Rockwood Children CH19

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Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries Benton E. Heyworth and Joshua M. Abzug

Midshaft Clavicle Fractures

Distal Clavicle Fractures

INTRODUCTION  720

INTRODUCTION TO DISTAL CLAVICLE FRACTURES  730

ASSESSMENT OF MIDSHAFT CLAVICLE FRACTURES  720 Mechanisms of Injury for Midshaft Clavicle Fractures  720 Injuries Associated With Midshaft Clavicle Fractures  721 Signs and Symptoms of Midshaft Clavicle Fractures  721 Imaging and Other Diagnostic Studies for Midshaft Clavicle Fractures  721 Classification of Midshaft Clavicle Fractures  722 Outcome Measures for Midshaft Clavicle Fractures  723

ASSESSMENT OF DISTAL CLAVICLE FRACTURES  730 Mechanisms of Injury for Distal Clavicle Fractures  730 Injuries Associated With Distal Clavicle Fractures  730 Signs and Symptoms of Distal Clavicle Fractures  730 Imaging and Other Diagnostic Studies for Distal Clavicle Fractures  731 Classification of Distal Clavicle Fractures  731 Outcome Measures for Distal Clavicle Fractures  731

PATHOANATOMY AND APPLIED ANATOMY RELATED TO MIDSHAFT CLAVICLE FRACTURES  723

PATHOANATOMY AND APPLIED ANATOMY RELATED TO DISTAL CLAVICLE FRACTURES  731

TREATMENT OPTIONS FOR MIDSHAFT CLAVICLE FRACTURES  723 Nonoperative Treatment  724 Operative Treatment of Midshaft Clavicle Fractures  724

TREATMENT OPTIONS FOR DISTAL CLAVICLE FRACTURES  732 Nonoperative Treatment of Distal Clavicle Fractures  732 Operative Treatment of Distal Clavicle Fractures  732

AUTHORS’ PREFERRED TREATMENT FOR DISTAL CLAVICLE FRACTURES  734

AUTHOR’S PREFERRED TREATMENT FOR MIDSHAFT CLAVICLE FRACTURES  726

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO DISTAL CLAVICLE FRACTURES  736

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES  729

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO DISTAL CLAVICLE FRACTURES  736

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES  729

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

Scapula Fractures

AUTHOR’S PREFERRED TREATMENT FOR ACROMIOCLAVICULAR DISLOCATIONS  746

INTRODUCTION TO SCAPULA FRACTURES  736

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO ACROMIOCLAVICULAR DISLOCATIONS  746

ASSESSMENT OF SCAPULA FRACTURES  736 Mechanisms of Injury for Scapula Fractures  736 Injuries Associated With Scapula Fractures  737 Signs and Symptoms of Scapula Fractures  737 Imaging and Other Diagnostic Studies for Scapula Fractures  737 Classification of Scapula Fractures  737 Outcome Measures for Scapula Fractures  738

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO ACROMIOCLAVICULAR DISLOCATIONS  746 Sternoclavicular Fracture–Dislocations

INTRODUCTION TO STERNOCLAVICULAR FRACTURE–DISLOCATIONS  747

PATHOANATOMY AND APPLIED ANATOMY RELATED TO SCAPULA FRACTURES  739

ASSESSMENT OF STERNOCLAVICULAR FRACTURE–DISLOCATIONS  747 Mechanisms of Injury for Sternoclavicular Fracture–Dislocations  747 Injuries Associated With Sternoclavicular Fracture–Dislocations  747 Signs and Symptoms of Sternoclavicular Fracture–Dislocations  747 Imaging and Other Diagnostic Studies for Sternoclavicular Fracture–Dislocations  748 Classification of Sternoclavicular Fracture–Dislocations  749 Outcome Measures for Sternoclavicular Fracture–Dislocations  749

TREATMENT OPTIONS FOR SCAPULA FRACTURES  739 Nonoperative Treatment of Scapula Fractures  739 Operative Treatment of Scapula Fractures  739

AUTHORS’ PREFERRED TREATMENT FOR SCAPULA FRACTURES  741

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO SCAPULA FRACTURES  742 SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO SCAPULA FRACTURES  742 Acromioclavicular Dislocations ASSESSMENT OF ACROMIOCLAVICULAR DISLOCATIONS  742 Mechanisms of Injury for Acromioclavicular Dislocations  742 Injuries Associated With Acromioclavicular Dislocations  742 Signs and Symptoms of Acromioclavicular Dislocations  742 Imaging and Other Diagnostic Studies for Acromioclavicular Dislocations  743 Classification of Acromioclavicular Dislocations  743 Outcome Measures for Acromioclavicular Dislocations  743 INTRODUCTION TO ACROMIOCLAVICULAR DISLOCATIONS  742

PATHOANATOMY AND APPLIED ANATOMY RELATED TO STERNOCLAVICULAR FRACTURE–DISLOCATIONS  749

TREATMENT OPTIONS FOR STERNOCLAVICULAR FRACTURE–DISLOCATIONS  750 Nonoperative Treatment of Sternoclavicular Dislocations  750 Operative Treatment of Sternoclavicular Fracture–Dislocations  751

AUTHORS’ PREFERRED TREATMENT FOR STERNOCLAVICULAR FRACTURE–DISLOCATIONS  754

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS IN STERNOCLAVICULAR FRACTURE–DISLOCATIONS  754 SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO STERNOCLAVICULAR FRACTURE–DISLOCATIONS  755

