Open reduction and internal fixation of displaced clavicle fractures in adolescents.

The literature available on patient oriented outcomes of operative management for clavicle fractures in adolescents is fairly limited. The purpose of this study was to analyze the potential of open reduction and internal fixation for displaced mid-shaft clavicle fractures in adolescent patients. We reviewed our series of surgical cases performed in 19 adolescents (mean age: 14.6 years) with displaced unilateral clavicle fractures. Baseline data acquisition included demographic and radiographic variables. A Synthes(®) LCP clavicular plate was utilized for fixation in all cases. Follow-up data included functional outcome assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (DASH), the simple shoulder test (SST) and additional binary questions. At a mean follow-up of 16 months, quick DASH scores were 4.0 (range: 0-35.5) and mean number of positive yes responses on the SST for all operative patients was 11 (range: 9-12). All cases proved complete radiological union at the 3-month follow-up. All patients returned to full athletics at a mean time of 14 weeks (range: 12-17 weeks). Two patients had minimal hypertrophic scars while no patient was noted with keloid formation or neurovascular deficit. One patient complained of implant prominence and occasional symptoms of discomfort at the 15 month follow-up and opted for implant removal. This was successfully performed with uneventful full recovery. All patients were fully satisfied with their choice for surgical intervention. Anatomical reduction with internal fixation and early mobilization of adolescent displaced clavicle fractures remains a viable treatment option with predictable results and no major complications in reliable hands.

Introduction

Open surgical treatment of displaced mid-shaft fractures of the clavicle continues to be a topic of controversy. Traditional treatment of clavicular fractures has been via non-operative methods both in children and adults.[1-6] Scientific literature has increasingly questioned the patient oriented outcomes in recent years. Many reports point out higher rates of complications such as shortening, nonunion, deformity and unsatisfactory patient-derived outcomes in cases of adult displaced mid-shaft clavicle fractures.[7-14] Two recent randomized controlled studies have demonstrated superior results in favor of the operative treatment in cases of completely displaced clavicle fractures in the adult population.[15,16] Definitive indications for internal fixation of closed clavicle fractures in adult patients are still debatable.

Skeletally immature patients with clavicle fractures represent a special cohort of patients that are known to have a high rate of fracture healing and good remodeling potential.[4],[17-20] However, as they transition into adolescence, their activity level and functional expectations rise rapidly and in fact may outweigh the activity expectations of most adults. Thus, they may have relatively greater functional impairment from residual disability at their age as compared to young or older adults. Despite these concerns, the literature available at present on true patient oriented outcomes of operative and non-operative management of clavicle fractures in adolescents is fairly limited, and as such, most data is extrapolated from the adult literature. Although, clavicle fractures in adolescents have been traditionally treated non-operatively, the positive outcomes achieved from fixation of displaced clavicle fractures in young adults could challenge this classical treatment philosophy. Sports and trauma sub-specialty orthopedists are increasingly being obligated to fix these fractures by patients and parents of highly functional and active adolescents.

The purpose of this retrospective study was to analyze the potential of open reduction and internal fixation for displaced mid-shaft clavicle fractures in cases of adolescent patients. We reviewed our outcomes of treatment of these fractures while studying demographic, radiographic and functional variables. We have compared our observations with recently reported studies and discussed current controversies regarding treatment of skeletally immature clavicle fractures to consider possible future directions of research and treatment.

Materials and Methods

Following Institutional Review Board approval, we reviewed our series of surgical cases performed from January 2009 to July 2010 that included 19 adolescents with displaced unilateral clavicle fractures. Inclusion criteria for surgery were: clavicle fracture that was completely displaced and shortened by more than 15 mm, dominant arm in a high-end athlete, comminuted fracture including a z-shaped configuration with central segmental fragment / butterfly irrespective of the amount of shortening (Figure 1), and tenting of the skin associated with fracture (impending open fracture).

Figure 1

45° cephalic tilt (Serendipity view) radiograph of the left clavicle demonstrating a mid-shaft fracture with z-shaped configuration and central segmental fragment.

