The main finding of this single-institution retrospective study was that the operative treatment of clavicle fractures became more common in children during the 12 years of study period (2008–2019) (Fig. 2). The children were treated non-operatively at the beginning of the study, but the incidence of surgical treatment had increased to 10.8 per every 100,000 children at risk by the end of the study period. Considering that the incidence of clavicle fractures in children has been reported at 29 to 100 per 100,000, the incidence of surgery (10.8%) is important—meaning that 10.8 to 37% of all pediatric clavicle fractures are operatively treated currently.
Our study confirms that during the last decade (2008–2019), a higher proportion of the patients was treated operatively as opposed to non-operative care. This finding is in steady accordance with the recent reports of adults’ clavicle fractures—the incidence of surgery increased from 1.3 to 10.8 per 100,000 persons in adults from 1987 to 2010 [13]. Huttunen et al. reported a 700% increase in surgical procedures and a 70% increase in the incidence of adults’ clavicle fractures in Sweden over a 10-year period (2001–2012) [14]. Children were not included in their analyses. In Virginia and Boston (USA), adolescent clavicle fractures were increasingly treated with open reduction and internal fixation from 1999 to 2011 [38]. Our findings of an increasing incidence of surgery in pediatric clavicle fractures support not only our hypothesis but also the respective recent literature on adult patients.
Our finding of the increasing incidence of surgical treatment of pediatric clavicle fractures is supported by the fact that adult-type surgical decision making has, in general, slowly but surely been applied to children [22]. Carry et al. asked pediatric orthopedists to evaluate whether the recent adult literature had influenced their clinical decision making in treating clavicle fractures in children. Half of the respondents (48.6%) reported the changed practice in treating their adolescent patients due to recent interest in the clavicle surgery of adults [6]. From this point of view, the increase in the surgical fixation of childhood clavicle fractures during the recent years in this study area was not surprising.
Increased interest in the surgical treatment of clavicle midshaft fractures has been supported by the idea that the results of non-operative treatment may not be as complication-free as previously reported [24]. Clavicle malunion impairs the shoulder girdle, and great shortening may not remodel [1, 11]. The clavicle will remain shorter than on the ipsilateral side, resulting in potential long-term morbidity. It has been suggested that the clavicle achieves most of its length at relatively early childhood, meaning that injuries later in childhood have less remodeling potential [22]. The risk of nonunion may also support surgical fixation albeit the risk is extremely low in children [12]. However, the clavicle’s medial growth plate begins to ossify no earlier than at 18 years and closes at 22–25 years of age [7]. For this reason, the clavicle has remodeling potential up to the mid-20s, which supports conservative treatment despite displacement.
In spite of the traditional preference for non-operative care and very limited or lacking evidence on the superiority of surgical stabilization, there is an increasing number of reports about the positive experience of the surgical stabilization of pediatric clavicles as well. Vander Have et al. reported the positive results of operative treatment in children as compared with non-operative treatment—time to radiographic healing was shorter, and return to the preinjury level of physical activities was faster after operative treatment. Furthermore, five out of 25 who were treated non-operatively suffered from symptomatic malunion, with a mean shortening of 26 mm of the clavicle. In addition, four required secondary corrective operation. The authors stated that plate fixation can restore clavicle anatomy and length, which also supports operative treatment in immature skeletons [35]. Positive results of ORIF surgery in clavicle fractures were reported by Kubiak and Slongo (Bern, Switzerland) as well. Among their 939 patients who presented with a clavicle fracture, 15 children were operatively treated, and all showed bone healing with few minor complications [16]. Namdari reported a series of 14 pediatric patients who were operated for clavicle fracture; all united and showed good recovery with a quick-DASH score of mean 7.0 points [24]. In a single-hospital series of 24 operatively treated clavicle fractures, postoperative satisfaction was 100%, and all united [22]. Hosalkar et al. reported 19 adolescent patients who were all treated by surgical fixation and were satisfied with their decision to undergo surgical care. Full return to sports was achieved in 14 weeks postoperatively (range 12 to 17 weeks) [10]. In contrast, Randsborg et al. evaluated the patient-reported outcomes after the non-operative treatment of 122 patients with a previous clavicle fracture. An Oxford Shoulder score questionnaire, quick-DASH, and VAS overall satisfaction were used. The shortening of the clavicle was associated with a worse Oxford Shoulder score and lower cosmetic and overall satisfaction [29]. During our study period, the portion of a > 15 mm shortening of the fractures increased from 0 to 27.6%. Since shortening is associated with lower overall satisfaction, it may be a possible explanatory factor for the increased rate of surgery, too.
