Rockwood Children CH19

729

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

nonunion and 1 delayed union, with the majority demonstrating good-to-excellent functional outcomes measure scores. 123 In addition, several small series have recently emerged regarding operative treatment. Mehlman et al. performed a retrospective review of 24 children in China with a mean age of 12 years who underwent operative treatment of com- pletely displaced clavicle shaft fractures. In their series, there were no nonunions and no infections. Twenty-one of the 24 patients were able to return to unrestricted sports activity. Three complications were reported including two patients who had scar sensitivity and one patient who had a transient ulnar nerve neurapraxia. However, all patients underwent hardware removal on an elective basis, so the implications or sequellae of retained hardware could not be ascertained. 102 Namdari et al. also performed a retrospective review of 14 skeletally immature patients who underwent ORIF of displaced midshaft clavicle fractures. No nonunions occurred in the cohort, but 8 patients had numbness about the surgical site, and 4 patients underwent hardware removal. 107 Vander Have et al. retrospectively reviewed 43 fractures, 25 of which were treated nonoperatively and 17 were treated operatively. The authors reported that five symptomatic mal- unions occurred in the nonoperative group, four of which were treated with a corrective osteotomy. All complications in the operative group were related to prominence of the hardware. 150 A recent comparative study of over 650 clavicle fractures in patients 10 to 18 years old retrospectively reviewed at a large regional pediatric trauma center demonstrated a nonunion rate of 0.2% in fractures treated nonoperatively, and a symp- tomatic malunion rate of 2%. 60 The authors demonstrated a significantly higher complication rate (16.2%) in fractures treated operatively, compared with those treated nonoperatively (5.2%). The results of Li et al. corroborated these findings in a smaller, single-site study, in which there was a 43% major com- plication rate in 37 adolescents treated with plate fixation, the most common of which was secondary surgery for symptomatic plate removal. 88 Most nondisplaced fractures have union by 4 to 8 weeks of time, whereas displaced fractures may take longer, approx- imately 10 weeks. 150 A retrospective multicenter investigation of all nonunion cases reported at 9 pediatric hospitals over an 11-year-period was performed by an adolescent clavicle fracture study group. The investigation yielded only 25 total cases, all of which were successfully treated with surgery, which speaks to about the ability to effectively treat this exceedingly rare compli- cation, should it arise following nonoperative treatment. Thus, the vast majority of pediatric patients treated with a simple sling have excellent outcomes and are able to return to their activi- ties without limitations. A small percentage of patients treated nonoperatively with significant fracture displacement may have subjective complaints of pain with prolonged activity, easy fati- gability, axillary pain, or drooping shoulders with bony prom- inence. 150 However, Bae et al. evaluated a group of 16 patients with displaced ( > 2 cm) mid-diaphyseal clavicle fractures treated nonoperatively. All fractures united with no meaningful loss of shoulder motion or abduction–adduction strength by isoki- netic testing. The vast majority of patients had low DASH and pain Visual Analog Scores (VAS) that were very low, means of

4.9 and 1.6, respectively. Only one patient out of 16 required a corrective osteotomy. 8 The authors concluded that routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone in the face of shortening. A simi- lar study by Schulz et al. demonstrated no functional outcome deficits, when compared with the uninjured limb, in 16 adoles- cent patients with a minimum of 1 cm shortening and a mean of 14 mm shortening of a displaced clavicle fracture, when assessed more than 2 years following nonoperative treatment. Clearly, further investigation, including prospective compara- tive cohort studies, is required to better determine the risk fac- tors for possible pain or functional compromise in the minority of pediatric patients who develop nonunion, symptomatic mal- union, or other complications following clavicle shaft fractures, based on the two different treatment options.

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

Midshaft Clavicle Fractures: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Hardware prominence

• Malunion • Nonunion • Wound complications

Patients who have prominence of their hardware can be suc- cessfully treated by removal of their hardware. 102,107,150 If a patient initially treated by nonoperative measures develops a symptomatic malunion, corrective osteotomy has been shown to be successful in eliminating symptoms (Fig. 19-8). 150 In the Vander Have series, all patients who underwent corrective oste- otomy of their malunion went on to union and resolution of their symptoms. 150 As previously described in the above multi- center study of 25 cases, clavicle nonunion in adolescents can be successfully treated by subsequent ORIF, with most cases uti- lizing only local bone grafting from clavicle callus, as most cases are hypertrophic nonunions.

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

Most pediatric and adolescent midshaft clavicle fractures can be treated successfully with nonoperative measures. ORIF should be performed for the rare open fracture, fractures with skin at risk of necrosis, and fractures with nerve or vascular injury. Future prospective studies are underway to better determine the potential benefits and complications of operative fixation versus nonoperative treatment in adolescents.