Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents

Kelly L Vander Have, Aaron M Perdue, Michelle S Caird, Frances A Farley
Journal of Pediatric Orthopedics 2010, 30 (4): 307-12

BACKGROUND: Midshaft clavicle fractures in adolescents have traditionally been treated nonoperatively. Recent studies in the adult literature have shown a higher prevalence of symptomatic malunion, nonunion, and poor functional outcome after nonoperative treatment of displaced fractures. The purpose of this study was to compare operative versus nonoperative treatment of displaced clavicle fractures in adolescents.

MATERIALS AND METHODS: Adolescents who sustained closed midshaft clavicle fractures between 2000 and 2008 were identified in our institutional trauma registry. Medical records were reviewed for patient demographics, injury characteristics, treatment, and outcomes.

RESULTS: Forty-two consecutive patients (mean age 15.4 y) with 43 closed midshaft clavicle fractures were identified. Twenty-five patients were treated nonoperatively with a sling or figure-of-8 brace. Seventeen patients were treated operatively with acute plate fixation for fractures displaced more than 2 centimeters. The average shortening at injury was 12.5 mm in the nonoperative group and 27.5 mm in the operative group (P=0.003). The mean time to radiographic union for displaced fractures was 8.7 weeks in the nonoperative group and 7.4 weeks in the operative group (P=0.02). There were no nonunions in either group. All complications in the operative group were related to local hardware prominence. The mean time to return to activities was 16 weeks in the nonoperative group and 12 weeks in the operative group. Symptomatic malunion, with a mean fracture shortening of 26 mm, developed in 5 patients in the nonoperative group. Four of these patients elected corrective osteotomy with internal fixation and all went on to union with resolution of their symptoms.

CONCLUSIONS: Plate fixation of displaced midshaft clavicle fracture reliably restores length and alignment. It resulted in shorter time to union with low complication rates. Symptomatic malunion in adolescents may be more common than earlier thought after significantly displaced fractures. Corrective osteotomy with plate fixation can restore clavicle anatomy and eliminate symptoms associated with malunion.

LEVEL OF EVIDENCE: Therapeutic level III.

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