Christine A. Ho, MD Texas Scottish Rite Hospital for Children Division Director, Dept of Orthopaedics, Children s Health Dallas Associate Professor,

Transcription

1 Christine A. Ho, MD Texas Scottish Rite Hospital for Children Division Director, Dept of Orthopaedics, Children s Health Dallas Associate Professor, Dept of Orthopaedics UTSW

2

3 Participants will learn clinical examination and radiographic evaluation of midshaft clavicle fractures Participants will recognize the age-related differences in treatment and clinical course in midshaft clavicle fractures Participants will understand advantages and disadvantages of nonoperative treatment of adolescent midshaft clavicle fractures Participants will understand advantages and disadvantages of operative treatment of adolescent midshaft clavicle fractures Participants will understand absolute and relative indications for operative treatment of adolescent midshaft clavicle fractures

4 One of most frequently fractured bones in children Nonoperative treatment is the mainstay for the vast majority! Clavicle grows 8.4mm per year Types of midshaft clavicle fractures Birth Children Adolescents

5 Midshaft clavicle fractures diagnosed with routine AP XR Do not need other imaging or other views (unlike medial or lateral physeal sleeve fxs

6 Compression of shoulders during delivery generally anterior clavicle May be asymptomatic Pseudoparalysis Differential Neonatal brachial plexus palsy Infection Congenital pseudarthrosis of clavicle Symptomatic tx, Sling and swathe Almost all heal in 4 weeks, regardless of displacement

7 Generally due to fall Greenstick in younger children No reduction needed Sling or figure of 8 for symptomatic relief for 2-4 weeks Warn family of bump of callus 6-9months to remodel Surgical indication impending skin breakdown Our institution: ZERO surgeries for clavicles 10yo and less in 20 years! Literature to suggest no orthopaedist is needed!

8 FOOTBALL! Direct blow or fall Shoulder is lower than other side, protracted Kid supports elbow with uninvolved hand SCM tension tilts head to fractured side, chin to uninvolved side Localized swelling, tenderness, crepitation Absolute Indications for Surgery Impending Open Fracture Surgical Treatment becoming more popular

9

10 132 Adult patients, 100% displaced, Mean shortening 15mm 67 = ORIF 65 = Sling Demographics, MOI, fx pattern similar ORIF JBJS 2007 Faster time to union (28 vs 16 wks, p=0.001) Better Constant Shoulder and DASH scores at all time points (p=0.001, p<0.01) 3% nonunions ORIF vs 11% nonunions in sling (p=0.04) 0 symptomatic malunions ORIF vs 14% sling (p=0.001) 1 year FU ORIF happier with appearance and shoulder

11 JBJS 2016 JOT 2017

12 JBJS 2013 JBJS 2017 ORIF decreases nonunion Constant and DASH better at 1y Outcomes not so different when you exclude nonunions Implant related complications, surgery to remove plate, Cost JBJS 2017

13 JPO 2015 From 2007 to 2011, operative management for 10-19yo increased from 309 to 530 clavicles (p<0.0001) but number of clavicle unchanged More surgery in western US (increased X2), Midwest, south > 2011 JPOB 2016 Increased number of midshaft clavicle fxs (20 -> 85) Increased percentage midshaft treated surgically (3% -> 20%, p<0.0001) Children Are Not Little Adults!

14 16 adolescent patients, 100% displaced (Schulz et al JBJS 2013) ROM same External rotation strength decreased 8% but rest of strength same or better Endurance strength same QuickDASH same as norms, Constant score same as uninjured side Mean shortening 1.15mm (some clavicles gained length) Others report some nonunions and shortening but no difference in outcomes (Strauss et al J Emerg Med 2012, Randsborg et al JPO 2014, Robinson et al Injury 2015, O Neill et al Int J Pediatr 2011). Nonoperative management has low rate of complications, high return to activities, high union rate

15 5 studies (ORIF and elastic nails) No nonunions 86% complication rate with ORIF in 36 patients (Li et al JPO 2018) Implant prominence, numbness, wound complications Elastic nail have high complications (Frye et al JPO 2012, Rapp et al JPO 2013) Symptomatic irritation, nail bending, impending skin perforations Operative treatment reliably leads to union but with a high rate of complications

16 5 studies, nonrandomized, selection bias 42 adolescents. 17=ORIF 25=sling (VanderHave et al JPO 2010) ORIF = faster union, faster return to activities 20% (5/25) of nonoperative had symptomatic malunions, 4 had osteotomies 641 adolescents. 115 = ORIF Med 2014) ORIF patients older, more shortening 526 = sling (Heyworth et al Orthop J Sports K wires, IMN with high complications (Antaback et al Act Cli Croat 2015) Patients who are older and with more shortening tend to get surgery, have almost 100% union, but have a high rate of complications

17 Polytrauma Open or impending open fractures Neurovascular injury Segmental fracture with Zed deformity Malunion does NOT cause a difference in ROM, strength although some patients unhappy with appearance, pain (Bae et al JPO 2013) Nonunion can be treated successfully with ORIF (Pennock et al JSES 2018)

18

19 Discuss familial expectations, patient extracurriculars Nonoperative warn of nonunion and possibility for delayed surgery, cosmetic problems, refracture Operative warn of need for HWR, numbness, hardware problems, refracture

20 Nonoperative treatment is still mainstay for uncomplicated adolescent midshaft clavicle fractures Symptomatic malunions and nonunions can be addressed if they occur If you operative, warn family of risks and avoid K-wires What we need to do is figure out which kids are at risk for symptomatic malunion/nonunion

21

22