PATHOANATOMY AND APPLIED ANATOMY RELATED TO ACROMIOCLAVICULAR DISLOCATIONS  744

TREATMENT OPTIONS FOR ACROMIOCLAVICULAR DISLOCATIONS  744

Nonoperative Treatment of Acromioclavicular Dislocations  744 Operative Treatment of Acromioclavicular Dislocations  745

720

SECTION TWO • Upper Extremity

Neonates can sustain a clavicle fracture during the birthing process, especially those babies who are large for gestational age or those involved in difficult deliveries. 15,63,82 Additional risk factors include a lower mean head-to-abdominal circum- ference ratio and a prior history of the mother having a previ- ous child with macrosomia. 63 Neonatal clavicular fractures have been cited as one of the most frequent complications of natural delivery. 30,70,75,86,118,128 However, there is no uniform screening method for determining whether or not a fracture occurred. Therefore, the exact incidence of neonatal clavicle fractures remains unknown. The incidence has been reported to be as high as 4.4%, but the true incidence may be even higher, as some are diagnosed postdischarge from nursery. 86 Clavicle frac- tures due to birth trauma need to be distinguished from the rarer congenital pseudarthrosis of the clavicle, which is gener- ally seen on the right side, except in dextrocardia (Fig. 19-1). Based on the child’s neonatal position in the uterus, the ante- rior shoulder, typically the right side, is the most likely loca- tion of the clavicle fracture, as the left occiput anterior (LOA) position is the most common. 63 In addition, this is the most common side of injury in neonatal brachial plexus palsy. There- fore, when an infant sustains a clavicle fracture during the birth- ing process and limited motion is present about the affected extremity, it is often unknown if the child has a concomitant brachial plexus injury or is not moving their arm secondary to the pain associated with the fracture, a so-called pseudopalsy. Once the fracture heals, typically in 1 to 3 weeks in a newborn, repeat assessment of the brachial plexus must be performed to distinguish pseudopalsy from a true nerve injury. The exact mechanism for sustaining the clavicle fracture during the birthing process remains unknown. It is likely related to lateral compression of the shoulder girdle against the pelvis. However, neonatal clavicle fractures have also been shown to occur during cesarean sections. 63 Toddlers who sustain clavicle fractures may sustain the injury due to a fall from a height or injuries sustained during child abuse. 22,75,119 In a series of children aged 4 years or

Midshaft Clavicle Fractures

INTRODUCTION

The clavicle is one of the most commonly fractured bones in children, representing 5% to 15% of all pediatric fractures. 114 The most common location for a clavicle fracture is the midshaft of the bone, accounting for up to 80% of fractures. 114,117,121,129 Despite this high incidence, literature is limited regarding man- agement and outcomes of pediatric clavicle fractures. Much of the literature cited throughout this chapter is therefore extrapo- lated from scientific studies performed in adult clavicle fracture populations. However, there is a clear increasing trend for oper- ative fixation in adults and older children. 143,162 Therefore, more scientific investigations regarding the management of clavicle fractures in children are being performed, the results of which are of utmost importance to elucidation of future treatment algo- rithms for this younger population. Until a more methodolog- ically rigorous and comprehensive body of evidence emerges regarding the optimal treatment approach in children and, in particular, adolescents, this remains one of the most controver- sial areas in pediatric orthopedics and sports medicine.

ASSESSMENT OF MIDSHAFT CLAVICLE FRACTURES

MECHANISMS OF INJURY FOR MIDSHAFT CLAVICLE FRACTURES

Clavicle fractures are common in children of all ages, from birth to skeletal maturity, with different mechanisms of injury result- ing in the fracture based on age.

Figure 19-1.  A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. B: Neonatal pseudarthrosis of the clavicle. ( B: reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2012.)

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

SIGNS AND SYMPTOMS OF MIDSHAFT CLAVICLE FRACTURES

younger, children abused had an incidence of clavicle fractures of approximately 4% compared with only about 1% in the control group. 119 School age clavicle fractures occurring in children are typi- cally the result of a fall where the child sustains a lateral compres- sive force to the shoulder. 140 Typical activities include falls off of playground equipment, falls from bicycles, and during sporting activities. Alternatively, a direct blow to the clavicle can lead to fracture in a child; however, this mechanism is less common. The common fall onto an outstretched hand does not typically transmit enough force to the clavicle to sustain a fracture, 67 but is another reported mechanism of injury in some cases. Adolescents sustain clavicle fractures due to similar mecha- nisms as school age children as well as due to high-energy mech- anisms or competitive athletics. Motor vehicle and all-terrain vehicle (ATV) accidents are common high-energy mechanisms in adolescents that can result in either isolated clavicular frac- tures or clavicular fractures associated with polytrauma similar to adults. 77,121 High-level competitive athletes also commonly sus- tain clavicle fractures due to collision sports, such as football, or much less commonly, due to repetitive, high-intensity training, leading to a stress fracture, though this has only emerged in case reports. 1 Specific sporting activities that can lead to stress frac- tures include rowing, diving, baseball, and gymnastics, among others. 1,153,160 The proposed mechanism leading to a clavicular stress fracture is excessive cyclic scapular protraction and retraction leading to clavicular fatigue. 1 Excessive motion at the sternocla- vicular and acromioclavicular (AC) joints transfers the forces to the clavicle itself, with the end result being these forces exceed- ing the ultimate tensile strength of the clavicle. 1 This most com- monly occurs in athletes who rapidly increase their training program. Injuries that are associated with clavicle fractures depend on the age of the child and violence of trauma with the fracture. Neo- nates can have a concomitant neonatal brachial plexus palsy. The most common type of neonatal brachial plexus palsy is an injury affecting C5 and C6 (Erb’s palsy) or C5, C6, and C7 with resultant limited shoulder movement, elbow flexion, forearm supination, and wrist extension. 48 Differentiation between a pseudopalsy, the child not moving their arm secondary to the clavicle fracture itself, and a concomitant l brachial plexus birth palsy can be made by 3 to 4 weeks of age, as the pain from the fracture will be markedly decreased. Toddlers who sustain clavicle fractures as a result of nonaccidental trauma are likely to sustain concomitant fractures, such as fractures of the rib, tibia/fibula, humerus, or femur, intracranial bleeding, eye con- tusions, retinal hemorrhage, and burns. 28,119 Finally, adolescents involved in high-energy mechanisms of injury can have asso- ciated polytrauma including injury to surrounding structures or vital organs. Concomitant rib fractures, scapula fractures, pneumothorax, brachial plexus injury, or subclavian vessel injury may be present. 67 Abdominal, head, spine, and/or lower extremity trauma can also occur. INJURIES ASSOCIATED WITH MIDSHAFT CLAVICLE FRACTURES

