So, great credit to Andy and the team at Rady and the rest of the FACTS team for this study, our disclosures in the program. So we've come to learn from our study group work that adolescent clavicle fractures do better than their adult counterparts. But this study was sort of a deep dive on maybe why, particularly why the symptomatic malunions are not as prevalent as with adult patients. So the role of fracture remodeling hasn't been well studied in the clavicle. This one study from Cincinnati suggested that relatively little clavicle growth remained for patients after 10 to 12 years old. Our takeaway was a little bit the converse, which is 20% of remodeling in the adolescent years is pretty good with that continued growth. There's also other studies suggesting we know this is the last bone in the body to complete ossification and it may go on all the way up to age 25. So even young adults maybe have remodeling capacity. So our goal was to evaluate and quantify clavicle remodeling in adolescent patients with completely displaced fractures and maybe identify factors that could influence this process. So this was a retrospective series from two different data sets. One our FACS-A cohort, our first main cohort from eight centers between 2013 and 2019. And then Rady and Boston Children's also looked retrospectively from 08 to 13. We were looking at patients from age to 10 to 19 years with completely displaced fractures that had been treated non-operatively that also had repeat imaging at a minimum of nine months. So we looked at the injury film and measured shortening, superior displacement and angulation. And then in that later film, as late as possible, considered the remodeled film, we looked at shortening and over 60% had side-to-side clavicular length assessments. So that's how we quantified shortening for these follow-ups. As well as residual superior displacement and residual angulation. We also just developed a basic classification system for complete or near-complete remodeling as seen here in this first image. Moderate remodeling as seen here in the middle image. And then minimal remodeling as seen here in the third image. And ran a reliability study on this and had agreement. So we found 98 patients with a mean age of 14 1⁄2, 85% were male, which is in keeping with the distribution of male females for these fractures overall. Our mean follow-up was almost 3 1⁄2 years. So our follow-up radiographs consisted of chest X-rays, some thoracic spine X-rays, unilateral shoulder or clavicle X-rays, and then bilateral shoulder or clavicle X-rays. We found that the superior displacement underwent 60% remodeling between the injury film and the follow-up film, angulation 46% improvement, and shortening 62%. So these were all statistically significant. When we looked at just those, which is about half the patients who had initial shortening greater than or equal to 20 millimeters, a common surgical threshold, we found 93% of them remodeled to under 20 millimeters, and over half actually remodeled to under 10 millimeters of shortenings with these side-to-side analyses. In terms of our qualitative assessment of remodeling, we saw that there was only minimal remodeling in a small cohort of those over 14, about 20%, and under 14 of 10%. But these were in those that had under 2 years of follow-up. So every patient that had more than 2 years of follow-up had either moderate or near-complete remodeling by our quantification, and it was greater in those that were younger. We developed an appendix of all the patients who had imaging to potentially be able to provide to surgeons who sort of doubt the phenomenon or patients and families who want to understand the phenomenon better. They may find in this appendix of over 70 patients a fracture just like their child's and a remodeled X-ray that might sort of bespeak the course. So this is a small subset, about 100 of our over 500 X-rays with incomplete data. We had, again, over 60% had shortening data, but because of the limits of the unilateral films in about 40%, it's not a PRO study. Less than 40% of patients were over 18 at the age of final follow-up, so we couldn't capture the entire spectrum of remodeling. But really we saw that substantial remodeling occurs even in older adolescents. This is time and age dependent, but over 80% undergo near-complete remodeling. It's speaking further to the growing notion that adolescent clavicle fractures are much different than adult clavicle fractures. Thanks very much. Thanks, Ben.

adolescent clavicle fractures

adult clavicle fractures

symptomatic malunions

remodeling in adolescent years

completely displaced fractures