Rockwood Children CH19

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SECTION TWO • Upper Extremity

Treatment of significantly displaced distal clavicle fractures is somewhat controversial, due to a relatively high nonunion rate reported in the adult literature. In a retrospective review performed by Neer, 108 he documented that all patients with type II distal clavicle fractures treated nonoperatively had either a delayed union (67%) or a nonunion (33%). Edwards et al. 37 treated 20 patients with type II distal clavicle fractures nonoper- atively and had a 45% delayed union rate and a 30% nonunion rate. Additional studies have shown similar nonunion rates ranging from 25% to 44% for type II fractures treated nonoper- atively. 115,130,131,134 In contrast, all type II fractures treated surgi- cally with ORIF have gone on to union. 37,108,134 While nonunion of significantly displaced pediatric distal clavicle fractures may be considered to be a more common occurrence than nonunion of pediatric midshaft clavicle fractures, it still represents a rare event, and operative considerations revolve more around con- cerns of symptomatic malunion and altered shoulder biome- chanics with overhead sports or activities. Absolute indications for operative treatment of distal clavicle fractures include open fractures, fractures with significant skin compromise, displaced intra-articular extension, and fractures with associated neurovascular injuries that require opera- tive intervention. Additional relative indications may include significantly displaced fractures in competitive athletes and adolescents, entrapment in the trapezius muscle, floating shoul- der-type injuries, and patients with polytrauma. The most com- mon indication for surgical treatment of distal clavicle fractures in the pediatric population is significant posterior displacement that suggests complete discontinuity of the proximal fragment and/or trapezial entrapment, in which case diffuse soft tissue swelling may be seen over the AC joint region with severe pain with any attempted shoulder motion. Children and younger adolescents are unlikely to experience disruption of the CC ligaments, given that the thick periosteum generally remains attached to the underlying ligamentous complex. Nevertheless, the proximal fragment may alternatively tear through the supe- rior periosteum with enough force to generate severe superior displacement and bony prominence. OPERATIVE TREATMENT OF DISTAL CLAVICLE FRACTURES Indications/Contraindications

TREATMENT OPTIONS FOR DISTAL CLAVICLE FRACTURES

NONOPERATIVE TREATMENT OF DISTAL CLAVICLE FRACTURES Indications/Contraindications

Nonoperative Treatment of Distal Clavicle Fractures: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications • Nondisplaced and

• Open fractures • Fractures with associated skin compromise • Fractures with concomitant neurovascular injury requiring surgical intervention

minimally displaced fractures (type I and type III fractures)

Most distal clavicle fractures in the pediatric and adolescent population can be managed nonoperatively with immobiliza- tion alone as long as significant displacement is not present. Typically, this is universally true for type I and type III fractures. However, types II, IV, and V fractures may have significant dis- placement with subsequent skin tenting, bony prominence, or instability present about the shoulder girdle. Contraindications to nonsurgical management include open fractures, fractures associated with skin necrosis, and fractures with concomitant neurovascular injury requiring surgical intervention. Due to the relative thickness of the soft tissues overlying the AC joint region, skin tenting causing skin at risk of necrosis associated with distal clavicle fractures is rare, compared to that of the more subcutaneous position of the bone in the diaphyseal region. Displaced fractures in the pediatric and adolescent pop- ulation (types II, IV, and V) should be treated on an individual basis depending on the patient’s age, the amount of displace- ment, and the patient’s activities. Technique The standard approach to nonoperative treatment includes use of a sling for approximately 6 weeks or sling and swath for the first 1 to 2 weeks, with progression to a simple sling when comfort levels allow. After 4 to 6 weeks, active range of motion may begin. Radiographs are taken at the 6-week follow-up visit to assess healing and progress to functional activities, though full contact in sports such as ice hockey, football, and lacrosse should generally be delayed until 2 to 3 months, after advanced bony bridging is observed radiographically. Outcomes Nonoperative treatment of nondisplaced or minimally displaced distal clavicle fractures typically has excellent outcomes with successful union occurring and patients able to return to full activities. While types I and III fractures have been shown to go on to delayed-onset symptomatic AC joint arthrosis in the adult literature, 109 this has not been replicated in pediatric studies.

Open Reduction and Internal Fixation Preoperative Planning ✔ ✔ ORIF of Distal Clavicle Fractures:

PREOPERATIVE PLANNING CHECKLIST

❑❑ Standard table capable of going into beach chair position

OR table

❑❑ Beach chair position with head and neck tilted away or supine ❑❑ Bump placed behind the scapula ❑❑ Leave plenty of sterile standing space above the shoulder adjacent to the head

Position/positioning aids