Do We Ever Need to Fix Clavicle Fractures in Adolescents?

@#Introduction: Clavicle fractures in adults are increasingly being treated by surgical fixation following reports of symptomatic non-union, malunion and poor functional outcome with conservative treatment. This has led to a similar trend in the management of clavicle fractures in adolescents. This study aims to evaluate the outcome and complications of non-operatively treated clavicle fractures in adolescents. Materials and methods: This is a retrospective, single institution study on adolescents aged 13-17 years who sustained a closed, isolated clavicle fracture, between 1997- 2015. Clinical records were reviewed for demographic information, injury mode, time to radiographic fracture union, time to re-attainment of full shoulder range of motion (ROM), and time to return to full activities and sports. Complications and fracture-related issues were recorded. Radiographs were analysed for fracture location, displacement and shortening. Results: A total of 115 patients (98 males, 17 females; mean age:13.9 ± 0.89 years) were included for study. 101 (88%) sustained a middle-third fracture while the remainder sustained a lateral-third fracture. A total of 96 (95%) of the middle-third fractures were displaced, and 12 (86%) of the lateral-third fractures were displaced. All displaced fractures in this study had shortening. Sports-related injuries and falls accounted for 68 (59%) and 34 (30%) of the cases respectively. Overall, the mean time to radiographic fracture union was 7.8 ± 4.35 weeks; there were no cases of nonunion. Full shoulder ROM was re-attained in 6.6 ± 3.61 weeks, and full activities and sports was resumed in 11.4 ± 4.69 weeks. There were 5 cases of re-fracture and a single case of intermittent fracture site pain. Conclusion: Clavicle fractures in adolescents can and should be treated non-operatively in the first instance with the expectation of good outcomes in terms of time for fracture union, reattainment of shoulder full range of motion, and return to activities. Surgical stabilisation should be reserved for cases for which there is an absolute indication.

Can Paediatric Femoral Fracture Hip Spica Application be Done in the Outpatient Setting?

@#children with femur fractures. This study compares the outcomes of spica cast application, in terms of quality of fracture reduction and hospital charges when performed in operating theatre versus outpatient clinics at a local institution. Materials and Methods: A total of 93 paediatric patients, aged between 2 months to 8 years, who underwent spica casting for an isolated femur fracture between January 2008 and March 2019, were identified retrospectively. They were separated into inpatient or outpatient cohort based on the location of spica cast application. Five patients with metaphyseal fractures and four with un-displaced fractures were excluded. There were 13 and 71 patients in the outpatient and inpatient cohort respectively who underwent spica casting for their diaphyseal and displaced femur fractures. Variables between cohorts were compared. Results: There were no significant differences in gender, fracture pattern, and mechanism of injury between cohorts. Spica casting as inpatients delayed the time from assessment to casting (23.55 ± 29.67h vs. 6.75 ± 4.27h, p<0.05), increased average hospital stay (41.2 ± 31.1h vs. 19.2 ± 15.0h, p<0.05) and average hospital charges (US$1857.14 vs US$775.49, p<0.05). Excluding the un-displaced fractures, there were no significant differences in the period of cast immobilisation and median follow-up length. Both cohorts had a similar proportion of unacceptable reduction and revision casting rate. Conclusion: Both cohorts presented similar spica casting outcomes of fracture reduction and follow-up period. With spica cast application in operating theatre reporting higher hospital charges and prolonged hospital stay, the outpatient clinic should always be considered for hip spica application.

Displaced Supracondylar Humerus Fractures in Children – Are They All Identical?

Introduction: This study aims to ascertain if there are any differences in supracondylar fractures between children under seven years of age and those above 7 years of age. Materials and Methods: All cases of displaced humerus supracondylar fractures that required surgical stabilization were identified and retrospectively reviewed. Demographic data, mode of injury, associated neurovascular injuries and details of surgery performed were obtained from clinical records. The Gartland classification and the extent of comminution of fractures were also documented from review of radiographs. Results: One hundred and twelve children were included in this study, of whom 61 (54.46%) were younger than seven years of age while 51 (45.5%) were aged seven years or older. Children aged seven or older had a greater incidence of associated neurological deficit at presentation (p=0.046). Of the six patients with nerve injury in the older age group, one patient (16.7%) had a radial nerve injury, two patients (33.3%) had ulnar nerve injuries while another two patients (33.3%) had median nerve injuries. There was one patient (16.7%) with both median and ulnar nerve injuries. Comminuted fractures were also more common in the older children (p=0.004). No significant differences were demonstrated between the groups with regard to age, gender and mechanism of injury, laterality, incidence of open fracture, vascular injuries and operative time. Conclusion: Children aged seven years or older who sustain supracondylar humeral fractures tend to get more comminuted fractures. There is also a higher incidence of associated neurological injury. These cases must be carefully examined for at presentation and parents need to be appropriately counselled about them.