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Functional and Radiographic Outcomes of Nonoperative Treatment of Displaced Adolescent Clavicle Fractures
Jacob Schulz, MD1; Molly Moor, MPH2; Joanna Roocroft, MA2; Tracey P. Bastrom, MA2; Andrew T. Pennock, MD2
1 Department of Orthopedics, Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467
2 Department of Orthopedics, Rady Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA 92123. E-mail address for A.T. Pennock: apennock@rchsd.org
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Investigation performed at Rady Children’s Hospital, San Diego, California



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jul 03;95(13):1159-1165. doi: 10.2106/JBJS.L.01390
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Abstract

Background: 

Studies of adult patients suggest that nonoperative treatment of clavicle fractures may result in functional disability, but this has not been demonstrated in adolescents. The purpose of this study was to determine the functional outcomes after nonoperative treatment of displaced, shortened, midshaft clavicle fractures in adolescents.

Methods: 

Adolescents ten to eighteen years of age with an isolated, completely displaced, shortened, midshaft clavicle fracture sustained between 2009 and 2011 were recruited for this study. Injury and final radiographs were assessed for displacement, shortening, and clavicle length. Maximal and endurance strength testing was performed with the Baltimore Therapeutic Equipment (BTE) machine, with use of the uninjured shoulder as an internal control. Shoulder range of motion and clavicle length were assessed clinically, and patient-oriented outcomes were obtained.

Results: 

Sixteen patients (four of whom were female) with an average age (and standard deviation) of 14.2 ± 2 years and a mean duration of follow-up of 2 ± 1 years were included in the study. Fifteen patients were right-hand dominant and one was ambidextrous, and thirteen of the fractures occurred in the nondominant limb. Compared with the uninjured limb, no differences were noted in range of motion or strength except for an 8% decrease in maximal shoulder external rotation strength (p = 0.04) and a 11% loss of shoulder abduction endurance strength (p = 0.04). Radiographs demonstrated a 100% union rate but significant shortening compared with the uninjured clavicle (p ≤ 0.001). SANE (Single Assessment Numeric Evaluation), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), and Constant scores were similar between sides. Fifteen of the sixteen patients were satisfied with the appearance of the clavicle, and all returned to full activity, including the preinjury (or a higher) level of sports participation.

Conclusions: 

Regardless of patient age, sports participation, and final clavicle shortening, no differences in pain, strength, shoulder range of motion, or subjective outcome scores were found between the injured and uninjured limbs of adolescents treated nonoperatively for a displaced, shortened, midshaft clavicle fracture.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Andrew Pennock, MD
    Posted on October 30, 2013
    Response to reader comments
    Rady Children's Hospital San Diego, San Diego, CA, USA

    Thank you for your insightful commentary.  Each of your points is well stated, and we agree that our study has limitations including selection bias, a small study cohort, and the utilization of outcome measures that have not been validated in this patient population. With that said, the results of our paper were not intended to provide the optimal treatment of displaced clavicle fractures in this adolescent population; they were merely to show that many adolescents can be effectively managed in a cost-effective, minimal risk manner with a non-operative approach.

    To your point on the enthusiasm for surgical treatment of these fractures, we have noted a dramatic rise in surgical cases at our institution over the last five years. This is in part due to “adult” clinical data supporting surgery, but also the rapid recovery that surgery offers, as well as patient and family requests. The expedited recovery is what many young athletes, parents, and coaches focus on when they push us to select surgical treatment. We believe, however, that it is incumbent on surgeons to remember that while surgery may get these patients back on the field 4 to 6 weeks faster, the risks of surgery and the costs to society may not be justified in these young patients who are first and foremost full-time students and not professional athletes.

    Furthermore, clavicle malunions in most adolescent patients are well tolerated and asymptomatic. The few that are symptomatic may choose to have a “delayed” surgery that provides “reliable and reproducible" results that allows near complete "restoration of objective muscle strength similar to that seen with immediate fixation," as quoted from a 2007 article from your institution. This implies that the few patients with symptoms can be offered a “delayed” surgery that yields nearly an identical outcome. Therefore, shouldn’t an initial non-operative approach be the norm and not the exception? Interestingly, it has been our institutional experience that many patients with symptomatic malunions choose to live with their bump and mild symptoms over having a corrective surgery that will leave them with a scar, possible numbness, and instrumentation that may need to be removed at a future date.

