The clavicle known more commonly as the "collar bone" is the most commonly fractured bone in children. No surprise there since falling on the point of the shoulder is the way the bone gets broken in the first place and falling is what young children do so well! By the very number of children who fracture their clavicle (10 to 15 per cent of all fractures in children), physicians are sure to see this problem in their practice.
Dr. Michelle S. Caird from the Department of Orthopaedic Surgery at the University of Michigan in Ann Arbor presents some helpful guidelines when treating clavicular shaft fractures. First, she says don't consider them to be the same as fractures in adults.
That's because children have a very thick outer covering of bone around the clavicle limiting displacement (separation) of the broken bones. They also have excellent ability to heal and remodel bone compared with adults. Surgery is rarely needed. A sling or figure-8 brace may be all that's needed for a few weeks before easing back into full speed ahead.
Adults are more likely to experience malunion, nonunion, and the need for operative care. Adults are also more likely to be unhappy with the results of treatment -- especially if they can no longer move the arm normally or if they have pain and decreased strength.
Sometimes surgery is necessary for children. The indications for operative treatment include multiple trauma to the body (usually signaling a more severe clavicular fracture), other shoulder injuries, shortened fractures (the two ends of the bones telescope onto each other), or comminuted fractures (many bone pieces).
When surgery is needed, there isn't one operative method that works best for all children. The surgeon must consider the needs of the child and the concerns of the parents or family. The surgeon's own experience and expertise also play a role in decisions about treatment.
The most commonly used surgical techniques include intramedullary (IM) fixation. IM refers to the use of a metal plate with screws to hold the bones together or a long pin through the length of the bone to hold it together until healing takes place.
Many decisions go into the operative care of children. Age, size, growth status, location and type of clavicular fracture, and activity level are just a few factors. Then type of fixation, type of incision, and potential for complications must be considered.
The most worrisome complications include infection, nerve or blood vessel damage, pin migration, shortening of the bone, and failure to heal to name a few. Then there are the problems that can occur when trying to remove the hardware used for fixation. For example, the bone can break again when trying to pull the pins out.
Dr. Caird uses two case presentations to help illustrate her point that children with clavicular fractures should not be treated in the same way adults with similar fractures would be treated. Both cases were teenagers with high-energy injuries from an all terrain vehicle accident (first case) and collision during ice hockey in the second case. For both of these adolescents, the middle of the clavicle was broken and severely displaced (telescoped and shortened). Surgery was needed for both boys.
In summary, there's no cookie cutter recipe for the treatment of clavicular fractures in young children and teens. The fact that many of these patients are still growing plays a huge role in the decision about what kind of treatment is best.
Dr. Caird offers some insight into the treatment of clavicular shaft fractures in this population. Physicians do not have a clear set of guidelines to follow when planning treatment. The decision-making process must take into account many factors not present in adults.
Reference: Michelle S. Caird, MD. Clavicle Shaft Fractures: Are Children Little Adults? In Journal of Pediatric Orthopaedics. June 2012. Vol. 32. No. 1. Supplement. Pp. S1-S4.