clavicle fractures at ~38 months. − 15% Nonunion − 31% Unsatisfied (28 pts complain of poor cosmesis) • Shortening >20mm associated with higher nonunion rate and unsatisfactory result • Recommend ORIF

J Bone Joint Surg [Br] 1997;79-B:537-9. Operative Treatment Options Surgical Techniques (Positioning)

Beach chair

• More comfortable for some • X-rays may be difficult Surgical Techniques (Positioning)

Supine

• Bump under shoulder • Radiolucent table • JACKSON FLAT TOP • Better for polytrauma Clavicle Fractures Techniques for Operative Treatment

Reduction Techniques/Aids

• Bump between scapulae • Manipulation of fragments with pointed clamps • Use of small or minifragment screws • Plate as reduction tool/laminar spreader Surgical Techniques (Reduction)

• Mini fragment screws/plates Surgical Techniques (Reduction)

Indirect reduction

• Mini distractor Clavicle Fractures Techniques for Operative Treatment Exposure • Supraclavicular nerves

18% incidence of numbness in upper breast Minimize periosteal stripping Surgical Management (Shaft Fractures)

Plate fixation

• Less muscle stripping

• More prominent? Surgical Management (Shaft Fractures)

Plate fixation

• Anteroinferior plating • AP screws longer and safer • Improved cosmesis • Easier plate contour • Superior plate placement was less likely to fail in axial compression (Tackle Football)

• Anteroinferior plate placement was less likely to fail in cantilever bending (More physiologic)

Favre et al. J Orthop Trauma. 2011 Nov;25(11):661-5. Clavicle Fractures Intramedullary Fixation

• Limited clinical evidence

• Complications include pin migration and loss of reduction (47%)

Judd et. al. Am J Orthop 2009 Clavicle Fractures Intramedullary Fixation Why it doesn’t make sense • S-shaped bone screw is Put a straight screw in this bone? straight • No rotational control • Highly comminuted fracture - can shorten • Need to make incision at fracture site if displaced or comminuted • Worsen outcomes and higher complication rate when compared to non-op treatment

J Trauma 2001 Clavicle Fractures • 34 patients with clavicle fractures treated TEN (titanium elastic nail) − In 15 cases an end cap was used • 62% required open reduction • 70% complication rate − Medial perforation, lateral penetration, nail breakage, nail dislocation, hardware irritation • Recommend amending operative technique and post operative treatment

Frigg et al. Am J Sports Med, 2008 The Controversies How Short is Too Short? • How do you measure shortening?

Two-dimensional radiographs can lead to misinterpretation of overlapping fragments Role of CT Scan • True total length - independent of its angle in reference to the frontal and sagittal planes • Interindividual variability in total clavicle length.

Pandya et al. J Am Acad Orthop Surg 2012;20: 498-505 Risk of CT Scan • Cost and radiation exposure. • Children – more radiosensitive than adults

Pandya et al. J Am Acad Orthop Surg 2012;20: 498-505 Shortening is relative! • Must consider inter-individual variation in total clavicle length.

• 2 cm of shortening in a 10-cm pediatric clavicle will result in relative shortening of 20%, whereas 2 cm of shortening in a 17-cm adult clavicle will result in relative shortening of 12%.

Smekal V et al: Length determination in midshaft clavicle fractures: Validation of measurement. J Orthop Trauma 2008; 22(7):458-462. Shortening is relative! • Same amount of shortening will result in different degrees of change in scapular position and sternoclavicular angulation. • Sequential clavicular shortening - 0%, 5%, 10%, 15%, and 20% • Scapulothoracic motion during passive arm elevation in 3 planes was monitored using an EMG tracking device. • Clavicular shortening of 10% affects scapular kinematics and might produce clinical symptoms.

Matsumura et al. AJSM 2010, Vol. 38, No. 5 Before Canada • Systematic review of 22 studies • 15% nonunion rate with non-op treatment •Displacement, Comminution •Female Gender, Age • Relative risk of nonunion reduced 86% with ORIF for displaced fractures

Zlowodzki et. al. J Orthop Trauma 2005 The Canadian Study • Completely displaced midshaft clavicle fracture

• 132 patients (age 16-60) randomized • ORIF (plate fixation) 62 patients • Non-operative treatment 49 patients • 111 patients followed for 1 year

Canadian Orthopaedic Trauma Society, J Bone Joint Surg Am. 2007 Jan;89(1):1-10. • Faster healing time in operative group • 16.4 weeks versus 28.4 weeks • Fewer nonunions in operative group (3% vs. 14%) • Fewer malunions in operative group (0% vs 18%) • Fewer complications in operative group (16% vs 39%) • Outcome scores improved in operative group

At 1 year patients in the operative group were more likely to be satisfied with their shoulder

Canadian Orthopaedic Trauma Society, J Bone Joint Surg Am. 2007 Jan;89(1):1-10. Are Children Little Canadians? POSNA SURVEY • Operative vs. Nonoperative in 4 common midshaft clavicle fracture patterns.

