POSNA 2019 Annual Meeting: Best Clinical Paper Two-Year Functional Outcomes of Operative vs. Non-Operative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results from a Prospective, Multicenter, Level 2 Study

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Benton E. Heyworth, MD
Andrew T. Pennock, MD
Ying Li, MD
Leslie A. Kalish, ScD
Brittany Dragonetti, BA
Henry B. Ellis, MD
Jeffrey Nepple, MD
S. Clifton Willimon, MD
David Spence, MD
Nirav K. Pandya, MD
Mininder S. Kocher, MD, MPH
Eric W. Edmonds, MD
Philip Wilson, MD
Michael Busch, MD
Coleen Sabatini, MD
Donald S. Bae, MD


Purpose: To investigate the two-year functional outcomes and complications following operative versus non-operative treatment of completely displaced midshaft clavicle fractures in adolescents.

Methods:  All patients 10-18 years old treated for a midshaft clavicle fracture between August, 2013 and August, 2018 at one of 8 geographically diverse, high-volume, tertiary-care pediatric centers were enrolled, with independent treatment decisions determined by individual providers. The sub-population of patients with completely displaced fractures was prospectively followed for over 2 years. Clinical course, complications, validated patient-reported outcome measures (PROs), quality of life metrics, and satisfaction scores were analyzed. To address the ceiling effect of the PRO/satisfaction data following clavicle injuries, a priori thresholds for ‘suboptimal’ scores were established (ASES scores <90, QuickDASH scores >10, EQ-5D <0.80). According to ‘intention to treat’ statistical principles, one post-operative complication (and a subsequent secondary operation) was analyzed within the non-operative cohort, given that the patient represented a ‘crossover’ from the non-operative to the operative treatment group.

Results: Of the 909 patients enrolled in the prospective study, 417 patients (45.9%) demonstrated completely displaced fractures and maintained enrollment over the study period, 277 (66%) of whom had reached two year follow up, and 151 of whom provided adequate PRO data, representing a 55% response rate. Of these patients, 55 (36%) underwent operative treatment, while 96 (64%) were treated non-operatively. Those treated surgically showed no difference in gender distribution (76% males,p=0.43), athletic participation (p=0.76), or fracture pattern (p=0.18), but were older (mean age 15.3 vs. 13.5 years, p<0.001) and had greater shortening (p<0.001) than those treated non-operatively. Within the subset with adequate complication data, listed in Table 1, complications were less common in non-surgical than surgical patients (p=0.0003), but this difference did not reach significance when sensory deficits were excluded (p=0.17). There was no difference in secondary surgeries (p=0.43). While greater percentages of operative than non-operative patients reported suboptimal PRO/satisfaction scores (ASES: 15% vs. 5%, QuickDASH 11% vs. 5%, satisfaction 11% vs. 5%), these differences did not reach significance (p=0.07, 0.20, 0.06, respectively).

Conclusion:  At eight large pediatric centers with many surgeons making independent treatment decisions, non-operative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes.

Significance:  These data establish a comprehensive functional assessment of adolescents treated for clavicle fractures, which represents the epidemiological sub-population most affected by this condition. Unlike several adult studies demonstrating superiority in operative treatment, this adolescent study demonstrates equivalent function and fewer complications associated with non-operative treatment.

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