Clavicle fractures in neonates commonly present after difficult deliveries with decreased active movement about the shoulder region, crying upon passive movement of the shoulder and entire upper extremity, swelling, crepitation, and an asymmetrical bony contour. The Moro (startle) reflex (a newborn reflex in which a noise or sudden movement causes the baby to extend their neck, arms, and legs followed by pulling the arms and legs back in) may be decreased as well. 63 Presence of limited digit motion or Horner syndrome (ptosis, miosis, and anhydrosis) indicates the presence of a more serious concomitant brachial plexus birth palsy with injury affecting the lower portions of the brachial plexus. Toddlers who sustain clavicle fractures associated with sus- pected abuse should undergo a complete head-to-toe survey, as if they were a trauma patient, looking for concomitant injuries and/ or signs of abuse. This includes a thorough neurologic evaluation, an ophthalmologic examination, and a skeletal survey to look for corner fractures or additional fractures in various stages of healing. Examination of an older child or adolescent with a clavicle fracture includes looking for deformity, swelling, and ecchymo- sis about the affected clavicle. Any tenting of the skin (Fig. 19-2) or open wounds should be noted. In addition, one should look at the lateral aspect of the shoulder for an abrasion or erythema, as this is most commonly the site of impact. Inspection may also demonstrate some drooping of the involved side as the scapula appears internally rotated and the shoulder appears shortened compared with the contralateral side. If significant swelling is present, this may be difficult to recognize. 67 Pain about the entire shoulder girdle is typically present; however, significant tenderness to palpation is present overly- ing the fracture itself. Crepitus, with palpation or any attempt of active or passive range of motion, may be present. As noted above, concomitant injury to the brachial plexus may occur, especially in the medial cord-ulnar nerve because of its location adjacent to the middle third of the clavicle. Therefore, a thor- ough neurologic examination is required for all patients who sustain clavicular fractures. This includes assessing motor and sensory function throughout the entire upper extremity. It may be difficult to have a child in pain perform certain functions necessary to complete the neurologic evaluation; however, it is imperative to be patient and repeat the examination as often as necessary to obtain the necessary information. Because of the location of the subclavian vessel, a thorough vas- cular examination is also necessary, especially in patients involved in high-energy mechanisms of injury. The vessel can spasm, have a thrombosis from blunt trauma, or rarely have a penetrating injury. Assessment of the radial pulse should be symmetric and if there is any concern for injury of the vessel, further diagnostic evaluation with advanced imaging should be performed.

IMAGING AND OTHER DIAGNOSTIC STUDIES FOR MIDSHAFT CLAVICLE FRACTURES

Initial imaging of a suspected clavicle fracture includes plain radiographs of the clavicle in two projections. Typically, a standard anteroposterior (AP) radiograph and a cephalic tilt

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SECTION TWO • Upper Extremity

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Figure 19-2.  Photographs depicting skin tenting from a displaced, segmental left diaphyseal clavicle frac- ture. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

view, ranging from 15-degree cephalad to 45-degree cephalad, are obtained (Fig. 19-3). These images provide visualization of the shoulder girdle region as well as the upper lung fields, both of which should be assessed for additional injuries. However, if clinical suspicion is present for additional injuries, dedicated series of the suspected part(s) should be obtained. Clavicle fractures are often detected on chest x-rays obtained for trauma patients, and rarely require additional imaging, if the general fracture pattern and approximate shortening can be assessed for completely displaced fractures. Advanced imaging is rarely needed to evaluate clavicle fractures, as the fracture pattern, displacement, and presence of comminution can almost always be assessed on plain films. As described in greater detail below, frac- tures or suspected dislocations about the sternoclavicular joint are frequently assessed with CT scans, but midshaft fractures, which are much more common, benefit from such imaging only in the case of a suspected or possible fracture nonunion or possible