• 949 Pediatric Society of North America members, 302 responded

• 32% response rate

Carry P. et al. J Pediatr Orthop 2011;31:44–49 Carry P. et al. J Pediatr Orthop 2011;31:44–49 • The respondents were also asked to indicate if the following factors influenced their preference for operative versus nonoperative management − findings in current literature supporting operative fixation in adults − arm dominance − athletic status

Carry P. et al. J Pediatr Orthop 2011;31:44–49 % of physicians that indicated recent adult literature has or has not influenced their treatment of similar fracture patterns in adolescents

J Pediatr Orthop 2011;31:44–49 POSNA Survey - Conclusions − POSNA members were nearly unanimously (>90%) in favor of nonoperative treatment for non- displaced and angulated type midshaft clavicle fractures.

− Treatment preferences for isolated segmental fractures were more variable - preference toward operative fixation for male (48%) and female (47%) adolescents 16 to 19 years old. • Nonoperative management was preferred in all fracture patterns.

Carry P. et al. J Pediatr Orthop 2011;31:44–49 The Finnish Study • Sling or stainless steel 3.5-mm recon plate • No difference in the Constant score, DASH score or pain at one-year follow-up • Operative group = 0 non-unions • Nonoperative group = 6 non-unions (24%) • One year after a displaced midshaft clavicular fracture, non-op tx resulted in a higher nonunion rate but similar function and disability compared with operative treatment.

Virtanen K et al. J Bone Joint Surg Am. September 2012;94:1546-53 • Retrospective review - 14 skeletally immature patients with closed, displaced, midshaft clavicle fractures treated with open reduction internal fixation • Mean age 12.9 y. 2 y follow-up. • 4/12 implants removed. 8/12 (57%) complained of numbness at the site of injury/surgery. • Preoperative mean fracture shortening and vertical displacement were 14.4 and 19.7 mm,

respectively. Namdari S et al. J Pediatr Orthop 2011;31:507–511 • All fractures healed. • High scores on commonly used instruments of outcomes assessment (QuickDASH, simple shoulder)

Namdari S et al. J Pediatr Orthop 2011;31:507–511 Retrospective studies of operative fixation in children show the feasibility and safety of fixation and are helping to define operative indications, but stronger evidence and reliable outcomes’ measures for the pediatric upper extremity are still needed.

(J Pediatr Orthop 2012;32:S1–S4) Online 2012 Musculoskeletal Trauma Self-Assessment Exam 19-year-old man sustained a closed clavicle fracture. If the patient had been treated nonsurgically, which of the following would most likely occur 1- Normal shoulder strength and function 2- Local sensory deficits 3- Fracture union 4- Infection 5- Malunion Online 2012 Musculoskeletal Trauma Self-Assessment Exam 19-year-old man sustained a closed clavicle fracture. If the patient had been treated nonsurgically, which of the following would most likely occur 1- Normal shoulder strength and function 2- Local sensory deficits 3- Fracture union 4- Infection 5- Malunion CAUTION! SURGICAL TREATMENT HAS COMPLICATIONS

Navarro et. al. AAOS 2012 • Review of ABOS Part II cases from 1998-2009 • 2895 clavicles treated surgically

• Implant Failure 4% • Vascular Injury • Infection 2.3% • Dislocation • Nonunion 1.9% • Hemorrhage • Nerve Palsy 1.7% • Spinal Cord Injury • Wound Dehiscence 1.4% • Death

Navarro et. al. AAOS 2012 CASES WOULD YOU FIX IT?

13 y/o female with isolated clavicle fracture 2 months

5 months “But what about the bump?” 16yo Male Baseball Player

4/2012 4/2012 8/2012 16yo Female Wrestler

2/2010 4/2010 6/2011 7/2011 Summary • Consider operative treatment of displaced midshaft clavicle fractures but choose wisely

• Adhere to principles of fracture reduction and stable fixation to optimize results

• Exercise caution with intramedullary fixation

• Be aware of complications Summary • Children are NOT little Canadians

• 85% of midshaft clavicle fractures “heal” without surgery

• Increasing trend toward operative management – POSNA Survey

• Employ a shared decision making process Thank You