Clavicle Fractures in Children and Adolescents

Transcription

1 Clavicle Fractures in Children and Adolescents John A. Schlechter, DO Children s Hospital Orange County Orange, CA

2 Objectives The Bone The Fracture The Treatment The Controversies

3 The Bone

4 The Clavicle S Shaped First bone to ossify in the 5 th week in utero Ogden JA, et al. Radiology of postnatal skeletal development: The clavicle. Skeletal Radiol 1979;4(4):

5 The Clavicle Initial growth (<5 years) central ossification center Continued growth occurs at the medial & lateral epiphyseal plates Secondary Ossification Centers Primary Ossification Center

6 The Clavicle Secondary center at the sternal end of the clavicle does not appear before the 18th year and may not unite until the 25th year Secondary Ossification Centers Primary Ossification Center Incomplete ossification up to age 24-26

7 The Fracture

8 Clavicle Fractures in Children Anatomic Considerations AT RISK: Subclavian vessels Brachial plexus Mediastinal Structures posterior displacement in medial injuries

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10 Clavicle Fractures in Children Epidemiology & Mechanism of Injury 8-15% of all pediatric fractures Fall onto shoulder 87% of cases (Stanley et al. JBJS Br. 1988) Direct blow to clavicle FOOSH Child abuse

11 Pediatric Clavicle Fractures Chronologic Division CHILD ADOLESCENT < 10 years > 10 years

12 FRACTURES MEDIAL 5% 80% MIDSHAFT 15% DISTAL ANATOMIC CLASSIFICATION

13 Imaging Clavicle Fractures A/P X-ray Serendipity view XR 40 cephalic tilt CT Scan

14 The Treatment

15 Clavicle Fractures in Children NONOPERATIVE TREATMENT Don t worry, it will heal. Low Nonunion Rate Reported % Beatty JH & Kasser JR, Eds. Rockwood and Wilkens Fractures in Children 6 th Ed. 2006

16 Clavicle Fractures Historical Treatment All clavicle fractures heal. The best way to prevent a clavicle fracture from healing is to operate on it. With surgery, you trade a bump for a scar. Malunion is of radiographic interest only, and doesn t affect function.

17 They all heal in a sling Neer 3 nonunions in 2235 middle-third clavicle fracture (.1%) #1 cause of nonunion was surgery Recommend ORIF for outer third, neuro or vascular compromise or soft tissue interposition Neer CS: Non-union of the Clavicle. Journal of the American Medical Association. 1960;172:1006.

18 They all heal in a sling Rowe 690 clavicle fractures(566 midshaft) MGH - Non op 0.8% nonunion - Surgery 3.7% nonunion Fix with K-wire Included pediatrics Rowe CR: An Atlas of Anatomy and Treatment of Midclavicular Injuries. Clinical Orthopedics and Related Research. 1968;58:29-42.

19 It Will Remodel Excellent remodeling potential Wilkes & Hoffer, JOT clavicle fractures treated without immobilization (age 2-17) All fractures healed Observed remodeling up to 90 & 4 cm overlap All patients recovered full ROM Recommended all clavicle fractures in children be treated non-operatively

20 Non Op Treatment Options

21 Option 1 Sling Pros Alerts others that the child is injured. Typically readily available in most primary and urgent care settings. Does not cross at the fracture site therefore it tends to provide immediate comfort to the injured shoulder.

22 Option 1 Sling Cons May allow unwanted shortening at the fracture site secondary to allowing the extremity to rest in an adducted internally rotated position. Disallows use of the hand/wrist/elbow of the injured extremity and potentially can lead to stiffness of those joints.

23 Option 2 Figure-of-Eight brace Pros This brace will tend to retract the scapula and shoulders in turn holding the bone out to length in a more anatomic position. Allows full free use of both hands. Can be hidden under a shirt quite easily.

24 Option 2 Figure-of-Eight brace Cons May cross at or over the fracture site and may prove to be quite uncomfortable. On average is twice the monetary cost when compared to an arm sling.

25 Clavicle Fractures in Children Traditional Operative Indications Open fractures Neurovascular compromise Skin at risk tenting Severely displaced???

26 Operative treatment of clavicle fractures in children: a review of 21 years 15 patients treated with ORIF of clavicle fractures 8 midshaft (age ) Indications: impingement of soft tissue potential skin perforation displaced/shortening/cosmesis/pain Technique: Elastic Nails (5), Ex-Fix (2), screw (1) Kubiak R, Slongo T. J Pediatr Orthop Nov-Dec;22(6):736-9.

27 Operative treatment of clavicle fractures in children: a review of 21 years Results All patients regained full ROM & function No major complications (Infection, Instability) Minor complications: Discomfort/local hypoesthesia at surgical site (4) Unsatisfactory scar (3) Pseudobursa at tip of ESIN (3) Skin perforation by ESIN (2) Refracture after repeated fall (1) Kubiak R, Slongo T. JPO 2002.

