Introduction

Clavicle fractures (CF) are very common injuries (2.6-10% of all fractures),1-5 with an incidence between 22.4 and 30 cases per 100 000 individuals,2-4 predominantly occurring in men (an estimated two-thirds of cases).1,5-7 They are also the most frequent fracture in children and adolescents (10-15% of all fractures),1,7,8 with an annual incidence between 29-100 cases per 100 000 individuals.3 The most common cause is a fall on the shoulder1,5-7 (about 87% of cases),1 although these fractures can also result from direct trauma to the clavicle or a fall onto the outstretched hand.1

These fractures primarily affect men under 25 years of age (associated with high-energy trauma during sports such as ice hockey and soccer [50-85% of cases])1,3,6 and people over 55 years of age (associated with falls).1 In addition, about 20% of women and more than one third of men who sustain such fractures are between 13 and 20 years of age.1

In most cases (69-90%), the fracture occurs in the middle third or midshaft of the clavicle1,2,4,5,8 due to the morphology of the bone.1,8 Middle third fractures are typically observed in young patients as a result of high-energy trauma, whereas distal-third fractures occur more frequently in elderly patients with osteoporosis. Proximal-third fractures are most often associated with high-energy trauma or polytrauma.2,4

Even though the majority of these fractures respond well to conservative treatment,1,7 severely displaced or comminuted fractures may require surgical fixation.1 These fractures are managed depending on the deformity and the patient’s bone remodeling capacity, which will depend on several factors, including age, clavicle growth potential, fracture location, and degree of deformity.9 In children and adolescents, unless there is shortening ≥2 cm or displacement >100%, conservative treatment is generally recommended, given their capacity for bone remodeling and excellent clinical outcomes.6,9 However, there is an increasing trend toward surgical treatment due to reported improved functional outcomes,8 although there is still controversy about the management of these fractures in this population.9

Conservative treatment involves analgesia, immobilization with a sling or figure-eight brace, but the latter may cause more discomfort, and appropriate follow-up care by orthopedics.1,10-12 This type of treatment rarely causes pseudarthrosis or malunion, probably due to the bone remodeling capacity, even though the latter decreases with age.13,14

While conservative treatment has good functional outcomes and fewer complications, in recent decades, the frequency of surgical procedures has increased due to athletic demand and expectations of rapid recovery.15 Plate fixation allows rapid consolidation and an effective return to sports practice, but it may involve complications, such as implant irritation, which in some cases requires implant removal.16-18

In this regard, a study of 696 adolescents with displaced midshaft clavicle fractures (58% treated conservatively) reported that there were no significant differences in terms of functional recovery between groups.19 In addition, although the surgery allows a faster return to work, it carries a higher risk of complications such as implant irritation, surgical site infections, or supraclavicular nerve injury.20,21

In terms of efficacy, both approaches have been reported to allow excellent functional outcomes, with no significant differences in the QuickDASH score. However, the level of satisfaction with the cosmetic outcome is higher in patients treated conservatively.22-24

Regarding complications, a 2019 systematic review concluded that although both approaches offer good outcomes, surgical treatment has higher complication rates.25 Nevertheless, a recent comparative study demonstrated that both methods allow achieving good outcomes without serious complications.26

In Peru, few studies have compared the effectiveness of conservative and surgical treatment for these fractures,27 and, to the best of our knowledge, they have only included the adult population. In view of the above, the objective of this study is to determine the effectiveness of conservative treatment versus surgical treatment in Peruvian adolescents with a displaced middle third clavicle fracture.

The data reported here, besides contributing to settle the existing controversy about the best therapeutic option for this population, could be used as a starting point to develop a management protocol in the country that optimizes functional outcomes and reduces the risk of complications in these patients, taking into account that there is no scientific evidence on the subject in Peru.

Methodology

Study type

Single-center, retrospective cohort study.