Mean age at baseline was 14.6 years (range: 13 years – 19 years). There were 13 males and six female patients. In 16 out of 19 cases, the dominant side was affected. Baseline data acquisition included demographic as well as radiographic variables. Plain radiographic evaluation involved a standard anteroposterior and a 45° cephalic tilt view[21] in order to assess fracture pattern and displacement including angulation. Radiographic analyses were performed by a senior orthopedic surgeon. Follow-up data included functional outcomes assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (DASH),[22, 23] the simple shoulder test (SST)[24] and additional binary questions.

In all cases, surgical treatment was performed using a standard positioning and similar surgical technique (described below) on a Jackson radiolucent flat table (Mizuho OS, Union City, USA) for optimal intra-operative radiographic assessment with the patient in the supine position and a bump between the scapulae for optimal positioning and intra-operative fracture reduction. A Synthes (LCP Superior Anterior Clavicle Plate, Paoli, USA) clavicular plate (side appropriate) was utilized for fixation in all cases.

Post-operatively, all patients underwent standardized protocol until full recovery. In the immediate post-operative period they were placed in a shoulder immobilizer with a bulky dressing and discharged home on post-op day (POD) 1 (n=14) or POD 2 (n=5). All patients came back for an initial post-operative check at 7–10 days. Following wound check they were allowed to start gentle oscillatory movements and pendulum exercises while placing the arm back in the shoulder immobilizer. Second follow-up in all cases was at 3–4 weeks from initial surgery and included repeat radiographs. The shoulder immobilizer was discontinued and a sling was provided for support (for a week more). Range of motion (ROM) exercises (active and active-assisted) were now started. Overhead activities and weight lifting (>1 kg) were specifically avoided. Patients were brought back at the 6–7 week interval and repeat radiographs were performed. At this time overhead activities were permitted (with continuation of ROM increase) and strengthening exercises were started. At 12 weeks post-surgery, the patients were allowed to return to full sports including contact sports if radiographs did not reveal any abnormalities and clinical exam remained normal with full recovery of strength.

Surgical technique - our preferred method

Cases are selected based on the indications as mentioned above. In addition to the indications mentioned previously, patients with polytrauma (not in this series) are also relative indications for clavicle fracture fixation in our institution, particularly with ipsilateral floating shoulder or upper extremity trauma.

We do not use the beach-chair position for performing this surgery. Patients are typically positioned on a radiolucent flat-top Jackson table (Mizuho OS, Union City, USA). Muscle relaxation is specifically requested in our cases for ease of reduction. A well-padded adequate sized bump is placed between the scapulae and the head is tilted to the opposite side. The ventilation tube should be carefully placed coming out from the angle of the mouth on the opposite side so as to be further away from the surgeon and assistants. The forehead is then taped to the Jackson table using a 5 cm silk tape for stabilization with appropriate head rest elevation so as not to hyper-extend the head during positioning. A separate arm board is used and placed parallel to the Jackson table (Mizuho OS, Union City, USA) on the side of surgery for resting the freely-prepped upper extremity during surgery. Parts are painted, prepared and draped in the standard sterile orthopedic fashion. A stockinette is utilized to cover the upper extremity during the case and is stopped short at the level of the upper arm, Ioban (3M, St. Paul, USA) surgical drapes may be used to cover the axilla during surgery. Both bipolar and unipolar bovies are utilized during exposure and dissection.

Surgical incision is typically an oblique incision extending to the inferior border of the clavicle on the medial side of the fracture (about 2.5 cm - 3 cm medial to the fracture) and extending to the superoposterior border of the clavicle on the lateral side of the fracture about 2.5 cm - 3 cm lateral to the fracture. Following the initial 5–6 cm incision, subcutaneous and deeper dissection is carefully performed with the help of sharp and blunt dissection. A medial window is now created so that dissection is continued right up to periosteum and bone on the medial part of the clavicle (medial to the fracture). Subperiosteal elevation is performed so as to comfortably place small Hohmann retractors. A small retag piece of gauze is now placed in the medial window and attention is directed to the lateral end of the incision. Similarly deeper dissection is performed up to the periosteum of the lateral part of the clavicle, and Hohmann retractors are placed. A blunt freer is now used to gradually deepen and dissect the central part of the incision over the fracture site while protecting the nerve branches as well as important vessels. Bipolar bovie is very helpful in this dissection.