28 Operative treatment of clavicle fractures in children: a review of 21 years CONCLUSION Surgical Indications Open fractures Impingement of soft tissue/potential risk for skin perforation Severe shortening of the shoulder girdle Displaced fractures with risk to neurovascular or mediastinal structures Kubiak R, Slongo T. J Pediatr Orthop Nov-Dec;22(6):736-9.

29 Severely Displaced?? Reviewed 66 COMPLETELY DISPLACED midshaft clavicle fractures at ~38 months. 15% Nonunion 31% Unsatisfied (28 pts complain of poor cosmesis) Shortening >20mm associated with higher nonunion rate and unsatisfactory result Recommend ORIF J Bone Joint Surg [Br] 1997;79-B:537-9.

30 Operative Treatment Options

31 Beach chair Surgical Techniques (Positioning) More comfortable for some X-rays may be difficult

32 Surgical Techniques (Positioning) Supine Bump under shoulder Radiolucent table JACKSON FLAT TOP Better for polytrauma

33 Clavicle Fractures Techniques for Operative Treatment Reduction Techniques/Aids Bump between scapulae Manipulation of fragments with pointed clamps Use of small or minifragment screws Plate as reduction tool/laminar spreader

34 Surgical Techniques (Reduction) Mini fragment screws/plates

35 Indirect reduction Surgical Techniques (Reduction) Mini distractor

36 Clavicle Fractures Techniques for Operative Treatment Exposure Supraclavicular nerves 18% incidence of numbness in upper breast Minimize periosteal stripping

37 Plate fixation Surgical Management (Shaft Fractures) Less muscle stripping More prominent?

38 Plate fixation Surgical Management (Shaft Fractures) Anteroinferior plating AP screws longer and safer Improved cosmesis Easier plate contour

39 Superior plate placement was less likely to fail in axial compression (Tackle Football) Anteroinferior plate placement was less likely to fail in cantilever bending (More physiologic) Favre et al. J Orthop Trauma Nov;25(11):661-5.

40 Clavicle Fractures Intramedullary Fixation Limited clinical evidence Complications include pin migration and loss of reduction (47%) Judd et. al. Am J Orthop 2009

41 Clavicle Fractures Intramedullary Fixation Why it doesn t make sense S-shaped bone screw is straight No rotational control Highly comminuted fracture - can shorten Need to make incision at fracture site if displaced or comminuted Worsen outcomes and higher complication rate when compared to non-op treatment Put a straight screw in this bone? J Trauma 2001

42 Clavicle Fractures 34 patients with clavicle fractures treated TEN (titanium elastic nail) In 15 cases an end cap was used 62% required open reduction 70% complication rate Medial perforation, lateral penetration, nail breakage, nail dislocation, hardware irritation Recommend amending operative technique and post operative treatment Frigg et al. Am J Sports Med, 2008

43 The Controversies

44 How Short is Too Short? How do you measure shortening? Two-dimensional radiographs can lead to misinterpretation of overlapping fragments

45 Role of CT Scan True total length - independent of its angle in reference to the frontal and sagittal planes Interindividual variability in total clavicle length. Pandya et al. J Am Acad Orthop Surg 2012;20:

46 Risk of CT Scan Cost and radiation exposure. Children more radiosensitive than adults Pandya et al. J Am Acad Orthop Surg 2012;20:

47 Shortening is relative! Must consider inter-individual variation in total clavicle length. 2 cm of shortening in a 10-cm pediatric clavicle will result in relative shortening of 20%, whereas 2 cm of shortening in a 17-cm adult clavicle will result in relative shortening of 12%. Smekal V et al: Length determination in midshaft clavicle fractures: Validation of measurement. J Orthop Trauma 2008; 22(7):

48 Shortening is relative! Same amount of shortening will result in different degrees of change in scapular position and sternoclavicular angulation.

49 Sequential clavicular shortening - 0%, 5%, 10%, 15%, and 20% Scapulothoracic motion during passive arm elevation in 3 planes was monitored using an EMG tracking device. Clavicular shortening of 10% affects scapular kinematics and might produce clinical symptoms. Matsumura et al. AJSM 2010, Vol. 38, No. 5

50 Before Canada

51 Systematic review of 22 studies 15% nonunion rate with non-op treatment Displacement, Comminution Female Gender, Age Relative risk of nonunion reduced 86% with ORIF for displaced fractures Zlowodzki et. al. J Orthop Trauma 2005

52 The Canadian Study

53 Completely displaced midshaft clavicle fracture 132 patients (age 16-60) randomized ORIF (plate fixation) 62 patients Non-operative treatment 49 patients 111 patients followed for 1 year Canadian Orthopaedic Trauma Society, J Bone Joint Surg Am Jan;89(1):1-10.

