VARIATION IN TREATMENT APPROACHES TO ADOLESCENT MIDSHAFT CLAVICLE FRACTURES IN PEDIATRIC VERSUS ADULT HOSPITALS

Abstract

Background: Optimal treatment of midshaft clavicle fractures in adolescents remains a topic of controversy. While adolescent midshaft clavicle fractures have historically been treated nonoperatively, recent randomized controlled trials of displaced midshaft clavicle fractures in the adult literature have raised the question of decreased symptomatic nonunion and malunion and improved functional outcomes with surgery. Consequently, the rates of surgical treatment of adolescent midshaft clavicle fractures, particularly in the older adolescent age group, has increased, despite a paucity of high-level evidence to justify this trend. Hypothesis/Purpose: To identify differences in treatment approach for isolated, displaced midshaft clavicle fractures in ‘older’ adolescent patients at adult versus pediatric hospitals. The secondary objective was to identify factors associated with surgery. Methods: Adolescents aged 15 to 18 years with isolated, displaced midshaft clavicle fractures treated at one of two adult tertiary care hospitals or one pediatric tertiary care hospital. Exclusion criteria included open fractures, skin tenting, nondisplaced fractures, medial third or distal third clavicle fractures, non-isolated injuries, and delay from injury to presentation of more than 2 weeks. Bivariate analysis and multivariable logistic regression analysis were used to identify factors associated with surgical treatment. Results: Two hundred and fourteen patients (median age: 16 years, mean BMI: 22.5, 85% male) were included. The cohort from the pediatric hospital was significantly younger, had lower BMI, had fewer comminuted fractures, and a higher proportion of angulated fractures (Table 1). One hundred six (50%) patients underwent surgical treatment. Bivariate analysis showed that older age (p = 0.004), higher BMI (p = 0.002), dominant upper extremity injury (p = 0.001), and treatment at an adult hospital (p < 0.0001) were associated with surgery. The fracture characteristics of comminution (p < 0.0001), greater displacement (p < 0.0001), and greater shortening (p < 0.0001) were associated with surgery. Multivariable logistic regression analysis showed superior-inferior fracture displacement (OR 1.13, 95% CI 1.06 to 1.20), dominant upper extremity injury (OR 2.60, 95% CI 1.19 to 5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28 to 12.2) to be independently associated with surgery. Conclusions: After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high quality prospective outcomes studies.