Summary

In this prospective multi-center study, the 12% of adolescent clavicle fracture patients with skin tenting, showed no differences in complications, PROs, or RTS with sling vs. ORIF, suggesting that early fracture settling, enhanced healing capacity, and bony remodeling in adolescents yield equivalent outcomes following non-operative treatment and close early observation.

Abstract

Introduction

Skin tenting is a commonly applied relative indication for operative treatment of clavicle fractures. However, the influence of this injury feature and optimal treatment for adolescent patients with skin tenting has been minimally investigated. This study therefore sought to evaluate the outcomes of non-operatively and operatively treated clavicle fractures associated with skin tenting in adolescents.

Methods

10-18 year-old patients with completely displaced mid-shaft clavicle fractures who received non-operative or operative treatment at eight participating institutions from 2013-2022 were screened for two categories of skin tenting at initial presentation: (1) ‘skin tenting’ or (2) ‘skin-at-risk for necrosis’ (tented, white, hypo-vascular). Demographics, fracture characteristics, and treatment were recorded, and patients were followed for a minimum of one year. Return to sport (RTS) time, validated patient-reported outcomes (PROs: ASES, Quick DASH, Marx shoulder activity, EQ-VAS), and complications were analyzed.

Results

92 of 768 (12%) prospectively enrolled adolescents with completely displaced midshaft clavicle fractures were reported with skin tenting (of either category) and demonstrated greater age, comminution, shortening, and superior displacement, when compared to patients without tenting (Table 1). Of those with tenting, 32 (35%) were treated non-operatively (Non-Op), while 60 (65%) underwent open reduction and internal fixation (ORIF) (Table 2). Three Non-Op patients (9%) converted to ORIF treatment at a mean of 20 days (range, 6-41 days) post-injury, due to increased symptoms or clinical concern. While Non-Op patients were, on average, less than one year younger than ORIF patients (Non-Op 14.5 years; ORIF 15.4 years, p=0.02), there were otherwise no significant differences between treatment cohort characteristics, including sex (p=0.13), shortening (p=0.10), superior displacement (p=0.06), and comminution (p=0.20). The majority of patients provided PROs at 1 or 2 years post-treatment (64%), with no differences in response rates, RTS, PROs, or complications between treatment cohorts (RTS: p=0.70, ASES: p=0.16, Quick DASH: p=0.07, Marx: p=0.26, EQ-VAS: p=0.68, complications: p=0.99).

Conclusion

In this prospective multi-center cohort study, 12% of adolescent clavicle fracture patients demonstrated skin tenting, but showed no differences in complications, PROs, or RTS, whether treated non-operatively or operatively. 9% of patients initially treated non-operatively converted to operative treatment, but had comparable outcomes to both overall treatment cohorts. These data suggest that early fracture settling, enhanced healing capacity, and bony remodeling potential unique to younger patients may allow for tolerance of skin tenting without adverse effects when non-operative treatment and close early observation are pursued.