refracture through a healing fracture. Distal fractures are assessed by CT scans at times to decide on degree and direction of displace- ment that might indicate need for operative intervention. CLASSIFICATION OF MIDSHAFT CLAVICLE FRACTURES Clavicle fractures are usually described based on the location of the fracture, the fracture pattern, and the presence or absence of dis- placement. Thus, clavicle fractures are either medial, midshaft, or lateral; nondisplaced or displaced; open or closed; comminuted or simple. Displaced fractures can be qualified as partially displaced, when the two fracture fragments of a two-part fracture are still in contact, with or without angulation, whereas completely displaced fractures have fracture fragments that are not in contact with each other, or are three-part or four-part fractures with comminution. The description of partially displaced fractures with angulation benefit from a measurement of the degree of angulation, as increas- ing angulation has been associated with a greater risk of refracture in some studies. 46,95 For completely displaced fractures, a measure- ment of the degree of “shortening,” as measured in millimeters (mm), has been used more commonly in adult clavicle fracture studies. For example, some authors have contended that shorten- ing greater than 14 or 20 mm may be associated with poorer out- comes with nonoperative treatment, when compared with lesser degrees of shortening. As a result, many have considered 20 mm as a potential threshold or an indication for surgery. However, import- ant studies by Schulz et al. 134a and Bae et al. 8 have suggested that even fractures with greater than 15 to 20 mm of shortening are not associated with functional limitations in adolescents treated nonoperatively. Moreover, new research suggests that traditional measurement techniques may grossly overestimate the ‘true’ short- ening of the clavicle, by not accounting for the oblique nature of clavicle fractures. 87a Thus, we believe that additional research is warranted before adult-based metrics are applied to the young who have greater healing and remodeling capacity. Classifications that go beyond this descriptive scheme, such as the AO classifica- tion, 44 have been proposed to evaluate clavicle fractures, but none are widely utilized, as they are either purely descriptive of fracture location 3 or cumbersome with multiple types and subtypes. 44,129

Figure 19-3.  Depiction of a 45-degree cephalic tilt to obtain an addi- tional view of the clavicle.

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

OUTCOME MEASURES FOR MIDSHAFT CLAVICLE FRACTURES

remodeling capacity may exist up through adolescence and into young adulthood. Medially the clavicle articulates with the sternum, forming the sternoclavicular joint, whereas laterally the bone ends in an articulation with the acromion, forming the AC joint. The medial inferior aspect of the clavicle is the site of attachment of the costoclavicular ligament, whereas laterally on the inferior aspect there is the conoid tubercle and trapezoid line, the sites of attachment for the conoid and trapezoid ligaments, respec- tively. All of these ligaments slant posteriorly as they approach the clavicle, and therefore when the clavicle elevates and the ligaments are put on stretch, the clavicle rotates posteriorly. In addition, these ligaments provide significant stability at both ends of the clavicle, thus making fractures in the middle third of the clavicle more likely. The pectoralis major originates from the medial aspect of the clavicle as well as the sternum and inserts onto the humerus at the intertubercular groove, whereas the deltoid originates from the lateral aspect of the clavicle as well as the acromion and scapular spine to insert onto the humerus at the deltoid tuber- osity. In addition, the sternocleidomastoid and sternohyoid muscles originate from the clavicle whereas the trapezius and subclavius insert onto the clavicle.

No specific outcome scores have been widely used to assess results following pediatric clavicle fractures, though the American Shoulder and Elbow Society (ASES) score, the Dis- ability of the Arm, Shoulder, and Hand (DASH) Score, the QuickDASH, and the Constant Shoulder Score have been uti- lized in some studies. The creation of a novel Pediatric & Ado- lescent Shoulder & Elbow Survey (Pedi-ASES) has stemmed from research demonstrating that adult shoulder outcome scores are associated with poor validity and comprehensibility. The Pedi-ASES may represent a future standard for use in pedi- atric and adolescent shoulder research. 60

PATHOANATOMY AND APPLIED ANATOMY RELATED TO MIDSHAFT CLAVICLE FRACTURES

The clavicle, also referred to as the collar bone, is an S-shaped bone that lies along the subcutaneous border of the anterior aspect of the shoulder girdle. An anterior convexity is present medially to permit the passage of the brachial plexus and axil- lary vessels from the neck region into the upper arm, whereas laterally there is an anterior concavity. Development of the clavicle begins at five and a half weeks’ gestation via intramembranous ossification, and by 8 weeks, the bone has developed into its S-shaped configuration. 47 Post- natally, the clavicle continues to grow at a steady rate until age 12, increasing approximately 8.4 mm per year. 99 After 12 years of age, the clavicle grows approximately 2.6 mm per year in females and 5.4 mm per year in males. Thus, 80% of the final clavicle length is reached by age 9 in females and age 12 in males. 99 However, because the clavicle is the last bone in the body to complete its ossification process, continuing up to the age of 25 in some patients, continued Figure 19-4.  A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remod- eling with growth. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

TREATMENT OPTIONS FOR MIDSHAFT CLAVICLE FRACTURES

The mainstay of treatment of pediatric and adolescent clavicle fractures is nonoperative, allowing the fracture to form cal- lous and heal in situ, even if significant displacement is pres- ent (Fig. 19-4). 8 It is well agreed upon that nondisplaced or minimally displaced fractures should be treated nonoperatively. Fractures that should proceed directly to operative intervention include open fractures, fractures with skin at risk of necrosis

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SECTION TWO • Upper Extremity

