Adolescent mid-shaft clavicular fracture displacement does not predict nonunion or inferior functional outcome at long-term follow-up.

AIMS: The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture. METHODS: We retrospectively reviewed a consecutive series of 677 adolescent fractures in 671 patients presenting to our region (age 13 to 17 years) over a ten-year period (2009 to 2019). Long-term patient-reported outcomes (abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and EuroQol five-dimension three-level (EQ-5D-3L) quality of life score) were undertaken at a mean of 6.4 years (1.2 to 11.3) following injury in severely displaced mid-shaft fractures (Edinburgh 2B) and angulated mid-shaft fractures (Edinburgh 2A2) at a minimum of one year post-injury. The median patient age was 14.8 years (interquartile range (IQR) 14.0 to 15.7) and 89% were male (n = 594/671). RESULTS: The majority of fractures were mid-shaft (n = 606) with angulation (Edinburgh 2A2, n = 241/606, 39.8%) or displacement (Edinburgh 2B1/2, n = 263/606, 43.4%). Only 7% of the displaced mid-shaft fractures underwent acute fixation (n = 18/263). The incidence of refracture over ten years following nonoperative management of mid-shaft fractures was 3.2% (n = 19/588) and all united without surgery. Fracture type, severity of angulation, or displacement were not associated with refracture. One nonunion occurred following nonoperative management in a displaced mid-shaft fracture (0.4%, n = 1/245). Of the angulated fractures, 61 had angulation > 30°, of which 68.9% (n = 42/61) completed outcome scores with a median QuickDASH of 0.0 (IQR 0.0 to 0.6), EQ-5D-3L 1.0 (1.0 to 1.0), and 98% satisfaction with shoulder function. For the displaced fractures, 127 had displacement beyond one cortical width of bone for which completed outcome scores were provided in 72.4% (n = 92/127). Of these 15 had undergone acute fixation. Following nonoperative treatment, the median QuickDASH was 0.0 (IQR 0.0 to 2.3), EQ-5D-3L 1.0 (1.0 to 1.0), and satisfaction with shoulder function was 95%. There were no significant differences in the patients' demography or functional outcomes between operative and nonoperative treatments. CONCLUSION: Nonoperative management of adolescent mid-shaft clavicle fractures results in excellent functional outcomes at long-term follow-up. Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. Cite this article: Bone Joint J 2021;103-B(5):951-957.

Rates of Displacement and Patient-Reported Outcomes Following Conservative Treatment of Minimally Displaced Lisfranc Injury.

BACKGROUND: While surgery is indicated in Lisfranc fracture-dislocations, the natural history and optimal management of minimally displaced injures are unclear. The aim of this study was to define the rate of subsequent displacement and to determine the clinical outcome after conservative treatment of minimally displaced Lisfranc injuries. METHODS: Over a 5-year period (2011-2016), 26 consecutive patients with minimally displaced Lisfranc injuries presenting to a single university teaching hospital were identified retrospectively using hospital electronic records. Patient demographics, injury mechanism, and radiological outcomes were recorded. Patient-reported outcome scores (PROMS) were collated at least 1 year postinjury and included the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). RESULTS: The rate of displacement was 54% (14/26). The median time to displacement was 18 days (range, 2-141 days). Forty-six percent (12/26) of the Lisfranc injuries remained minimally displaced after 12 weeks of conservative treatment. Initial weightbearing status was not associated with the risk of subsequent displacement (P = .9). At a mean follow-up of 54 months, PROMS were comparable between patients whose injury remained minimally displaced and those that required surgery for further displacement, despite the delay to surgery (AOFAS 78.0 vs 75.9, MOXFQ 24.8 vs 26.3, P > .1). CONCLUSION: There was a high rate of displacement after initial conservative management of the minimally displaced Lisfranc injuries. Subsequent surgical management of displaced injuries resulted in outcomes comparable to those that remained minimally displaced. LEVEL OF EVIDENCE: Level III, retrospective comparative series.