54 Faster healing time in operative group 16.4 weeks versus 28.4 weeks Fewer nonunions in operative group (3% vs. 14%) Fewer malunions in operative group (0% vs 18%) Fewer complications in operative group (16% vs 39%) Outcome scores improved in operative group At 1 year patients in the operative group were more likely to be satisfied with their shoulder Canadian Orthopaedic Trauma Society, J Bone Joint Surg Am Jan;89(1):1-10.

55 Are Children Little Canadians?

56 POSNA SURVEY

57 Operative vs. Nonoperative in 4 common midshaft clavicle fracture patterns. 949 Pediatric Society of North America members, 302 responded 32% response rate Carry P. et al. J Pediatr Orthop 2011;31:44 49

58 Carry P. et al. J Pediatr Orthop 2011;31:44 49

59 The respondents were also asked to indicate if the following factors influenced their preference for operative versus nonoperative management findings in current literature supporting operative fixation in adults arm dominance athletic status Carry P. et al. J Pediatr Orthop 2011;31:44 49

60 % of physicians that indicated recent adult literature has or has not influenced their treatment of similar fracture patterns in adolescents J Pediatr Orthop 2011;31:44 49

61 POSNA Survey - Conclusions POSNA members were nearly unanimously (>90%) in favor of nonoperative treatment for nondisplaced and angulated type midshaft clavicle fractures. Treatment preferences for isolated segmental fractures were more variable - preference toward operative fixation for male (48%) and female (47%) adolescents 16 to 19 years old. Nonoperative management was preferred in all fracture patterns. Carry P. et al. J Pediatr Orthop 2011;31:44 49

62 The Finnish Study

63 Sling or stainless steel 3.5-mm recon plate No difference in the Constant score, DASH score or pain at one-year follow-up Operative group = 0 non-unions Nonoperative group = 6 non-unions (24%) One year after a displaced midshaft clavicular fracture, non-op tx resulted in a higher nonunion rate but similar function and disability compared with operative treatment. Virtanen K et al. J Bone Joint Surg Am. September 2012;94:

64 Retrospective review - 14 skeletally immature patients with closed, displaced, midshaft clavicle fractures treated with open reduction internal fixation Mean age 12.9 y. 2 y follow-up. 4/12 implants removed. 8/12 (57%) complained of numbness at the site of injury/surgery. Preoperative mean fracture shortening and vertical displacement were 14.4 and 19.7 mm, respectively. Namdari S et al. J Pediatr Orthop 2011;31:

65 All fractures healed. High scores on commonly used instruments of outcomes assessment (QuickDASH, simple shoulder) Namdari S et al. J Pediatr Orthop 2011;31:

66 Retrospective studies of operative fixation in children show the feasibility and safety of fixation and are helping to define operative indications, but stronger evidence and reliable outcomes measures for the pediatric upper extremity are still needed. (J Pediatr Orthop 2012;32:S1 S4)

67 Online 2012 Musculoskeletal Trauma Self-Assessment Exam 19-year-old man sustained a closed clavicle fracture. If the patient had been treated nonsurgically, which of the following would most likely occur 1- Normal shoulder strength and function 2- Local sensory deficits 3- Fracture union 4- Infection 5- Malunion

68 Online 2012 Musculoskeletal Trauma Self-Assessment Exam 19-year-old man sustained a closed clavicle fracture. If the patient had been treated nonsurgically, which of the following would most likely occur 1- Normal shoulder strength and function 2- Local sensory deficits 3- Fracture union 4- Infection 5- Malunion

69 CAUTION! SURGICAL TREATMENT HAS COMPLICATIONS Navarro et. al. AAOS 2012 Review of ABOS Part II cases from clavicles treated surgically Implant Failure 4% Infection 2.3% Nonunion 1.9% Nerve Palsy 1.7% Wound Dehiscence 1.4% Vascular Injury Dislocation Hemorrhage Spinal Cord Injury Death Navarro et. al. AAOS 2012

70 CASES

71 WOULD YOU FIX IT? 13 y/o female with isolated clavicle fracture

72 2 months 5 months

73 But what about the bump?

74 16yo Male Baseball Player 4/2012

75 4/2012

76 8/2012

77 16yo Female Wrestler 2/2010

78 4/2010

79 6/2011

80 7/2011

81 Summary Consider operative treatment of displaced midshaft clavicle fractures but choose wisely Adhere to principles of fracture reduction and stable fixation to optimize results Exercise caution with intramedullary fixation Be aware of complications

82 Summary Children are NOT little Canadians 85% of midshaft clavicle fractures heal without surgery Increasing trend toward operative management POSNA Survey Employ a shared decision making process

83 Thank You