OPERATIVE TREATMENT OF MIDSHAFT CLAVICLE FRACTURES

(i.e., skin with pallor or clear dysvascularity), and fractures with associated neurovascular injuries clearly affecting motor func- tion or blood supply to the upper extremity. Decreased sensa- tion in the skin of the chest wall distal to the fracture may be reported, and likely stems from contusions or stretch injuries to the superficial supraclavicular sensory nerves. While case reports of supraclavicular nerve branches entrapped in frac- ture callus have been published, 71 and may benefit from surgi- cal exploration and neurolysis, these represent the minority of cases, and chest wall numbness does not represent an indepen- dent indication for surgery. Of note, these nerves are at risk for injury during primary surgical fixation. NONOPERATIVE TREATMENT Nonoperative treatment of clavicle fractures is performed by immobilizing the child’s shoulder girdle, typically with a sling. Younger children may benefit from a sling and swath, at least in the first several days postinjury, primarily to improve com- fort levels. While more traditional figure-of-eight dressings or shoulder immobilizers can be utilized, these are more cumber- some and have not been shown to provide improved results. Neonates who sustain a clavicular fracture during the birthing process can be immobilized with a swath technique, such as placing Webril or an soft elastic bandage around the torso and arm, but, due to the speed of callus formation, can usually be discontinued within 1 week. Follow-up radiographs are obtained at typical intervals until fracture union occurs. A two-week postinjury radiograph allows for confirmation of maintenance of the fracture alignment or degree of shortening seen at the time of injury, as some nondis- placed fractures can displace in the early postinjury phase. Such a visit will also allow for a progression to use of the sling only when ambulating or at school, while the sling can often be discontinued when at home, as comfort allows from the 2-week to the 6-week period. A 6-week visit frequently shows significant callus formation stabilizing the fracture, which can allow for discontinuation of the sling, with an understanding that refractures can occur with falls or premature return to sports. 25 However, noncontact fitness activities can usually be allowed at 6 weeks, provided there is advanced heal- ing. Return to contact sports only after the 3-month radiographs has confirmed a healed fracture with clear bony bridging. Calder et al. have suggested that follow-up radiographs are unnecessary in pediatric patients, given the near-universal expected fracture heal- ing rate in a child. However, we routinely obtain radiographs until union is clearly established. Nonoperative Treatment of Midshaft Clavicle Fractures: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications • Nondisplaced fractures • Open fractures • Minimally displaced fractures • Fractures at risk of skin necrosis • Fractures associated with neurovascular injury Indications/Contraindications

Absolute indications for operative treatment of clavicle frac- tures in the pediatric and adolescent population include open fractures, fractures with skin tenting severe enough to risk skin necrosis (Fig. 19-5), and fractures associated with neurovascu- lar injury. Additional relative indications may include floating shoulder injuries and fractures associated with polytrauma. Floating shoulder injuries involving midshaft clavicle fractures and fractures of the glenoid neck treated by open reduction internal fixation (ORIF) of the clavicle alone can be sufficient as ligamentotaxis can reduce the other fracture via the coracocla- vicular (CC) ligament. 9 Fractures with significant displacement that are treated non- operatively in adults have been shown to subsequently heal with a malunion that can cause changes to shoulder mechanics. These alterations have been shown, at times, to lead to pain with overhead activities, decreased strength, and decreased endur- ance. 61,100 Therefore, multiple studies have investigated the benefit of operative fixation versus nonoperative management of displaced midshaft clavicle fractures. The most impactful of such studies was randomized controlled trial of an adult Cana- dian population with a mean age of 33.5 years, in which the operative cohort was shown to have improved functional out- come measures and lower rates of nonunion and symptomatic malunion than the nonoperative cohort. 26 A recent meta-analy- sis evaluating the results of randomized clinical trials that com- pared nonoperative and operative treatment in adults confirmed a significantly higher nonunion and symptomatic malunion rate in the nonoperative group. In addition, patients treated with operative intervention had earlier functional return. 101 Not only is it unclear whether these data are transferable to adolescents, but more recent randomized controlled trials in other adult populations 132,152 have suggested that the indications for sur- gery are more limited in adult populations than suggested by the McKee Canadian study. Clearly, younger children, especially less than age 13 years, have the potential to remodel even a foreshortened, displaced fracture. The approach to older ado- lescents has evolved into a shared decision-making process with families of young athletes, with considerations toward the

Figure 19-5.  Radiograph of a segmental right diaphyseal clavicle frac- ture causing skin tenting and subsequent compromise. Note the verti- cal nature of the segmental fragment. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Prac- tical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

laterality of the fracture, the sports played, and the tolerance level for a malunion that is likely to demonstrate a full return to function, but perhaps along an unpredictable timeline. To date, no studies in adolescent populations have demonstrated clear superiority of operative treatment over nonoperative treatment, given the significantly lower rates of nonunion and symptom- atic malunion in adolescents relative to adults.

Open Reduction and Internal Fixation or Intramedullary Fixation Preoperative Planning ✔ ✔ Operative Treatment of Midshaft Clavicle

Fractures: PREOPERATIVE PLANNING CHECKLIST

❑❑ Standard table capable of going into beach chair position ❑❑ Supine beach chair position with head and neck tilted away ❑❑ Bump placed behind the scapula