Once the dissection exposes the fracture, either ends of the bone are held with lobster clamps for ease of control. The fracture site is now cleaned, the hematoma evacuated, and the fracture edges are cleared with curettes and a dental pick. Care is taken not to break any bone spikes that would provide rotational stability. Irrigation is now performed with copious amonts of saline and the fracture is reduced. The importance of muscle relaxation for ease of reduction cannot be over-emphasized. Once the fracture is well reduced, the appropriate length (and side) of the clavicular plate is selected and placed on the bone. Fluoroscopy image confirms the adequacy of length as well as the potential need for any change in plate configuration (we have never had to bend or manipulate the current available synthes clavicle plating system (LCP Superior Anterior Clavicle Plate, Paoli, USA). Subsequent to this the plate fixation is achieved using 3.5 mm cortical fully threaded screws in the compression mode. Although locking screws can be placed through these holes, we have not felt the need to use locking screws in healthy, adolescents with good bone qualtity and strength. One should be careful intra-operatively while drilling the holes for the screw placement as excessive inadvertent plunging can lead to pleural injury and has the potential to cause pneumothorax.

Following the placement of the plate, fluoro images are obtained again to confirm the adequacy of reduction as well as the screw lengths (we prefer to not have more than 2 screw threads beyond the far cortex in these cases (Figure 2). Upon satisfactory radiographs, the wound is irrigated and the incision is closed in layers and a bulky foam-tape dressing is given. We do not give regional blocks in these cases because they make the immediate post-operative neurological examination more difficult. PCA or oral pain medications may be utilized in these cases.

Figure 2

Intra-operative fluoro image confirming the anatomic reduction as well as the appropriateness of screw lengths.

Results

Nineteen patients met the inclusion criteria and had open fixation of their clavicle fractures. All patients suffered a complete displacement with a minimum shortening of 2 cm (range: 1.5 cm – 3.8 cm) and / or comminution (n=12). The z-variant of fracture with a longitudinal split in the central fragment was the most common variant of comminution (11 cases, 57.9%). Mean follow-up was 16 months (range: 12 months – 30 months). Mean follow-up quick DASH scores were 4.0 (range: 0 – 35.5) and mean number of positive yes responses on the SST for all operative patients was 11 (range: 9–12). All 19 patients were completely painfree and enjoying full function with return to pre-injury athletics at the final follow-up. Clinical union was complete in all cases at six weeks and all cases proved complete radiological union at the 3-month follow-up (Figure 3). All patients returned to full athletics at a mean time of 14 weeks (range: 12 weeks – 17 weeks). Two of the 19 patients had minimal hypertrophic scars while no patient was noted with keloid formation, scar numbness, or neurovascular deficit. One patient complained of implant prominence and occasional symptoms of discomfort at the 15 month follow-up and opted for implant removal. This was successfully performed with uneventful full recovery. All patients were (on binary questionnaire survey) fully satisfied with their choice for surgical intervention and had no concerns with scar formation or cosmesis.

Figure 3

Serendipity view at 6 weeks demonstrating solid healing and well positioned implant.

Discussion

Surgical intervention for clavicle fractures in adolescents and young adults is increasingly considered an acceptable line of treatment.[25-29] Closed clavicle fractures in children are well-known for their high potential for remodeling and healing despite their degree of displacement or angulation.[4],[17-20] Therefore, they are traditionally treated non-operatively and seem to do well with time. In contrast to the young pediatric population, several studies involving adult patients have reported fairly moderate outcomes related to conservative (non-operative) treatment.[7-14] On the other hand, there are some reports of potentially favorable results following operative management in adults with satisfactory patient-derived outcomes and fewer rates of nonunion.[15,16]

Hill et al. have noted unsatisfactory patient-oriented outcomes in 16 out of 52 adult patients (31%) for the conservative treatment of displaced mid-shaft clavicle fractures.[10] Somewhat moderate results for the non-operative treatment were also reported by Nordqvist et al. who noted unsatisfactory patient-oriented outcomes in 22 out of 68 patients (32%).[12] Of note, a multicenter, randomized comparative study between the non-operative treatment and ORIF revealed superior functional outcomes and a lower rate of mal-union and nonunion for the operative treatment of displaced mid-shaft clavicle fractures in adult patients in contrast to conservative management.[15] This is in keeping with a recent systematic review of 2144 clavicular fractures in 22 case series reporting that the rate of nonunion for displaced mid-shaft clavicle fractures was 2.2% (10 of 460 patients) after internal fixation compared with 15.1% (24 of 159 patients) after non-operative treatment.[30] This represents a relative risk reduction for nonunion of 86% if surgical reduction and internal fixation is performed. This review further outlined advantages of the primary plate fixation compared to non-operative treatment.

