日 小整会誌 (J Jpn Ped Orthop Ass) 1 8 (2) : 361-364. 2009

Is Follow-up Essential For Pediatric Clavicular Fractures?
Dr. Saurabh Singh， M. S. ( Ortho) ， M. Ch ( Ortho) *Department of Orthopedics. Institute of Medical Sciences. Banaras Hi口du Univ巴rsity. Varanasi. India

Dr. Devdatt N. Neogi， M. S. ( Ortho ) ， M. Ch ( Ortho)
D巴partment of Orthopedics. AII India Institute of Medical Sciences. New Delhi. India

Dr. Chethan N.， M. S. ( Ortho ) ， DNB ( Ortho )Department of Orthopedics. AII India Institute of Medical Sciences. New Delhi. India

Abstract : [Purposel To assess whether simple manag巴ment options like cuff and collar sling aree丘巴ctive in paediatric clavicle fractures and to determine whether r巴gular follow up is required[Methodsl A study of 54 consecutive fractures of the clavicle in children less than 10 years of age
was conducted at Institute of Medical Sciences (IMS) . Banaras Hindu University (BHU) ， Varanasi
and All India Institute of Medical Sciences (AIIMS) ， New Delhi， India b巴tween December 2005 and]un巴 2008
[Resultsl Ther巴 waおs m叫巴 predomina
union r印at民巴 waおs a舵chiev巴d wi比th cons巴rvative treatment wi比th no significant c∞omplicatio叩ns. How巴ve引r伺 avisible d 巴fおorml比ty P巴引rs剖1St民ed in up tωo 80% of the children. The compliance with treatment protocol
was lesser in th巴 younger age group and better with older children.
[ Conclusionl Simple methods like cu妊 & collar sling is sufficient for the management of clavicle
fractures in children. Immobilization for mor巴 than 2 weeks is not nec巴ssary and regular follow up
is not essential.

Introductionof these fractures occur in the middle third andare mostly as a result of low velocity injuries.

Pediatric inj uries are always a cha11enge andContrary to earlier beliefs， a11 pediatric clavicle

unique because of the growing musc uloskeletal
system3) . Also these injuries cause much m巴ntal

fractures including those of the lateral third canagony to the par巴nts. The clinical examination ofshould be explored only if the child is more thanthese injuries is difficult due to th巴 apprehension

10 years old.

be managed cons巴rvatively and surgical optionof the child and the poor tolerance level to pain by

We have tried to analyze the requirement ofchildren. Although pediatric shoulder trauma issurgical management and the importance ofuncommon， the clavicle is the most commonly

follow up on the outcomes with respect tofractured bone in the pediatric age groupl ) . Most

fracture un ion and functional outcome of the•Key words : pediatric fractures， clavicle fracture， cuff and collar sling immobilization: Corresponding Author
Dr. Saurabh Singh， Departm巴nt of Orthopedics， Institute of Medical Sciences. Banaras Hindu University. Varanasi. India
Tel : + 91-9838759998
E-mail : drsaurabhsinh@gmail.com

361

children. Also the modes of injury were analyzed
and the compliance to treatment was tak巴n mto
consideration.

Materials & Methods
Between December 2005 and J une. 2008. 86
children of age less than 10 years with an acutefracture of the clavicle were managed in Depart­

mography scans were done in any patient.
The protocol followed for the treatment was asfollows :i . In children < 4 years with undisplaced
fractures-Cuff and collar slingii . In children < 4 years with displaced frac­tures-Strapping with cu丘 and collar slingiü .

In childr巴n >4 years-Figure of 8 bandage

ment of Orthopaedics at IMS. BHU. Varanasi andAll patients underwent a standard radiograph

All India Institute of Medical Sciences. New Delhi.

of clavicle and physical 巴xamination at one. 出r巴巴，India.

six. and twelve weeks. The final follow-up

The indication for inclusion in the study wasevaluation consisted of determination of theisolated clavicular fractures in children with anradiological union and clinical union as well as aage less than or equal to 10 years. 86 children met

physical examination 出at included shoulder

this criterion and were evaluated and managed

movements目 In addition. the parents completed aaccording to 出e protocols laid down. Of the 86

subj ective questionnair巴 to rate the outcome as

children who met the criteria. thirty-two wereexcellent. good. mod巴rate. or poor. A radiologicalnot evaluated because of inadequate follow-up.

assessment was also done at the 白nal follow-up

Thus. 54 patients were available for assessment.

visit to assess the union and any residual

37 of the patien ts were male and 17 were female.

deformity.

The mean age was 2 . 8 y巴ars ( range. new born to10 years) . All fractures were classified according
to the Allman's classification system. 49 childr巴n
had fracture of middle third of clavicle. 3 children
had fractur巴 of lateral third and 2 children had
medial third fracture of the clavicle.

