Friday, August 26, 2016

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!

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