Rockwood Children CH19

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

Pediatric Midshaft Clavicle Fractures

< 13 years

ê 13 years

Any age

Completely displaced

Open fracture

Sling

I&D + ORIF

Severe skin tenting (necrosis or skin-at-risk)

Moderate/severe neurovascular compromise

ORIF

Nondisplaced, minimally/moderately angulated ( < 30°)

Partially displaced, severely angulated ( ê 30°)

Completely displaced, severe 2 shortening ( > 20 mm)

Completely displaced, Ä 20 mm 2 shortening

Sling

Sling

Sling vs. ORIF 1

Sling vs. ORIF 3

1 Shared decision-making approach, based on latest evidence, including slightly increased refracture risk; 95 may be relevant to contact athletes 2 Assessment of true shortening should be achieved with ‘cortex to corresponding cortex’ technique, rather than ‘end to end’ technique 87a 3 Shared decision-making approach, based on latest evidence, including a low risk of symptomatic malunion; may be relevant

Algorithm 19-1.  Authors’ preferred treatment for midshaft clavicle fractures.

arm of high-level baseball pitchers and other overhead or throwing athletes, consideration of the low risk of a poten- tial symptomatic malunion, which may alter the short-term biomechanics of the throwing motion, may be discussed.

When families favor operative treatment, plate fixation is recommended over intramedullary fixation, provided there is awareness of a relatively high ( ∼ 18%) rate of potential plate irritation and the need for secondary removal surgery.

Postoperative Care Whether ORIF or intramedullary fixation is performed, the patient is placed in a sling for 2 weeks, after which a wound check is performed, elbow and wrist range of motion recom- mended, and an emphasis on sling use when out of the house and at school. Patients are permitted to discontinue sling use while in the home from 2 to 6 weeks. At 6 weeks, a clinical examination is utilized to assess tenderness at the fracture site

and radiographs in two planes are obtained to assess bone heal- ing. If the examination and radiographs are consistent with healing, the sling is discontinued and the patient is encouraged to begin range of motion and strengthening. Provided there is adequate healing, noncontact athletes are permitted return to sports activities around 6 to 8 weeks postoperatively. For contact athletes, return to contact activities are permitted at 3 months, provided there is advanced bony bridging.