OR table

In addition, the plate is less prominent in this location. Supe- rior placement of the plate is technically easier and allows for better resistance of the biomechanical forces acting to displace the fracture. Positioning Options for positioning during ORIF of clavicle fractures include using the beach chair position (i.e., ∼ 60 degrees), hav- ing the patient supine, or different degrees of torso elevation in between the two, that is, “sloppy beach chair” positioning (e.g., ∼ 45 degrees). With either position, a bump may be placed behind the scapula to bring the fracture fragments forward for ease of dissection. Surgical Approach ORIF is performed via a direct surgical approach to the clavicle using a skin incision that follows Langer lines. In an attempt to avoid problems, by having the incision directly over the plate, and to improve aesthetics, incise the skin on the inferior aspect of the clavicle, 32 or even up to 1 to 2 cm distal to the clavi- cle, with proximal dissection to the fracture site. Once the skin is incised, the platysma is dissected, revealing the underlying cutaneous supraclavicular nerves as they cross the clavicle, which should be identified and protected to avoid chest wall numbness, dysesthesias, or neuromas. Meticulous subperios- teal dissection is then carried out to expose the fracture site while ensuring maintenance of the soft tissue attachments to any malrotated or segmental fracture fragments. Preservation of the integrity of the periosteum, which may be torn at the site of the fracture, is critical to the postfixation closure of this layer, which will aid in optimization of bone healing and minimiza- tion of hardware irritation. The posterior periosteal sleeve also protects the underlying neurovascular structures. Intramedullary fixation is performed by making a similar approach using a small incision over the fracture site to expose Figure 19-6.  Radiograph of a right midshaft clavicular fracture treated with an intramedullary elastic nail, which subsequently went on to frac- ture. (Reprinted with permission fromWaters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

Position/positioning aids

❑❑ Contralateral to fracture

Fluoroscopy location

❑❑ Surgeon’s choice of implant

Equipment

❑❑ Shoulder girdle, entire clavicle, and ipsilateral limb are prepped and draped into the field to allow for visualization traction and manipulation ❑❑ Medially, the ipsilateral sternoclavicular joint should be included in the operative field

Draping

As with any procedure that will use implants, it is imperative to have the desired hardware available before proceeding to the operating room. Options for treatment of pediatric and ado- lescent clavicle fractures include anatomically designed clavicle plates, standard nonlocking and locking plates, and intramed- ullary devices including pins, wires, screws, and elastic nails. Intramedullary fixation has the potential benefits of requir- ing less soft tissue stripping at the fracture site, better aesthetics with smaller skin incisions, easier hardware removal, less poten- tial for hardware irritation, and less bony weakness following hardware removal compared with plate fixation. However, the ability to resist torsional forces is less with intramedullary fixa- tion compared with plating which can result in fracture of the intramedullary implant (Fig. 19-6). Furthermore, the potential for the intramedullary device to migrate is a major concern for many surgeons, thus limiting its usage. More modern intra- medullary devices with locking potential have decreased con- cerns regarding migration of traditional Kirschner-wire (K-wire) constructs, but are more likely to require secondary hardware removal surgeries to avoid soft tissue irritation at the posterior lateral clavicle entry sites. If plate fixation is being planned, one must determine what the preferred location of the plate will be, anteroinferior or superior. Anteroinferior plates have the advantage of perform- ing drilling in a posterosuperior direction, and thus the drill is not directed toward the surrounding neurovascular structures.

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SECTION TWO • Upper Extremity

only the ends of fracture fragments. An additional percutaneous incision is placed over the superolateral part of the clavicle to place the intramedullary device in an antegrade manner.

favor closure of the overlying fascial layer and platysma layer, to optimize soft tissue coverage over the subcutaneous plate. Final assessment of the supraclavicular nerves is performed to be certain they are intact and without entrapment. A meticu- lous dermal layer and subcuticular closure is then performed to obtain the best cosmetic result possible and decrease the chance of wound complications. Sterile dressings are applied followed by placement of the patient into a sling. Intramedullary Fixation ✔ ✔ Intramedullary Fixation of Midshaft Clavicle Fractures: KEY SURGICAL STEPS ❑❑ Skin incision in line with Langer lines ❑❑ Dissection of platysma ❑❑ Exposure of fracture site ❑❑ Drilling of the medial segment of the fracture in preparation for device placement ❑❑ Drilling of distal fragment medullary canal and then posterior lateral cortex ❑❑ Placement of intramedullary device in a retrograde manner through fracture site ❑❑ Reduction of fracture fragments ❑❑ Advancement of device antegrade across the fracture ❑❑ Closure A skin incision is made overlying the fracture site in line with Langer lines. The platysma is dissected, and supracla- vicular cutaneous nerves are identified and protected. The fracture site is exposed in a subperiosteal manner. The soft tissue attachments to malrotated and comminuted fragments are preserved. The intramedullary canal of the medial frac- ture fragment is drilled in preparation for device placement, with care taken to ensure no violation of the anterior medial cortex occurs. The distal fragment medullary canal and then the posterior lateral cortex are drilled so that the drill can be visualized just beneath the skin. A percutaneous skin incision is made where the drill is tenting the skin. The intramedullary device is placed in a retrograde manner through fracture site to exit through posterior lateral skin incision. Fracture frag- ments are reduced, and the device is advanced in an antegrade manner across the fracture. If available, device-specific mecha- nisms are placed to prevent migration or permit compression. The periosteum, overlying fascial layers, platysma layer, and skin are closed. A sling or shoulder immobilizer is applied.

