What are the surgical indications for a mid shaft clavicular fracture in a 15-year-old male?

Surgical Indications for Mid-Shaft Clavicular Fracture in a 15-Year-Old Male

In adolescent patients with displaced midshaft clavicle fractures, surgical treatment may offer no benefit compared with nonsurgical treatment, as it is associated with similar union rates and substantial revision surgery rates for implant removal. 1

Nonsurgical vs. Surgical Management in Adolescents

• For adolescents (18 years and younger), nonsurgical management is generally preferred as the primary treatment approach for midshaft clavicular fractures 1
• Surgical treatment in adolescents has not demonstrated significant benefits over conservative management and is associated with high rates of subsequent surgeries for hardware removal 1
• The American Academy of Orthopaedic Surgeons (AAOS) recommends a sling as the preferred immobilization method for most acute clavicle fractures, rather than a figure-of-eight brace 2

Specific Indications for Surgical Intervention

Despite the general preference for nonsurgical management in adolescents, surgery may be considered in the following circumstances:

• Open fractures requiring debridement and stabilization 2
• Fractures with neurovascular compromise 3
• Polytrauma patients where early mobilization is critical 1
• Severely displaced fractures with significant shortening (>1.5cm) that may affect functional outcomes 2
• Fractures with skin tenting or threat of skin compromise 3

Radiographic Assessment

• Upright radiographs are recommended for proper assessment as they better demonstrate the true degree of displacement compared to supine radiographs 2
• Complete displacement and comminution should be carefully evaluated as potential risk factors for poor outcomes with nonsurgical management 4

Surgical Options When Indicated

If surgery is deemed necessary based on the above indications:

• Both plate fixation and intramedullary nailing provide equivalent long-term clinical outcomes with similar complication rates 1
• Plate fixation may be more beneficial in the presence of fracture comminution 1
• Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal or deformation 2
• Anterior inferior plating may lead to lower implant removal rates compared with superior plating 1

Important Considerations and Potential Complications

• Adolescents have greater healing potential than adults, which supports conservative management in most cases 3
• Surgical complications in adolescents include a high rate of hardware removal procedures 1
• The risk of nonunion is generally lower in adolescents compared to adults 3
• Long-term functional outcomes are typically excellent with nonsurgical management in the adolescent population 1

Decision-Making Algorithm

1. Assess fracture characteristics (displacement, comminution, shortening)
2. Evaluate for absolute surgical indications (open fracture, neurovascular compromise)
3. Consider patient factors (age, activity level, skeletal maturity)
4. If no absolute indications exist, proceed with nonsurgical management as first-line treatment 1, 2
5. Monitor healing progress with follow-up radiographs
6. Consider delayed surgical intervention only if complications develop (nonunion, severe malunion with functional deficit) 4