Not only plating but also intramedullary nailing has been reported as a technical option in adolescent clavicle fractures. Frye et al. treated 17 patients with an intramedullary nail, and all fractures showed full bone healing [8]. The rate of major complications after plate fixation has been reported to be low [16, 17]. However, despite increasing reports of good outcomes after clavicle fixation, there is still a lack of level-A research [4]. Furthermore, the published studies of operative treatment in children are based on small groups, and most of them have no control group. Operatively treated children would probably have no or few symptoms if treated non-operatively because of the good prognosis of nonoperative treatment. With all this in mind, it is reasonable that the majority of clinicians treating clavicle fractures in children and adolescents still prefer non-operative care [6, 20]. There is demand for a randomized controlled trial to determine which patients benefit from operative treatment.
We found in this study that there was a 3.6-fold increase in sports-related clavicle shaft fractures from 2008 to 2019. Contact sports such as ice hockey and particular winter sports (alpine skiing and snowboarding) were among the most common recreational activities in the study cases. This is in agreement with the previous understanding. Clavicle fractures in children are known to be associated with high-energy sports injuries: up to half of all operatively treated fractures were sports related among 882 children at Boston Children’s Hospital [34]. In general, children’s participation in organized sports has become more popular in the study country, which can partly explain our finding [25]. This appears reasonable given that active junior athletes and their families are likely to appreciate the shortest possible time to preinjury sports level, and surgical fixation may have therefore been their primary choice.
We also found that the mean age of the patients was higher at the end of the study period. Due to our low numbers of patients, we cannot address this as a fact. The finding of the changed average age needs to be confirmed in another study setting in the future. However, higher age is in line with both the higher need for surgical care and the higher participation in particular sports as it is usually older children and adolescents who are more active in frequent goal-orientated, organized training [25]. It seems that both, a change in recreational activity toward organized sports, such as downhill skiing and ice hockey, and the associated higher age of children, have contributed to an increase in the surgical care of pediatric clavicle fractures. As a conclusion, more preventive interventions should be focused on the coaching of organized junior sports, especially those involving participants > 9–10 years of age.
This is a single-institution retrospective study of surgical care performed in a geographic catchment area with a satisfactorily long study period. As opposed to many epidemiological studies of surgical care that are based on single hospital discharge registries without more detailed information about the individual patients, we reviewed the injury and treatment characteristics of all the enrolled patients. The background factors were available for all, and the patients living outside the catchment area were excluded. Radiographs were available for all, and we were able to exclude with certainty all others than middle-third-shaft fractures. In contrast, epidemiological studies that are based on the ICD code S42.0 from discharge registries cannot distinguish middle-third-shaft fractures from medial or lateral clavicle fractures, and their diagnoses cannot be confirmed. The enrollment of the study material was taken to be inclusive. The respective pediatric population at risk was accurately determined yearly by Statistics Finland. The incidence of surgical treatment was based on the entire children’s population at risk in the area, and the epidemiological findings are reliable. We also determined the rate of operative vs. non-operative treatment yearly, but we are aware that this rate is prone to remarkable change due to the small numbers of cases annually. However, the rate of operatively vs. non-operatively treated cases increased significantly, which is in line with the increase in the incidence of surgical treatment.
The study is subject to some criticism. Despite the relatively large catchment area with approximately 55,500 children, the yearly numbers of operatively treated patients were small in the beginning of the study period. This is reasonable, taking into account the previously unwavering trust in the non-operative treatment of pediatric clavicle fractures [32]. For this reason, the analyses of the characteristics and potential risk factors were performed in three-year periods to attain a satisfactory number of patients per group. We are aware that some isolated cases may have been treated outside the study area, such as during their travels or in private hospitals, but their small numbers would not have affected the conclusion. It is possible that our records are not perfect and that coding errors may have occurred, causing small numbers of cases to be missing. As a limitation, we were not aware of the fundamental reasons why the individual study cases were treated non-operatively or operatively; while we used a retrospective study setting, these primary circumstances were not clear. We agree that the decision making regarding treatment protocol may have been dependent on the preferences of the individual physicians and the operation room resources available that time. Being a single-institution study, these findings cannot be generalized globally. However, this epidemiological approach describes recent authentic changes in the treatment of childhood clavicle fractures in a sufficiently large pediatric population in a setting with a possibility for round-the-clock operational treatment, and our findings align with some earlier epidemiological studies in children and adolescents [34, 38]. A further limitation of the research is the lack of long-term follow-up, which is warranted in future studies as long-term rather than short-term outcomes are more important in evaluating the superiority of any treatment procedure in children’s traumatology [31]. Nonunion, as a short-term complication, is extremely rare, but shortening and malunion may have long-term disadvantageous effects which are not currently widely known. As a limitation, we did not examine our patients postoperatively or have them fill out patient reported outcome measures (PROMs), and therefore we cannot determine if the operative treatment is better than the non-operative. Due to a limited number of operatively treated cases, no subgroup analyses between the different fixation methods were performed in this study.
