Completely Displaced Midshaft Clavicle Fractures With Skin Tenting in Adolescents: Results From the FACTS Multicenter Prospective Cohort Study

Saturday, October 21, 2023

10:14 AM – 10:20 AM PST

Location: 4B

Presenting Author / Corresponding Author(s)

Benton E. Heyworth, MD

Attending Orthopedic Surgeon
Boston Children's Hospital
Boston, Massachusetts, United States

Disclosure(s): Allosource, Inc.: Grant or Research Support, or I am listed as the PI (Ongoing); Arthrex, Inc.: Consultant (Ongoing); Imagen, Inc.: Stock Shareholder (excluding mutual funds) (Ongoing); Kairos Surgical: Consultant (Ongoing); Vericel, Inc.: Grant or Research Support, or I am listed as the PI (Ongoing)

Co-Author(s)

JP

Joshua Pang, BA
SW

Samuel C. Willimon, MD
PW

Philip L. Wilson, MD
DB

Donald S. Bae, MD
MB

Michael T. Busch, MD
EE

Eric W. Edmonds, MD
HE

Henry B. Ellis, MD
MK

Mininder S. Kocher, MD
YL

Ying Li, MD

C.S. Mott Children's Hospital
JN

Jeffrey J. Nepple, MD
np

nirav pandya, MD
CP

Crystal A. Perkins, MD
AP

Andrew T. Pennock, MD
CS

Coleen S. Sabatini, MD
DS

David D. Spence, MD

Purpose: Skin tenting is a commonly applied "relative indication" for surgery for clavicle fractures. However, the true clinical impact of skin tenting on outcome has not been investigated in adolescents. This study compared the clinical and patient-reported outcomes (PROs) of nonoperatively and operatively treated clavicle fractures with skin tenting in adolescents.

Methods: Data from all 10 to 18-year-old patients with completely displaced midshaft clavicle fractures treated at 8 participating institutions from 2013-2022 was filtered to identify a cohort with either of 2 categories of skin tenting at initial presentation: (1) skin tenting or (2) skin-at-risk for necrosis (tented, white, hypovascular). Demographics, fracture characteristics, treatment, complications, return to sport (RTS) timing, and PROs (American Shoulder and Elbow Surgeons [ASES], QuickDASH [abbreviated version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire], Marx shoulder activity, EuroQol Visual Analog Scale [EQ-VAS]) were analyzed for patients with a 1-year follow-up minimum.

Results: 91 of 767 (12%) prospectively enrolled adolescents with completely displaced midshaft clavicle fractures presented with skin tenting. Study patients demonstrated older age, greater comminution, shortening and superior displacement than those without skin tenting. 60 patients (66%) underwent open reduction and internal fixation (ORIF), while 31 (34%) were treated nonoperatively (Non-Op). 3 patients (10%) converted to ORIF at a mean of 27 days (range, 6-62 days) post-injury due to increased symptoms or clinical concern by a provider. The Non-Op cohort was, on average, < 1 year younger than the ORIF cohort (Non-Op 14.5 years; ORIF 15.4 years, P = 0.02), but no differences in sex (P = 0.13), shortening (P = 0.10), superior displacement (P = 0.06), or comminution (P = 0.20) between cohorts. 64% provided PROs at 1 or 2 years post-treatment, with no differences in response rates, RTS, PROs, or complications between cohorts (RTS: P = 0.78, ASES: P = 0.07, QuickDASH: P = 0.06, Marx: P = 0.25, EQ-VAS: P = 0.65, complications: P = 0.83).

Conclusion: In this study, 12% of adolescents with completely displaced clavicle fractures presented with skin tenting, approximately one-third of whom were treated nonoperatively, demonstrating no differences in complications, PROs, or RTS, when compared to ORIF patients or the small percentage of patients (10%) that converted from nonoperative to ORIF treatment. Despite historical dogma derived from adult studies, current evidence suggests that skin tenting, if monitored appropriately in the early post-injury period, may not be appropriate as a surgical indicator for adolescent clavicle fractures, perhaps due to early fracture settling, enhanced healing capacity, and bony remodeling unique to this younger population, demonstrated in recent studies.

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