So, a reminder to everybody in the audience that there is a feature through the app to ask questions if you don't want to get up to the microphone. You can just simply go to this session, click on Q&A, I think we've already gotten one of them. And you can ask us questions electronically, we'll be happy to pass those on. You can also come up to the microphone. Why don't we start with the clavicle paper? One of our audience members had a question that I think I would ask, too, and I would say five-year outcomes, so what? My patients care about how quickly can they get back to sport? How quickly can they stop hurting? And how quickly do they need to stop seeing me? Do you have any indication from your cohort on speed of recovery with nonoperative treatment and how that compares to an operative intervention? Yeah, so nonoperative management is going to have a slower speed to recovery than operative management. The surgery can occur faster, and the surgical operative recovery is going to be quicker than non-op. But the difference between the two, it may be negligible with regards to how our patients are considering the length of recovery. A season of baseball or whatever else may be gone after surgery as much as it would be with nonoperative management. So yes, it's important to get our patients back to doing what they like to do, but the difference between the two may be negligible. And as a follow-up, a lot of us have seen the studies by Ben Haworth and the FACTS group, and I think they're very similar to your findings. Is there a reason to ever operate on a clavicle shaft fracture in an adolescent? Yeah, I think that there's a two-centimeter idea, and I think that calculating the amount of growth left in these kids and the amount of function that somebody has, that is one potential reason. There are also patients where surgery is the right call. And if these are kids that are considering college scholarships or things like that, and we need to get them back quicker, then there might be room for operative management. But on the whole, I think that there's an argument for non-op management as well. Andy? You did a great job there. Is this working? Yeah. Yeah. I just want to piggyback on that. So I'm the lead author on this. You can get athletes back if you operate on them. Interestingly, in our prospective data, that's what we're focusing on with the FACTS, a second cohort now. And I think I said Dr. Hayworth in the room, but a few hundred patients have been enrolled in that. And really the goal is to look at some of these early differences. What are the real benefits? Can we get them back two weeks faster, four weeks faster, six weeks faster? What's the realistic expectation? And interesting, we're not finding dramatic differences. And it kind of begs the question, why? And I think sometimes there's a few-week delay. By the time we get them to the OR, they get to our clinic, we get them to the OR, that's a few weeks. You've lost a few weeks that way. Most of us aren't allowing even ones we fixed to go back at four weeks. I mean, can they go back? Yes. But do we feel comfortable with them going back to football with a clavicle plated at four weeks? That's probably a little aggressive. So you take four weeks plus the two it took to get them to the OR, that's six weeks. And then those differences start diminishing. And so as part of the FACTS study, we're not seeing differences, even though they probably do exist. So Andy, how much skeletal immaturity does the kid have to have where he or she may behave this way, as opposed to behaving more like an adult, where our historical indications for surgery may be that. What's the age cutoff for those that treat both children and adults? Is it 18? Is it 19? Is it 20? Like, where do you draw the line? I think that's the million-dollar question. We haven't figured that out. Clearly this data and the larger FACTS data would suggest that clearly going up to age 17, they aren't behaving like adults, and by and large, they do great with non-operative treatment. So we try to tease out, does the 3-centimeter shortening need surgery? We've looked at that. It doesn't really seem to. Does the butterfly fragment need surgery? They still do just as well in non-operative. What about the just frank combination? What about the skin at risk? We try to tease out every subset we can and we've yet to find a group where the surgical outcomes are better than the non-operative outcomes. It is there. I just can't tell you the cutoff and who that exact person is. But by and large, the majority of these completely displaced clavicle fractures in 14- to 17-year-old age group can be treated non-operatively. Yeah. That's fantastic. Dr. Andrews? Let me just say one thing to make you a little bit cautious about getting them back early with internal fixation. If it works, it's great, but here's an example anecdotally. In an SEC quarterback, starting quarterback for one of the SEC schools that I helped take care of, we decided to go ahead and do an internal fixation because we could get him back quicker. He went back to playing an SEC game on Saturday afternoon at five weeks post-op, fell on his arm and just disrupted the whole fixation. And that remains in my memory bank about thinking I'm going to get him back quicker by operating on him. So that's just one case, but I'm sure that's happened more than once. So just thinking you're going to get him back quicker by an operation sometimes will get you in trouble. And to that point, there's just about no data on what is a safe timeline for return after ORF. There's a paper, I think, from some of your colleagues in Alabama showing that with an average return of five weeks in collegiate athletes, the return of re-injury is quite low, but if it happens to you, it's meaningful. And so then for the paper on what happens to kids after, you know, Little League, Shoulder Little League, this is fascinating to me because obviously we see a lot of this. I was actually shocked that 40% of those people end up quitting their sport because of persistent pain. How do we do better? Is it longer periods of not throwing? Is it different rehabilitation? Is it being more forceful about position changes? But that seems like a high number of people stopping sport participation due to pain. Yeah, I would agree. I was rather surprised by how many people actually listed pain as one of the reasons why they stopped playing and not like just, you know, loss of enjoyment. But I think more and more patients are having to choose an individual sport earlier and earlier, which I think is really causing a lot more stress and leading to more of these injuries and also leading to more recurrence and more consistent pain. These kids don't have an off season. There is no off season for them. And so when there is no off season, there is no time for them to heal. I think that this pain can kind of persist to the point where, you know, they're not enjoying it anymore. And the pain kind of, you know, it's just not worth it for the enjoyment that they get out of it and ultimately leads to them quitting baseball. Perfect. Well, with that, I think we're, oh, Dr. Andrews, I hate to dominate this discussion, but your talk is next. So you're only taking away from your time. This is important. The first thing, it's a great talk, but you cannot use the name little leg elbow and little leg shoulder. That's patent and there have been some threatened lawsuits about using that publicly, those terminology. So you have to use youth elbow and youth shoulder injuries, youth, not little leg. The other thing is you showed that fragmentation real quick. That fragmentation is different than amoelepicondylitis. That's actually an avulsion of the ligament that peels off with a little fleck of bone or maybe a little fleck of periosteum and you don't even recognize it. But it's a ligament injury. And we've studied that with our professional players, the ones that are coming in for Tommy John's, and we're seeing about 40% of them have that little ossification from an injury when they were 12, 13, 14 years old. And now they're in for a Tommy John's procedure. So you may not pick it up in your study with the amount of time that you've had, but it's certainly dominant when you get into the professional ranks. About 40% of them, if you go back, they forgot about it. You have to really pull it out of them and get the history that they had that injury when they were 12 or 13, and now they're having a Tommy John's when they're 25. Thank you. Thanks, Jimmy, for that perspective. And with that, we'll kind of segue into the next session.

clavicle fractures

operative treatment

nonoperative treatment

recovery speed

youth shoulder injuries