Study population and sample

The study population consisted of adolescents aged 12 to 18 years with a displaced middle third clavicle fracture treated (surgically or conservatively) at the Orthopedic and Trauma Surgery Service of the Hospital Víctor Lazarte Echegaray (Trujillo, Peru) between January 2018 and December 2022.

Sample size was calculated using an online calculator for simple random samples, obtaining a sample size of 18 patients per group.

Data collection and variables

Once the patients for each group were selected (simple random sampling), their medical records were reviewed to collect the following information: age at the time of fracture (12-14 and 15-17 years), biological sex, cause of fracture (direct or indirect trauma [i.e., fall on the shoulder]), fracture laterality, occurrence of complications (pseudarthrosis, need for reoperation, neurological injury, surgical site infection, implant irritation), Quick DASH score, and level of satisfaction with the cosmetic outcome.

It should be noted that, in accordance with hospital protocols, the QuickDASH score (used to evaluate treatment effectiveness in terms of functional recovery) and the level of satisfaction with cosmetic outcomes, which was assessed using a 5-point Likert scale (very satisfied, satisfied, somewhat satisfied, dissatisfied, completely dissatisfied), were measured either three months after surgery or three months after the end of conservative treatment. These evaluations were carried out virtually (teleconsultation) or in person.

Statistical analysis

Once collected, the data obtained were entered into and organized in a database created in Microsoft Excel and then exported to the SPSS software (version 26.0) for analysis.

Data are described using absolute frequencies and percentages for qualitative variables and medians and interquartile ranges for continuous variables (Quick DASH score), since they showed a nonparametric distribution (Shapiro-Wilk and Kolmogorov-Smirnov tests). Bivariate analyses (Chi-square test [X2] and Mann-Whitney U test) were performed to evaluate the differences between groups (surgical vs. conservative treatment) in all the variables analyzed. A significance level of p<0.05 was considered.

Ethical considerations

The present study was approved by the bioethics committees of Universidad Privada Antenor Orrego (Resolution of the Bioethics Committee N°0554-2023-UPAO of August 2, 2023) and Hospital Víctor Lazarte Echegaray (PI N°80 CIYE - O.C.I. Y D-RALL-ESSALUD-2023 of July 8, 2024). It followed the ethical principles for biomedical research involving human subjects established in the Declaration of Helsinki.28 It also took into account the provision of Article 25 of the Peruvian General Health Law (Law No. 26842) on the confidentiality of patient information used for academic or scientific research purposes.29

Finally, in accordance with article 93 of the Peruvian Code of Ethics and Deontology,30 it is confirmed that no modifications of any kind were made and that the content of the medical records was not altered.

Results

All patients were male. A higher proportion of adolescents aged 15-17 years was observed in the surgical treatment group (66.7%), while the age group 12-14 years predominated in those who received conservative treatment (66.7%); the difference in age distribution between the two treatment groups was statistically significant (p=0.046). Indirect trauma (i.e., fall on the shoulder) was the main cause of fracture (94.4 % in the surgical treatment group and 100 % in the conservative treatment group; p=0.310) (Table 1).

Table 1. Clinical and sociodemographic characteristics of the sample by treatment (n=36).

Variables	Total	Type of treatment		Chi-Square X2	p-value
		Surgical	Conservative
	n (%)	n (%)	n (%)
Age
12 - 14	18 (50.0)	6 (33.3)	12 (66.7)	4.000	0.046
15 - 17	18 (50.0)	12 (66.7)	6 (33.3)
Sex
Male	36 (100)	18 (100)	18(100)	*	*
Affected side
Right	16 (44.5)	8(44.5)	8(44.5)	0.000	1.000
Left	20(55.5)	10(55.5)	10(55.5)
Mechanism of trauma
Direct trauma	1 (2.8)	1 (5.6)	0 (0.0)	1.029	0.310
Indirect trauma (i.e., falls)	35 (97.2)	17 (94.4)	18 (100)

Source: Own elaboration.

* No differences were evaluated because sex was a constant variable.

