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

OUTCOME MEASURES FOR MIDSHAFT CLAVICLE FRACTURES

remodeling capacity may exist up through adolescence and into young adulthood. Medially the clavicle articulates with the sternum, forming the sternoclavicular joint, whereas laterally the bone ends in an articulation with the acromion, forming the AC joint. The medial inferior aspect of the clavicle is the site of attachment of the costoclavicular ligament, whereas laterally on the inferior aspect there is the conoid tubercle and trapezoid line, the sites of attachment for the conoid and trapezoid ligaments, respec- tively. All of these ligaments slant posteriorly as they approach the clavicle, and therefore when the clavicle elevates and the ligaments are put on stretch, the clavicle rotates posteriorly. In addition, these ligaments provide significant stability at both ends of the clavicle, thus making fractures in the middle third of the clavicle more likely. The pectoralis major originates from the medial aspect of the clavicle as well as the sternum and inserts onto the humerus at the intertubercular groove, whereas the deltoid originates from the lateral aspect of the clavicle as well as the acromion and scapular spine to insert onto the humerus at the deltoid tuber- osity. In addition, the sternocleidomastoid and sternohyoid muscles originate from the clavicle whereas the trapezius and subclavius insert onto the clavicle.

No specific outcome scores have been widely used to assess results following pediatric clavicle fractures, though the American Shoulder and Elbow Society (ASES) score, the Dis- ability of the Arm, Shoulder, and Hand (DASH) Score, the QuickDASH, and the Constant Shoulder Score have been uti- lized in some studies. The creation of a novel Pediatric & Ado- lescent Shoulder & Elbow Survey (Pedi-ASES) has stemmed from research demonstrating that adult shoulder outcome scores are associated with poor validity and comprehensibility. The Pedi-ASES may represent a future standard for use in pedi- atric and adolescent shoulder research. 60

PATHOANATOMY AND APPLIED ANATOMY RELATED TO MIDSHAFT CLAVICLE FRACTURES

The clavicle, also referred to as the collar bone, is an S-shaped bone that lies along the subcutaneous border of the anterior aspect of the shoulder girdle. An anterior convexity is present medially to permit the passage of the brachial plexus and axil- lary vessels from the neck region into the upper arm, whereas laterally there is an anterior concavity. Development of the clavicle begins at five and a half weeks’ gestation via intramembranous ossification, and by 8 weeks, the bone has developed into its S-shaped configuration. 47 Post- natally, the clavicle continues to grow at a steady rate until age 12, increasing approximately 8.4 mm per year. 99 After 12 years of age, the clavicle grows approximately 2.6 mm per year in females and 5.4 mm per year in males. Thus, 80% of the final clavicle length is reached by age 9 in females and age 12 in males. 99 However, because the clavicle is the last bone in the body to complete its ossification process, continuing up to the age of 25 in some patients, continued Figure 19-4.  A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remod- eling with growth. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

TREATMENT OPTIONS FOR MIDSHAFT CLAVICLE FRACTURES

The mainstay of treatment of pediatric and adolescent clavicle fractures is nonoperative, allowing the fracture to form cal- lous and heal in situ, even if significant displacement is pres- ent (Fig. 19-4). 8 It is well agreed upon that nondisplaced or minimally displaced fractures should be treated nonoperatively. Fractures that should proceed directly to operative intervention include open fractures, fractures with skin at risk of necrosis

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B