Paper 61: Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

OBJECTIVES: The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes. METHODS: A retrospective review was performed of all clavicle fractures extending to the level of the corococlavicular ligaments or more lateral, which were treated operatively at a single tertiary-care pediatric hospital between the years of 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic fracture characteristics, surgical techniques, time to radiographic healing, return to sports, and complications were analyzed. RESULTS: Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), though type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns were also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of implant removal was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Total complication rate, including unplanned removal of implant, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014). CONCLUSIONS: Posteriorly displaced fractures comprised the vast majority of surgically-treated distal clavicle fractures in pediatric and adolescent athletes. When chosen in the appropriate patient, based on age and fracture pattern, suture-only constructs can lead to similar time to radiographic healing and faster return to sports compared to plate-based constructs, with significantly reduced need for removal of hardware. These data provide a foundation for future comparative research to further elucidate precise surgical indications and optimal treatment approaches in this population.