The literature on outcomes of operative versus non-operative management of clavicle fractures in adolescents is evolving, and as such, definitive indications for internal fixation are currently not well-established. The purpose of this study was to evaluate the outcome of ORIF of displaced clavicle fractures in a cohort of active, athletic, adolescent patients. All patients underwent surgery following a detailed informed consent with both patients and parents having understood all options of treatment including non-operative established management. All patients in our cohort requested surgical fixation.

We noted good outcomes (related to radiographic union, clinical function, return to athletic activities, and scar formation) in our cohort of adolescent patients who underwent surgical fixation using our technique. There were no major complications in this study group and only one patient requested implant removal after radiographic healing.

Our results are in agreement with previously reported studies. Kubiak and Slongo conducted a retrospective review of 15 children (14 boys, 1 girl, mean age: 13.1 years, age range: 9.3 years – 15.6 years) who underwent surgical treatment of clavicle fractures between 1989 and 2000.[25] This series included intramedullary stabilization (n=5), external fixation (n=2), osseous suture (n=3), k-wire fixation (n=4), and / or screw fixation (n=2) in eight mid-shaft clavicle fractures, two medial fractures, and five lateral fractures. One fracture occurred in combination with a true disruption of the acromioclavicular joint. As in our study, there were no major complications. All patients had reached full range of motion (ROM) at a mean follow-up of 88 days. They concluded that indications for operative treatment of clavicle fractures in children are rare. However, if surgical treatment is conducted, satisfactory results without major complications may be expected.

Mehlman et al. have reported their results on operative treatment of completely displaced clavicle shaft fractures in children.[26] This retrospective study involved 24 children (mean age: 12 years and 8 months, range: 7 years – 16 years) whose displaced clavicle shaft fractures were treated through ORIF. Healing rate, complication rate, as well as radiographic and functional variables were assessed. The mean follow-up was 2 years and 2 months. Similar to our case series, no infections and no nonunions were observed. Twenty-one of 24 patients (87%) returned to unrestricted sports activities. All fractures healed and all orthopedic implants were later electively removed. Complications included scar sensitivity in two patients and transient ulnar nerve neuropraxia in one patient related to the initial injury. The authors concluded that the ORIF procedure of displaced clavicle shaft fractures in children can be performed safely. Furthermore, they noted that growth and remodeling in the adolescent/teenage clavicle (i.e. close to skeletal maturity) is not as predictable and may resemble that of an adult rather than a young child as most clavicle length is reached at a relatively early age. In consideration of the age group, high functional demand, thinner periosteal tube, limited potential for complete remodeling and a need to return to athletic activities as early as possible, we also believe that adolescent clavicle fractures represent a unique injury. Interestingly, we report a similar healing rate (100%) with ORIF in a comparable study group, although Mehlman et al. [26] did not evaluate specific radiographic indices or patient-specific outcomes. In contrast to the studies of Kubiak and Slongo[25] and Mehlman et al.,[26] who performed operative fixation of clavicle fractures in children, we were able to elaborate that operative treatment can yield good outcomes as measured by the Quick DASH and SST.

Functional outcomes after ORIF of displaced, closed mid-shaft clavicle fractures in skeletally immature patients have been recently published by Namdari et al.[27] This study involved a study cohort of 14 adolescents (mean age: 12.9 years, range: 10.6 years – 15.3 years). Demographic and radiographic indices as well as radiographic and functional outcomes were assessed using the Quick DASH questionnaire, SST, and additional binary questions at a mean follow-up of 37.9 months ranging from 24.1 months to 115.7 months. In their series, patients treated operatively performed well on the DASH and SST at follow-up and all patients treated operatively obtained union. Of note, there was an increased rate of painful hardware and residual incisional numbness at the site of injury and / or surgery. Based on personal communication with the authors of this study, we recognized that many of these cases were done in a beach chair position and had some technique differences as compared to ours.

