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