Regarding the occurrence of complications, no patient, regardless of the type of treatment received, presented pseudarthrosis, neurological injury, surgical site infection, or implant irritation. However, 4 of the adolescents who underwent surgery (22.2%) experienced pain due to implant protrusion on the superior aspect of the clavicle and required a second surgical intervention that included the removal of the osteosynthesis material after fracture healing; in the conservative treatment group, no complications that required a corrective surgical procedure were reported (p=0.034) (Table 2).

Table 2. Occurrence of complications in Peruvian adolescents with middle third clavicle fractures by type of treatment (n=36).

Complications	Total	Type of treatment				Chi-Square X2	p-value
		Surgical		Conservative
	n (%)	n	%	n	%
Pseudoarthrosis
No	36 (100)	18	100	18	100	*	*
Neurological injury
No	36 (100)	18	100	18	100	*	*
Surgical site infection
No	36 (100)	18	100	18	100	**	**
Second surgical intervention
Yes	4 (11.1)	4	22.2	0	0.0	4.500	0.034
No	32 (88.9)	14	77.8	18	100

* No differences between groups were evaluated because none of the patients presented this complication.

** No differences between groups were evaluated because this complication is exclusively surgical.

Source: Own elaboration.

Significant differences were observed in the level of satisfaction with the cosmetic outcomes of the treatment, with greater satisfaction being observed in those treated conservatively (p=0.001). The proportion of satisfied and very satisfied patients was much higher in those treated conservatively than in those who underwent surgery (27.8% and 50% vs. 11.1% and 0.0%). In contrast, in the surgical treatment group there was a higher frequency of somewhat satisfied patients (22.2% vs. 50.0%). Moreover, none of the adolescents who received conservative treatment expressed dissatisfaction with the cosmetic outcomes, while the proportion of dissatisfaction in the surgical treatment group was 38.9% (6 dissatisfied patients and 1 completely dissatisfied) (Table 3).

Table 3. Level of satisfaction with cosmetic outcomes in the sample by type of treatment.

Level of satisfaction	Treatment				Total	Chi-Square X2	p-value
	Surgical		Conservative
	n	%	n	%	n (%)
Very satisfied	0	0.0	9	50.0	9 (25.0)	19.210	0.001
Satisfied	2	11.1	5	27.8	7 (19.4)
Somewhat satisfied	9	50.0	4	22.2	13 (36.1)
Dissatisfied	6	33.3	0	0.0	6 (16.7)
Completely dissatisfied	1	5.6	0	0.0	1 (2.8)
Total	18	100	18	100.0	36 (100)

Source: Own elaboration.

Finally, there were no statistically significant differences in QuickDASH scores between groups (median surgical treatment score: 1.1 vs. median conservative treatment score: 0.0; p=0.784) (Table 4).

Table 4. Effectiveness of surgical treatment and conservative treatment in terms of functional outcomes in Peruvian adolescents with displaced clavicle fracture (n=36).

	Type of treatment	n	Median	IQR	Mann-Whitney U	p-value
Quick DASH score	Surgical	18	1.1	5.08	154.000	0.784
	Conservative	18	0.0	9.64

IQR: Interquartile rangeSource: Own elaboration.

Discussion

The present study aimed to determine the effectiveness of surgical and conservative treatment for displaced middle third clavicle fractures in Peruvian adolescents (12 to 18 years old), finding that both approaches achieved satisfactory functional outcomes, with no statistically significant differences in the QuickDASH score after treatment (median score: 1.1 vs. 0.0, respectively; p=0.784).

These findings are consistent with those reported in the literature.19,22-24,31 For example, in a Norwegian study conducted in 109 adolescents aged 12 to 18 years with displaced midshaft clavicle fractures treated either surgically (n=48) or conservatively (n=61), Riiser et al.24 also reported outstanding outcomes in both groups and no significant differences in the QuickDASH score (median score: 0 vs. 1.12, p=0.395). However, recent studies, such as the literature review by Mitchell et al.,31 point out that, although both types of treatment offer good functional outcomes, there has been a greater trend towards the use of surgery for the treatment of these fractures in adolescents in recent decades, which has been largely influenced by studies conducted in adults, without considering that the bone remodeling capacity in adolescence and early adulthood is superior to that of the adult population.