Clavicle fractures are common. An epidemiologic study involving 535 patients (mean age for the entire cohort of patients: 29.3±22.0 years) revealed that clavicle fractures account for 2.6 % of all fractures and 44 % of those in the shoulder girdle.[31] Fractures of the middle third of the clavicle were noted to be the most common (81%). This is related to the fairly thin junction between the middle and the lateral third and the lack of stabilizing ligamentous or muscular attachments.

Deforming forces on the mid-shaft clavicle fracture such as the upward and backward pulling of the medial fragment by the sternocleidomastoid muscle and the downward dragging of the lateral fragment related to the weight of shoulder girdle and upper extremity may eventually cause multifaceted three-dimensional (3D) mal-alignment of the fracture (Figure 4).[32] Additionally, the trapezoid muscle pulls the lateral third medially causing shortening of the shoulder girdle. In the study of Postacchini et al., 88.2% of all clavicle fractures occurred in the first decade of life with 55% being non-displaced.[31] In adults, the incidence of displaced fractures was higher than that of non-displaced fractures. Regarding the middle third of the clavicle, fractures were displaced in 48% of cases and comminuted in 19%. Interestingly, in our study cohort involving adolescent patients, we noted the z-variant being the most common variant of comminution (11 cases, 57.9%).

Figure 4

Diagrammatic illustratiuon of deforming forces in a mid-shaft clavicle fracture. The upward and backward pull is exerted on the medial fragment by the sternocleidomastoid muscle and the downward dragging of the lateral fragment is related to the weight of the upper extremity that may eventually cause multidirectional mal-positioning and displacement of the fracture.

In order to assess the pattern of injury, displacement, shortening and / or angulation, radiographs in two projections are traditionally obtained in fractures. Clavicle fractures are routinely studied with single bi-planar radiographs of the involved clavicle or shoulder. However, there is considerable lack of consistency related to measurements based on this bi-planar film and reproducibility of these measurements is relatively low, which can lead to misinterpretation of overlapping fragments.[33] Advanced imaging such as computer tomography (CT) (although not indicated in all routine cases), which allows reconstructions of the clavicle in three dimensions, may overcome this barrier (Figure 5). Furthermore, measurement of the true total clavicle length is more accurate in these images. At our institution we have compared standard clavicular radiographs with CT scans including the 3D reconstructions and have noted that the standard clavicular films remarkably underestimate the degree of displacement, and thus, cannot accurately assess all the components of the deformity that includes shortening or translation, angulation, rotation and shoulder girdle changes. Therefore, in our practice, for patients that meet the inclusion criteria for surgical intervention (or are on the cusp) we commonly utilize CT scans for 3D assessment to further evaluate total length, shortening, and comminution. Of note, CT scanning has its own disadvantages such as cost and radiation exposure. Furthermore, correlation between supine CT scan measurements of clavicle fracture shortening and standing plain radiograph measurements has not been studied well.

Figure 5

Advanced imaging with 3D computed tomography that allows reconstruction of the fractured clavicle for accurate assessment of the pattern of injury, displacement, shortening, rotation and / or angulation of the fracture.

This study has limitations. First, it is a retrospective study lacking a matched-control group of age, gender and activity-matched non-operative patients. Second, the study sample of this series was relatively small for a meaningful power analysis, and third, baseline measurements such as pre-operative ROM and strength assessment were not available for a true post-procedure comparison, although in these cases the opposite extremity serves as a reasonable internal control. Finally, although the Quick DASH questionnaire and the SST have been previously used in children, these instruments are only validated for the adult population.

In conclusion, anatomical reduction with internal fixation and early mobilization of adolescent displaced clavicle fractures remains a viable treatment option with predictable results and no major complications in reliable hands. We certainly need further prospective, controlled, randomized studies likely multi-center based that involve a sufficient number of cases in order to determine whether operative fixation may be preferred to non-operative fixation for all comers.