The average duration of follow-up was six
months (range. one to ten months)

Results
Th巴 union rate achieved was 100 % with anaverage time for clinical union of 2 . 5 weeks.

The mechanism of injury was mostly hous巴­

There was male pr巴dominance with 68% ofhold injuries in children aged less than 4 years

childr巴n b巴ing males. The age distribution

with fall from b巴d being most common in children

show巴d an increased incidenc巴 in children aged

aged less than 2 years.. In older children of moreless than 4 years with th巴 distribution being 1 5.

than 4 years the predominant mechanism of

19. 1 1 and 9 in age groups of 0-2 years. 2-4 years.

injury was recreational injuri巴s. Th巴se wer巴 low

4-7 years and 7-10 years respectively

velocity injuries in most cases ( 53 childr巴n) andhad no associated injuries.
A standard anteroposterior radiograph of theMost fractures i. e. 92 % occurred at middle
third with th巴 incidence of fractur巴s of lateral andm巴dial third being 5 % and 3% respectively.

clavicle and shoulder was made for all patientsTh巴 time for clinical union ranged from 1 week

and th巴 fractures were grouped according to th巴in children aged less than 1 year to 3 weeks inradiographic classification of Allman. No otherchildr巴n aged 1 0 years with an average of 2 . 5

additional radiographic views or computed to・w巴eks. The radiological union was seen about 1 to362

Fig. l .

a : Malunion o f f1羽ture clavicle middle
thirdb : Clinically visible deformityc : Full functional rang巴 of movements_2 weeks later with an average time for radiologi­tion to rule out child abuse， as abuse cannot

cal union of 3 . 7 weeks

usua11y be determined by fracture type alone 101

The average duration of immobilization was 2

Road traffic injuries or high velocity injuries

weeks with a rang巴 of 5 days to 3 weeks. Thereusually lead to polytrauma and compound

was an unexpect巴dly high rat巴 of s巴lf-discontin u

fracturesofMost of th巴 fractures (92 % ) occurred in thechildren aged less than 3 years discontinuing

middle third of the clavicle， which correlates withother studies l13lSI .

ation of tr巴atment with more than 50%
treatment without the physician's consent

Although the union rate achieved was 100 % ，Few authors hav巴 recorded that there is risk ofthere was a clinica11y visibl巴 deformity i n u p toca11us formation in the absence of surgical

40 % of the children with about 1 5 % of them

reduction of the lateral third and they also insist

having shortening of up to 2 centimeterson the value of inv巴stigation by CT scan'l) . But inHowev巴r this was not correlative to the function­

our series， there has b巴巴n no such associated risk

al status with all the patients having fu11 andand so we do not recommend routine CT scans

painless range of shoulder motion (Fig. 1 ) .

for lat巴ral third clavicle fractures.

Discussion

The powerful re-mode11ing characteristics offractures in children means that even thoseTh巴 clavicle is the common巴st bone to b巴

fractures that ar巴 displaced or involve the lateral

fractured in children and accounts for 5-15% of

end of the clavicle appear to unite without

a11 fractures. Complications arising from simple，complication71

isolated clavicle fractures in children are rare andoperative intervention is seldom indicatedKubiak R & Slongo T recommended thatsurgery is usually necessary only in children

The predominant mechanism of ll1J ury wasabove 10 years of age6) Our study also shows thathousehold inj uries in younger children andchildren under 10 years do not require surgical

recr巴ational injuries in older childr巴n. Unlike theintervention . 1n children treated operatively forstudy by Taitz et al， there was no incidence ofclavicular fractures， and fixed with K wires，

child abuse in our studylOI ー But it is necessary toalthough there is an additional benefit that nohave a detailed and proper history and examina

further immobilization is required after fixation，363

tbe irritation of skin above the protruding end of
the pin has been a common problem5)
Clinically visible deformity， as a hump， andshortening are common complications seen withc o n s e r v a t i v e m a n a g e m e n t of c l a v i c u l a r
fracturesll )The deformity visible as a lumpusually disappears with time although shortening
may occur. The shortening does not produc巴 any
functional deficit although it might r巴mall1
permanentム9)

The follow up visits of the child along withparents can b巴 minimized or almost stopped as it
is seen that clinical union occurs is as less as 1-3weeks， depending on the age of the child.
Radiographic evaluation at periodic intervals
afforded no benefit and could be wisely discontin
ued. Our findings that follow up of paediatricclavicular fractures are not essential and otherauthors have documented that the risk ofcomplications is exceptionally rare as we1l2)
WHAT THIS STUDY ADDS

1 . Immobilization for more than 2 weeks
lS not necessary

2 . Simple methods like cuff & collar slinglS SU丘icient3 . Follow up is not essential

4 . Advanced investigations such as
Computed Topography ( CT ) is notreQ山red
5 . Surgical intervention is not reQuired
even for fractures of lateral third ofclavicle
6 . Shortening is not associated with lossof movements

364References

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