Technique Open Reduction and Internal Fixation ✔ ✔ ORIF of Midshaft Clavicle Fractures: KEY SURGICAL STEPS

❑❑ Skin incision in line with Langer lines ❑❑ Dissection of platysma ❑❑ Exposure of fracture site ❑❑ Reduction of fracture ❑❑ Plate application ❑❑ Assessment of reduction ❑❑ Closure

We use the sloppy beach chair position at 45 degrees and make our skin incision approximately 1 to 1.5 cm inferior to the clavicle. Following exposure of the fracture fragments, reduc- tion is performed utilizing bone holding forceps. It is imper- ative to restore the length and contour of the clavicle during the reduction process. This may require utilization of smooth wires, suture, or interfragmentary screws. Because comminuted fractures are among the more common fractures that, overall, undergo operative fixation, interfragmentary fixation of a free fragment with a 2.0- or 2.7-mm lag screw is helpful in turn- ing a three-part or four-part fracture into a two-part fracture amenable to optimal plate placement. Once the reduction is near-anatomic, the plate is applied on the superior aspect of the clavicle. During drilling and screw placement, we protect the underlying neurovascular structures by placement of a mallea- ble retractor inferior to the clavicle. Following provisional plate placement, fluoroscopic imaging and/or direct visualization is utilized to assess the plate position to ensure avoidance of far-medial or far-distal eccentric screw or plate position, which can increase the change of peri-implant fracture and hardware irritation. Compression techniques with eccentric drilling within the oblique holes of the plate are considered critical to an anatomic final reduction and optimization of healing rates. Final biplanar fluoroscopic views are used to confirm optimal screw length and establish a radiographic postoperative base- line for future assessment of healing of the fracture. The wound is then thoroughly irrigated and the periosteum closed. We

Author’s Preferred Treatment for Midshaft Clavicle Fractures (Algorithm 19-1)

Most pediatric and adolescent clavicle fractures are treated nonoperatively with immobilization for 6 weeks. Patients then undergo home or formal rehabilitation to restore range of motion and strength before resuming full activities. Oper- ative treatment is performed for open fractures, fractures at risk for skin necrosis, and fractures associated with neuro- logic or vascular injury (Fig. 19-7). For completely displaced

fractures with significant shortening clearly greater than 20 mm, or severely comminuted fractures, a shared deci- sion-making process is pursued with the patient and family. Based on research demonstrating exceedingly low nonunion rates and symptomatic malunion rates in adolescents, even in the face of significant shortening, nonoperative treatment is generally recommended. For such fractures in the dominant

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

Pediatric Midshaft Clavicle Fractures

< 13 years

ê 13 years

Any age

Completely displaced

Open fracture

Sling

I&D + ORIF

Severe skin tenting (necrosis or skin-at-risk)

Moderate/severe neurovascular compromise

ORIF

Nondisplaced, minimally/moderately angulated ( < 30°)

Partially displaced, severely angulated ( ê 30°)

Completely displaced, severe 2 shortening ( > 20 mm)

Completely displaced, Ä 20 mm 2 shortening

Sling

Sling

Sling vs. ORIF 1

Sling vs. ORIF 3

1 Shared decision-making approach, based on latest evidence, including slightly increased refracture risk; 95 may be relevant to contact athletes 2 Assessment of true shortening should be achieved with ‘cortex to corresponding cortex’ technique, rather than ‘end to end’ technique 87a 3 Shared decision-making approach, based on latest evidence, including a low risk of symptomatic malunion; may be relevant

Algorithm 19-1.  Authors’ preferred treatment for midshaft clavicle fractures.

arm of high-level baseball pitchers and other overhead or throwing athletes, consideration of the low risk of a poten- tial symptomatic malunion, which may alter the short-term biomechanics of the throwing motion, may be discussed.

When families favor operative treatment, plate fixation is recommended over intramedullary fixation, provided there is awareness of a relatively high ( ∼ 18%) rate of potential plate irritation and the need for secondary removal surgery.

Postoperative Care Whether ORIF or intramedullary fixation is performed, the patient is placed in a sling for 2 weeks, after which a wound check is performed, elbow and wrist range of motion recom- mended, and an emphasis on sling use when out of the house and at school. Patients are permitted to discontinue sling use while in the home from 2 to 6 weeks. At 6 weeks, a clinical examination is utilized to assess tenderness at the fracture site

and radiographs in two planes are obtained to assess bone heal- ing. If the examination and radiographs are consistent with healing, the sling is discontinued and the patient is encouraged to begin range of motion and strengthening. Provided there is adequate healing, noncontact athletes are permitted return to sports activities around 6 to 8 weeks postoperatively. For contact athletes, return to contact activities are permitted at 3 months, provided there is advanced bony bridging.

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SECTION TWO • Upper Extremity

A

B

C

D

Figure 19-7.  A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two. (Reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)

Potential Pitfalls and Preventive Measures

between the bone and surrounding neurovascular structures. Subsequently, retractors can be placed in this layer and direct visualization can be used during the drilling and screw place- ment process to avoid damaging the neurovascular structures. Maintenance of soft tissue attachments to comminuted or malrotated small fragments will aid the surgeon in the reduction process. Furthermore, if these fragments are completely devoid of soft tissue attachments, devitalization may cause bony union to be delayed or not occur. Wound complications can be prevented by utilizing the infe- rior skin incision rather than a direct approach to the clavicle. In addition, a meticulous layered closure at the end of the pro- cedure will permit the best cosmetic outcome while minimizing the chance of wound issues. Outcomes Despite the high incidence of pediatric clavicle fractures and the fact that the vast majority of these fractures are treated nonopera- tively, limited data exist regarding the outcomes of these injuries. Generally, union rates from 95% to 100% have been reported with nonoperative treatment. 54,78,150 A recent study of 185 ado- lescent clavicle fractures with a median age of 14.4 years, 38% of which were completely displaced, demonstrated only 1 case of

