title: Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle.
abstract: BACKGROUND
  Recent investigations of displaced clavicle fractures in adults have demonstrated a higher prevalence of nonunion, symptomatic malunion, diminished functional outcome, and decreased strength with nonoperative treatment. Although these data have led to increased surgical management of displaced fractures, little published information is available regarding the consequences of malunion in the pediatric population. The purpose of this investigation was to assess pain, functional outcome, range of motion, and strength in children with displaced clavicle fractures treated nonoperatively.
  
  
  METHODS
  Clinical evaluation of 16 patients with mid-diaphyseal clavicle fractures and >2 cm of initial displacement was performed; all had undergone nonoperative treatment and went on to radiographic malunion. The mean age at the time of injury was 12.2±3.3 years. Pain, aesthetic appearance, and satisfaction with treatment were rated by patients on a visual analog scale (VAS) (range 0 to 10 with 10 indicating the worst score). Patient-based outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Pediatric Outcomes Data Collection Instrument (PODCI). Bilateral shoulder motion was measured by a physical therapist. Isokinetic strength testing of the bilateral shoulders was performed with a Biodex dynometer. Range of motion and strength were analyzed with a multivariable regression, controlling for hand dominance. The mean follow-up was 27.2 months after injury.
  
  
  RESULTS
  All displaced fractures treated nonoperatively achieved union. Overall, there was reduced forward flexion and abduction on the injured side compared with the contralateral sides of 7.3 and 6.5 degrees, respectively, adjusted for hand dominance (P<0.05). Biodex testing did not detect any significant difference in abduction or adduction torque or power between affected and unaffected shoulders. The mean VAS score for pain was 1.6, with 4 patients reporting pain ≥to 3. The mean VAS scores for satisfaction with aesthetic appearance was 2.7, with 4 patients reporting scores >5. The mean VAS scores for satisfaction with treatment was 2.0, with only 1 patient scoring >5. The mean DASH score was 4.9±7.5, with 3 patients scoring ≥10. The mean scores on the DASH sports and performing arts module was 1.9±4.2, with only 1 patient scoring ≥10. The mean global PODCI score was 94.5±6.0. The mean PODCI scores for upper extremity function, sports, and pain were 97.9±5.5, 95.4±5.3, and 84.6±20.5, respectively. Only 1 patient was symptomatic enough to require corrective osteotomy.
  
  
  CONCLUSIONS
  Skeletally immature patients with established clavicle fracture malunions do not develop clinically meaningful loss of shoulder motion or abduction/adduction strength. Routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone. Further investigation is required to determine the risk factors and causes of pain and functional compromise in the minority of pediatric patients with symptomatic malunions.
  
  
  METHODS
  Level IV.
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA 02115, USA. donald.bae@childrens.harvard.edu
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae
authors.forename: Apurva S
authors.initials: AS
authors.lastname: Shah
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Kalish
authors.forename: John Y
authors.initials: JY
authors.lastname: Kwon
authors.forename: Peter M
authors.initials: PM
authors.lastname: Waters
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002968:Clavicle / Q000293:injuries*; D005260:Female; D005500:Follow-Up Studies; D017102:Fracture Healing; D050723:Fractures, Bone / Q000628:therapy*; D005599:Fractures, Ununited / Q000473:pathology*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D053580:Muscle Strength; D053581:Muscle Strength Dynamometer; D010146:Pain / Q000209:etiology; D010147:Pain Measurement; D017060:Patient Satisfaction; D016059:Range of Motion, Articular; D012044:Regression Analysis; D012785:Shoulder Joint / Q000503:physiopathology*; D011795:Surveys and Questionnaires; D019415:Torque