[Treatment of clavicle fractures in children and adolescents : Conservative and surgical treatment options with a focus on the figure-of-eight style brace and intrafocal intramedullary nail osteosynthesis].

OBJECTIVE

Conservative treatment using a backpack bandage (RSV) for clavicle fractures in children and adolescents serves to restore anatomy and function. The technique used in adult patients with elastic stable intramedullary nailing (ESIN) from the medial end of the clavicle involves the risk of growth disturbance of the growth plate, which has been open for a very long time; in addition, a cosmetically disturbing scar usually forms there. Treatment with an intrafocal intramedullary nailless osteosynthesis allows length and axis to be restored within the age-specific correction limits using a soft tissue-sparing surgical method in adolescents with, among other things, severe shortening of the fracture. Sufficient stability ensures early functional follow-up treatment without weight-bearing.

INDICATIONS

Conservative therapy using a figure-of-eight style brace or an arm sling can be applied to nearly all clavicle fractures in children and adolescents. Displaced and significantly shortened fractures can be addressed with intramedullary nail osteosynthesis.

CONTRAINDICATIONS

Open injuries at the site of the figure-of-eight style brace application should be immobilized with the Gilchrist bandage. Multifragmentary or open fractures are not suitable for intramedullary nail osteosynthesis.

SURGICAL TECHNIQUE

The figure-of-eight style brace is applied in a figure-eight fashion around both shoulders or clavicles. A loop or knot is tied between the shoulder blades. For intrafocal intramedullary nailless osteosynthesis, an incision is made approximately 3-4 cm along the course of the clavicle directly above the fracture. After blunt dissection, the nail is first extracted laterally through the clavicle dorsally through the cortical bone. Here, the lateral clavicle may need to be reamed intramedullary and dorsolaterally through the opposite cortex using a 2.5-3.2 mm drill bit to facilitate insertion of the ESIN. A stab incision is made over the palpable end of the nail and the nail is removed. The ESIN is then grasped with the Jacob's reamer and advanced medially after reduction of the fracture. It may be useful to reduce the curvature at the tip of the ESIN. This is done as long as simple advancement is possible and until the clavicle stabilizes. The lateral end of the nail is pinched off subcutaneously and the wound is closed in several layers on all sides.

POSTOPERATIVE MANAGEMENT

Conservative treatment involves immobilization for 2-3 weeks, depending on age, until the patient is free of symptoms. Depending on age, the patient should refrain from sport for 4-8 weeks. The aim of osteosynthesis is early functional follow-up treatment without weight bearing. Rest is recommended for 8 weeks, which only applies to adolescents. Metal should be removed early after consolidation around the 8th-12th week.

RESULTS

Our own patients and the literature show excellent results for conservative treatment in children and adolescents. Clearly dislocated and, above all, shortened fractures can be very effectively reduced and treated using the technique described. The results show reconstruction of the length of the clavicle with very good functional results in adolescents using the described osteosynthesis technique. A flat learning curve was observed with regard to the remaining nail length, so that premature perforation occurred in a total of 4 cases at two centers. These cases healed without sequelae after premature metal removal (3 times) or reshortening. Pseudarthrosis, vascular/nerve damage or infections were not observed in either conservative or surgical procedures. Secondary dislocation of the fracture did not occur.