Midshaft Clavicle Fractures: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Neurovascular injury/ pneumothorax

• Utilize subperiosteal dissection • Place retractors inferiorly when drilling from superior to inferior direction • Maintain soft tissue attachments to comminuted or malrotated fragments • Maintain soft tissue attachments to comminuted or malrotated fragments • Anatomically reduce and stabilize segmental fractures

• Delayed union/ nonunion

• Malunion

The most dreaded intraoperative complication would be dam- age to a neurovascular structure or creation of a pneumothorax. Both of these exceedingly rare iatrogenic complications can be prevented by utilizing meticulous technique during the expo- sure of the fracture fragments and drilling/screw placement during the plate application. When exposing the fracture frag- ments, it is imperative to stay subperiosteal to create a layer

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

nonunion and 1 delayed union, with the majority demonstrating good-to-excellent functional outcomes measure scores. 123 In addition, several small series have recently emerged regarding operative treatment. Mehlman et al. performed a retrospective review of 24 children in China with a mean age of 12 years who underwent operative treatment of com- pletely displaced clavicle shaft fractures. In their series, there were no nonunions and no infections. Twenty-one of the 24 patients were able to return to unrestricted sports activity. Three complications were reported including two patients who had scar sensitivity and one patient who had a transient ulnar nerve neurapraxia. However, all patients underwent hardware removal on an elective basis, so the implications or sequellae of retained hardware could not be ascertained. 102 Namdari et al. also performed a retrospective review of 14 skeletally immature patients who underwent ORIF of displaced midshaft clavicle fractures. No nonunions occurred in the cohort, but 8 patients had numbness about the surgical site, and 4 patients underwent hardware removal. 107 Vander Have et al. retrospectively reviewed 43 fractures, 25 of which were treated nonoperatively and 17 were treated operatively. The authors reported that five symptomatic mal- unions occurred in the nonoperative group, four of which were treated with a corrective osteotomy. All complications in the operative group were related to prominence of the hardware. 150 A recent comparative study of over 650 clavicle fractures in patients 10 to 18 years old retrospectively reviewed at a large regional pediatric trauma center demonstrated a nonunion rate of 0.2% in fractures treated nonoperatively, and a symp- tomatic malunion rate of 2%. 60 The authors demonstrated a significantly higher complication rate (16.2%) in fractures treated operatively, compared with those treated nonoperatively (5.2%). The results of Li et al. corroborated these findings in a smaller, single-site study, in which there was a 43% major com- plication rate in 37 adolescents treated with plate fixation, the most common of which was secondary surgery for symptomatic plate removal. 88 Most nondisplaced fractures have union by 4 to 8 weeks of time, whereas displaced fractures may take longer, approx- imately 10 weeks. 150 A retrospective multicenter investigation of all nonunion cases reported at 9 pediatric hospitals over an 11-year-period was performed by an adolescent clavicle fracture study group. The investigation yielded only 25 total cases, all of which were successfully treated with surgery, which speaks to about the ability to effectively treat this exceedingly rare compli- cation, should it arise following nonoperative treatment. Thus, the vast majority of pediatric patients treated with a simple sling have excellent outcomes and are able to return to their activi- ties without limitations. A small percentage of patients treated nonoperatively with significant fracture displacement may have subjective complaints of pain with prolonged activity, easy fati- gability, axillary pain, or drooping shoulders with bony prom- inence. 150 However, Bae et al. evaluated a group of 16 patients with displaced ( > 2 cm) mid-diaphyseal clavicle fractures treated nonoperatively. All fractures united with no meaningful loss of shoulder motion or abduction–adduction strength by isoki- netic testing. The vast majority of patients had low DASH and pain Visual Analog Scores (VAS) that were very low, means of

4.9 and 1.6, respectively. Only one patient out of 16 required a corrective osteotomy. 8 The authors concluded that routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone in the face of shortening. A simi- lar study by Schulz et al. demonstrated no functional outcome deficits, when compared with the uninjured limb, in 16 adoles- cent patients with a minimum of 1 cm shortening and a mean of 14 mm shortening of a displaced clavicle fracture, when assessed more than 2 years following nonoperative treatment. Clearly, further investigation, including prospective compara- tive cohort studies, is required to better determine the risk fac- tors for possible pain or functional compromise in the minority of pediatric patients who develop nonunion, symptomatic mal- union, or other complications following clavicle shaft fractures, based on the two different treatment options.

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

Midshaft Clavicle Fractures: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Hardware prominence

• Malunion • Nonunion • Wound complications

Patients who have prominence of their hardware can be suc- cessfully treated by removal of their hardware. 102,107,150 If a patient initially treated by nonoperative measures develops a symptomatic malunion, corrective osteotomy has been shown to be successful in eliminating symptoms (Fig. 19-8). 150 In the Vander Have series, all patients who underwent corrective oste- otomy of their malunion went on to union and resolution of their symptoms. 150 As previously described in the above multi- center study of 25 cases, clavicle nonunion in adolescents can be successfully treated by subsequent ORIF, with most cases uti- lizing only local bone grafting from clavicle callus, as most cases are hypertrophic nonunions.

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO MIDSHAFT CLAVICLE FRACTURES

Most pediatric and adolescent midshaft clavicle fractures can be treated successfully with nonoperative measures. ORIF should be performed for the rare open fracture, fractures with skin at risk of necrosis, and fractures with nerve or vascular injury. Future prospective studies are underway to better determine the potential benefits and complications of operative fixation versus nonoperative treatment in adolescents.