Summary

In this large, prospective, geographically diverse multi-center study of adolescents with completely displaced clavicle fractures, in which a shared decision-making model was used for treatment decisions, females and Hispanic/Latino patients were less likely to receive operative treatment, warranting future study to insure equitable and appropriate care for this common adolescent injury.

Abstract

Introduction

The optimal management of adolescent clavicle fractures has been a topic of significant controversy over the last decade. Partially due to a lack of high-level evidence for this sub-population, treatment approaches have been highly reliant upon shared decision-making and individualized care. The purpose of the current study was to evaluate differences in treatment decisions made for cohorts of adolescents with completely displaced clavicle fractures sub-stratified based on sex, ethnic group, and race.

Methods

10-18 year old patients with mid-diaphyseal clavicle fractures treated from 2013-2022 with non-operative or operative care at one of eight participating institutions were screened and enrolled around time of injury. Centers were located in each of the 5 regions of the continental U.S to achieve geographic and population-based diversity. Treatment approaches were dictated by any musculoskeletal caregiver utilizing shared decision-making principles with the patient and parent(s)/guardian(s). Demographic data (age, sex, race, ethnicity) was recorded and compared between operative (Op) and non-operative (NonOp) cohorts. Patient-reported outcomes (PROs: ASES, Quick DASH), were collected and analyzed.

Results

764 patients (230 Op, 534 NonOp) were included (Table 1). A significantly higher rate of female patients underwent non-operative treatment (p=0.04). A significantly higher rate of Hispanic/Latino patients also underwent non-operative treatment (p=0.003). There were no significant differences between treatment groups based on race, as analyzed between White (p=0.15), Black (p=0.83), Asian/Pacific Islander (p=0.22) and Multiracial (p=1.00) patients. The majority of patients provided PROs at 1 or 2 years post-treatment (26.5 (+/-10.5) months). Regardless of treatment, male patients reported significantly higher PROs than female patients (p<0.001). Within subgroups, male (p=0.02) and non-Hispanic (p=0.02) NonOp patients reported significantly higher scores on both PROs than Op patients. Black NonOp patients reported significantly higher ASES scores than Black operative patients. Asian NonOp patients reported significantly higher QuickDASH scores than Asian operative patients. Other subgroups did not show significant differences in PROs.

Conclusion

In this large, prospective, geographically diverse multi-center cohort study of adolescent patients with completely displaced clavicle fractures, in which treatment decisions were made collaboratively, females and Hispanic/Latino patients were less likely to receive operative treatment. However, the degree to which these significant sex-based and ethnicity-based differences in treatment selection are influenced by caregiver biases vs. sub-population differences warrants future study to insure equitable and appropriate care for this common adolescent injury. Males reported higher PROs than females and four NonOp subgroups (male, non-Hispanic, Black, Asian) reported higher PROs than Op patients, which also warrants further investigation.