Clavicle Fractures in Adolescents: Big Kids or Little Adults?

By Jeffrey J. Nepple

Summer brings great opportunities for children and adolescents to be active outdoors.  Whether it be sports camps or exploring outdoors on their bike, many sports injuries are most common during the summer.  Clavicle (also known as collarbone) fractures are among the most common type of fractures in adolescents.  Most commonly these injuries are the result of falling directly on the shoulder (picture flying over the front of your bike’s handlebars) or trying to catch yourself after a similar accident.  Breaking your clavicle generally causes fairly severe pain initially are often leads to a trip to an injury clinic or emergency room that day.  The clavicle is located very close to vital structures including the lung, large blood vessels, and important nerves.  Shortness of breath (difficulty and breathing) or numbness or weakness in your arm would be a reason to seek immediate medical care.

Top. An adolescent patient with a displaced left clavicle mid-shaft fracture. Bottom. Same patient treated non-surgically, 3 months after the initial injury. The white substance between the two ends of the clavicle is new bone formation, indicating healing of the fracture.

The treatment of clavicle fractures is currently a very controversial topic.  Traditionally, clavicle fractures have always been treated conservatively, or without surgery, except for rare circumstances.  Recent studies have questioned if everyone with a clavicle fracture really does as well as once thought.  Although rare in children and adolescents, 5-10% of displaced clavicle fractures fail to heal (nonunion) in adults.  Severe clavicle fractures often result in significant overlap (shortening) due to the muscular forces on the fracture fragments, and in some cases prominence on the overlying skin.  This overlap of fracture fragments does not change during healing (termed malunion) and is generally permanent since the clavicle (unlike many other bones) has limited remodeling potential.  While many patients have no problems with this shortening, recent studies demonstrate that when the overlap is greater than 2 cm in adults, issues including pain and shoulder weakness are commonly present.  Surgical treatment with a plate and screw generally restores the anatomy of the clavicle, but also has potential rare complications.  These landmarks studies have swung the pendulum towards treating clavicle fractures with surgery in adults.

Top. An adolescent patient with a displaced left mid-shaft clavicle fracture. Bottom. The same patient with a surgically reduced clavicle using a plate and screws.

 However, these studies fail to inform our decisions in children and adolescents.  Are children and adolescents just “little adults” and should be treated similarly?  Should we be more or less likely to treat them with surgery?  We really don’t know ….. yet.  Ongoing research may someday answer that question.  Washington University and Young Athlete Center providers are currently recruiting 10 to 18 year old patients with clavicle fractures to answer this question as part of a large multicenter study.  The study will track the outcomes of patients regardless which treatment the patient, family, and physician decide on.  It will likely take thousands of clavicle fractures to answer these questions and tell us what the ideal treatment of clavicle fractures is in the young athlete.  The good news is we are only a few years away!

Combating Dehydration and Heat Illness

by Terra Blatnik, MD

      August is usually the month where fall sports kick into high gear.  Kids return from summer vacation and are immediately thrown into very high intensity activities that often happen in very hot temperatures.  Everyone always dreads “two-a-day” practices!  These aren’t as common as they used to be but still occur in some sports.  The addition of high levels of activity and hot temperatures can put kids at risk for dehydration and heat illness.  It is important for parents and coaches to be aware of how to best keep young athletes hydrated and to recognize the signs of heat injury.

         Here are a few tips for hydration for all athletes, young and old:

•       Hydrate before, during, and after!  Getting in enough fluid during all of these times is key.  Athletes should begin hydrating several hours before practice or games.  They should have a water bottle handy or access to water during practices and drink every 15-20 minutes.  After practice or games, the goal is to replace all of the fluid that was lost.  A good rule of thumb is 20-24 oz for every pound lost. 
•       Water is the best choice if activity is less than 60 minutes—Activities under 60 minutes do not deplete electrolytes enough to require a sports drink like Gatorade.  If practice or games go beyond the one hour mark, you can use an electrolyte/carbohydrate containing drinks to replace these electrolytes and sugars. 
•        Rehydrate between activities—It is important that if kids are involved in two-a-days or have different sports on the same day that they need to be fully rehydrated before starting that second practice.  Starting a second practice without recovering from the first one can lead to further dehydration, poor performance, cramping, etc.

       The first few days of practice in the heat are usually the hardest and put your athlete most at risk for heat illness (i.e. heat related cramps, heat exhaustion, and heat stroke).  It is best to gradually increase activity in hot temperatures so that the body can get adapted.  Proper hydration is important and it can also be helpful for kids to wear loose fitting, light colored, and moisture wicking clothing.

 

       Most importantly, coaches, parents, and athletes need to understand and recognize the early signs of heat illness so that they can treat these young athletes appropriately.

Common signs of heat illness include:

·       Headaches

·       Nausea/abdominal pain

·       Cramping (calf muscles are the most common)

·       Dry or sticky mouthy

·       Fatigue

        If athletes are experiencing these symptoms during practice or games (or more severe symptoms like confusion), they should be pulled off the field, encouraged to start drinking fluids, and put into a shady area.  Further action (like calling 911) should be considered if symptoms worsen or if the athlete isn’t able to drink on her own. 

      The most important thing you can do is encourage lots of fluids and closely monitor all practices and games when the temperatures are high to ensure that your young athlete stays hydrated and healthy!