Rockwood Children CH19

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SECTION TWO • Upper Extremity

OPERATIVE TREATMENT OF MIDSHAFT CLAVICLE FRACTURES

(i.e., skin with pallor or clear dysvascularity), and fractures with associated neurovascular injuries clearly affecting motor func- tion or blood supply to the upper extremity. Decreased sensa- tion in the skin of the chest wall distal to the fracture may be reported, and likely stems from contusions or stretch injuries to the superficial supraclavicular sensory nerves. While case reports of supraclavicular nerve branches entrapped in frac- ture callus have been published, 71 and may benefit from surgi- cal exploration and neurolysis, these represent the minority of cases, and chest wall numbness does not represent an indepen- dent indication for surgery. Of note, these nerves are at risk for injury during primary surgical fixation. NONOPERATIVE TREATMENT Nonoperative treatment of clavicle fractures is performed by immobilizing the child’s shoulder girdle, typically with a sling. Younger children may benefit from a sling and swath, at least in the first several days postinjury, primarily to improve com- fort levels. While more traditional figure-of-eight dressings or shoulder immobilizers can be utilized, these are more cumber- some and have not been shown to provide improved results. Neonates who sustain a clavicular fracture during the birthing process can be immobilized with a swath technique, such as placing Webril or an soft elastic bandage around the torso and arm, but, due to the speed of callus formation, can usually be discontinued within 1 week. Follow-up radiographs are obtained at typical intervals until fracture union occurs. A two-week postinjury radiograph allows for confirmation of maintenance of the fracture alignment or degree of shortening seen at the time of injury, as some nondis- placed fractures can displace in the early postinjury phase. Such a visit will also allow for a progression to use of the sling only when ambulating or at school, while the sling can often be discontinued when at home, as comfort allows from the 2-week to the 6-week period. A 6-week visit frequently shows significant callus formation stabilizing the fracture, which can allow for discontinuation of the sling, with an understanding that refractures can occur with falls or premature return to sports. 25 However, noncontact fitness activities can usually be allowed at 6 weeks, provided there is advanced heal- ing. Return to contact sports only after the 3-month radiographs has confirmed a healed fracture with clear bony bridging. Calder et al. have suggested that follow-up radiographs are unnecessary in pediatric patients, given the near-universal expected fracture heal- ing rate in a child. However, we routinely obtain radiographs until union is clearly established. Nonoperative Treatment of Midshaft Clavicle Fractures: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications • Nondisplaced fractures • Open fractures • Minimally displaced fractures • Fractures at risk of skin necrosis • Fractures associated with neurovascular injury Indications/Contraindications

Absolute indications for operative treatment of clavicle frac- tures in the pediatric and adolescent population include open fractures, fractures with skin tenting severe enough to risk skin necrosis (Fig. 19-5), and fractures associated with neurovascu- lar injury. Additional relative indications may include floating shoulder injuries and fractures associated with polytrauma. Floating shoulder injuries involving midshaft clavicle fractures and fractures of the glenoid neck treated by open reduction internal fixation (ORIF) of the clavicle alone can be sufficient as ligamentotaxis can reduce the other fracture via the coracocla- vicular (CC) ligament. 9 Fractures with significant displacement that are treated non- operatively in adults have been shown to subsequently heal with a malunion that can cause changes to shoulder mechanics. These alterations have been shown, at times, to lead to pain with overhead activities, decreased strength, and decreased endur- ance. 61,100 Therefore, multiple studies have investigated the benefit of operative fixation versus nonoperative management of displaced midshaft clavicle fractures. The most impactful of such studies was randomized controlled trial of an adult Cana- dian population with a mean age of 33.5 years, in which the operative cohort was shown to have improved functional out- come measures and lower rates of nonunion and symptomatic malunion than the nonoperative cohort. 26 A recent meta-analy- sis evaluating the results of randomized clinical trials that com- pared nonoperative and operative treatment in adults confirmed a significantly higher nonunion and symptomatic malunion rate in the nonoperative group. In addition, patients treated with operative intervention had earlier functional return. 101 Not only is it unclear whether these data are transferable to adolescents, but more recent randomized controlled trials in other adult populations 132,152 have suggested that the indications for sur- gery are more limited in adult populations than suggested by the McKee Canadian study. Clearly, younger children, especially less than age 13 years, have the potential to remodel even a foreshortened, displaced fracture. The approach to older ado- lescents has evolved into a shared decision-making process with families of young athletes, with considerations toward the

Figure 19-5.  Radiograph of a segmental right diaphyseal clavicle frac- ture causing skin tenting and subsequent compromise. Note the verti- cal nature of the segmental fragment. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Prac- tical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)