    While a randomized controlled study on this topic would add to our knowledge base, we believe such as study would unfortunately be an unrealistic goal in this patient population. A trial of this nature involves surgery in minors; few parents are likely to subject their children to an experimental study design when it involves drastically different approaches, risks, and costs. For this reason, our institution has partnered with several other pediatric hospitals to create a prospective registry that will allow us to better address this controversial injury with more data.

    Michael D McKee - MD FRCS(C), Niloofar Dehghan - MD FRCS(C)
    Posted on October 16, 2013
    Limited retrospective review, need for future randomized clinical trials
    St Michael's Hospital, University of Toronto, Toronto, Canada

    We would like to congratulate Dr. Schulz and colleagues on this article. Their study is the first to use modern comprehensive outcome measures (including objective strength testing) for this patient population and is an important addition to the literature on this topic: it helps temper the current enthusiasm for surgical intervention for these injuries. While there have been seven randomized trials comparing operative versus non-operative treatment for displaced fractures of the clavicle in adults, to our knowledge none have included patients under 16 year of age, and there is only one retrospective comparative study focusing on adolescents. However, as a small, retrospective, review, the paper by Schulz et al. does have some drawbacks that we would like to address:

    1. Only sixteen of one hundred and fifty-five potential patients were evaluated, including (most significantly) forty-three who underwent primary fixation. As the authors point out, this introduces a clear selection bias. Patients with more severe injuries, greater deformity or displacement, more symptoms, or those who clearly wanted fixation may have been offered (and accepted) surgical fixation. The same functional assessment tests may have revealed many of these excluded individuals to be unhappy with their outcome had they received non-operative care.

    2. While one could argue the clinical relevance of the difference, there is evidence for significant decreases in rotational strength and abduction endurance in these young patients, and it is unclear what the prognosis for this will be. As with most muscle or strength issues, deficits will only increase with the aging process and it is unclear what effect this will have in maturity. In addition, there were a few patients in this study who had shoulder pain or were unhappy with the appearance of their shoulder: our experience with the “natural history” of such pain following mal-united clavicle fractures in young patients has been fairly negative (most eventually opt for surgical correction in our experience).

    3. The mean shortening of these fractures was 11.75 mm, which is considerably less than the mean displacement measured in most randomized trials on this topic. Since functional outcome deficits have been shown to correlate with displacement (especially shortening >20mm), it may be that this group is a select one with lesser degrees of deformity and an intrinsically good prognosis following non-operative treatment. This again is an issue with selection bias, and the final conclusions may not be applicable to patients with more severe deformity/shortening.

    4. Rapid recovery from injury is becoming increasingly important to our society. As has been shown repeatedly in prospective studies (including the sole comparative study of operative versus non-operative treatment in adolescents), one of the main benefits of primary fixation is less pain immediately post-injury and a more rapid return to function. Through its design, the study by Schulz et al. is not able confirm or refute this potential advantage.

    5. While the outcomes used are the best available (indeed, we have used them in multiple studies), it may be that they are not particularly sensitive in capturing deficits in shoulder function following clavicle injury. As well, to our knowledge, the DASH was developed and validated in adults, and there may be concerns regarding the appropriateness and comprehension of the questionnaire by this age group.

    We do not wish to appear overly critical of this study: it is timely information in what has become an increasingly controversial topic. In fact, the most heated debates that we have witnessed at recent American Academy of Orthopaedic Surgeons (AAOS) and Canadian Orthopaedic Association (COA) annual meetings have been on the topic of operative versus non-operative treatment of displaced clavicle fractures in adolescents. We are at the same point now that we were at with adult fractures a decade ago: we know that most patients will do well with non-operative treatment, we know that a subset of adolescents may benefit from primary fixation, and we know that operative intervention is safe and reliable. What we truly need is a large-scale randomized trial to define the indications, benefits, risks and prognostic factors for adolescents with this common injury, and appeal to those in a position to do so to demonstrate leadership and commitment on the issue.

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