Regarding the age distribution of patients, surgical treatment was more frequent in adolescents aged 15-17 years (66.7%), while conservative management was more common in patients aged 12-14 years (66.7%), showing a statistically significant difference between groups (p=0.046). Furthermore, with the exception of one patient in the surgical treatment group, all fractures were caused by indirect trauma resulting from a fall onto the shoulder with the arm in adduction, mostly while playing sports (16 were playing soccer and 9 were playing basketball, while 6 and 4 were caused by domestic and traffic accidents, respectively). These findings concur with what has been reported in the literature.1-4,6,7 For example, in a recent literature review, Naveen et al.32 reported that sports injuries are one of the most common causes of midshaft clavicle fractures in adolescents (45%-66% of cases).

Concerning post-treatment complications, 22.2% of the adolescents who underwent surgical treatment required a second surgical intervention to remove the implant due to pain caused by the protrusion of the plate on the upper aspect of the clavicle, although there were no complications in patients treated conservatively (p=0.034). These results are in line with the findings reported by Kim et al.21 in a study conducted in South Korea on 94 adolescents with midshaft clavicle fractures divided into 4 treatment groups (conservative treatment with figure-eight braces [n=24], open reduction and internal fixation with plate [n=33], minimally invasive osteosynthesis with plate [n=16], and intramedullary fixation with threaded Steinmann pin [n=21]). There were no documented post-treatment complications in the conservative treatment group, while the rate of complications in the patients who underwent surgical treatment varied between 14.28 and 36.36% depending on the technique used.

The rate of surgical complications found in our patients is higher than what was reported by Rossi et al.23 in a study conducted in Argentina with data from 40 adolescents (13-18 years; mean age: 16.2 years) with displaced midshaft clavicle fractures treated by open reduction and internal fixation with plate (18% of the patients had complications and 10% required reoperation to remove the osteosynthesis material after fracture healing due to protrusion and discomfort). However, it is lower than the implant removal rates due to protrusion and pain described by Ariga et al.26 in Japanese patients ≥ 16 years with displaced midshaft clavicle fractures treated with superior (53.8%) or anteroinferior (n=28.1%) plate fixation. In any case, it is worth mentioning that the majority of patients in the study by Ariga et al.26 were adults, with mean ages of 47.4 ± 14.9 and 47.8 ± 17.1 in the superior plaque (n=39) and anteroinferior plaque (n=32) groups, respectively.

As for the level of satisfaction with the cosmetic outcomes of the treatment, 50% and 27.8% of the adolescents treated conservatively said they were very satisfied and satisfied. In contrast, the proportion of somewhat satisfied and dissatisfied patients was 50.0% and 33.3% in the surgical treatment group, while only 11.1% expressed satisfaction with the cosmetic outcome, with the difference between groups being statistically significant (p=0.001). These findings are in agreement with what was reported in the study by Riiser et al.,24 in which the level of satisfaction with cosmetic outcomes (measured with the VAS) was significantly higher in conservatively treated adolescents (median score: 1 [IQR: 0-8] vs. 0 [ IQR: 0-10]; p=0.026).

The main limitation of this study is its small sample size, which prevents the generalization of the results. Therefore, prospective multicenter studies are recommended. However, the present research provides relevant information on late morbidity in Peruvian adolescents with middle third clavicle fractures, and, unlike a prospective study, it required less time and was less costly.

Conclusion

Both therapeutic approaches provide satisfactory functional outcomes. However, conservative treatment is significantly superior to surgical treatment in terms of lower morbidity and greater satisfaction with cosmetic outcomes.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

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