I'd like to thank my co-authors, Naveen Jasti, Peter Waters, and Don Bay. Disclosures are in the program. So distal or lateral clavicle fractures and the AC joint injuries represent about 15% of clavicle injuries. It's less common than the more common mid-shaft fractures, but more common than SC joint injuries. But the indications in surgical decision-making for this younger age group has been largely derived from adult research. We know, though, pediatric and adolescent surgeries are unique. The clinical considerations, these are distinct fracture patterns, and these patients have enhanced healing potential, and they also have more robust periosteum with usually intact ligamentous structures, such as the CC and AC ligaments. So they're unique intraoperative technical considerations. There's very little in the literature on this injury, mostly in small series and case reports. Really, the best study on this is 75 patients looked at by Nanopoulos et al., but only 12 or 16% had surgery, mostly with K wires, which most have moved away from. And then Liebs et al. looked at 69 patients in this age group, but only one case of surgery. So we really needed to look at a larger cohort of skeletally immature patients at our institution with distal clavicle fractures that had undergone surgery and hypothesized that these pediatric surgical cases would be distinct from the adult surgical cases in terms of fracture patterns and features, as well as techniques, and that the clinical outcomes would be favorable with low rates of nonunion and high rates of return to sports. We included patients 19 years and younger who had distal clavicle fractures from the CC ligaments and distal, but excluded those that extended to the CC from primarily mid-shaft fractures, as well as older patients. We looked at demographic characteristics, radiographic characteristics, the surgical techniques, and then clinical outcomes in terms of complications, secondary surgeries, time to union, and time to return to sport. We did not have PROs. We used the radiographic classification system proposed by Nanopolis, though it has not been widely adopted from their study. So we had 52 patients of mean age, just under 14. The vast majority were males, an even higher percentage than in mid-shaft clavicle fractures in pediatric and adolescent patients. In terms of the types of fractures, over 70% or so were simple patterns, displaced, transverse, or oblique fractures, with 12% comminuted and 15% AC dislocations. In terms of the mechanism of injury, 70% came from sports, with the most common sports in our region being snowboarding and skiing injuries, hockey, and football injuries. In terms of radiographic parameters, we saw posterior and superior displacement means of a centimeter and CC distance mean of two centimeters. Interestingly, and importantly, the primary direction of displacement was posterior in 90% of these patients. Terms of how these were fixed, plates were used in 54%. And then an important takeaway of the study is a third were isolated suture-based fixation, whether through the fragments, through the CC ligaments complex in the periosteum, or through the AC joint. Other techniques, such as dog bone, myrceline tape, and isolated lag screw fixation were less common. Here's just examples of our techniques. Plates with the historical hook plate were some in our series, and then the distal clavicle locking plates with the smaller fragments. Here's a 13-year-old dirt bike racer with posterior displacement that's fairly severe, as you can see, into the trapezium, and a suture-based technique both through the fracture fragments as well as, you can see, through the holes in the clavicle and then sutured underneath to the thick CC ligament complex, as well as an anterior drill hole through the anterior periosteum and the thick periosteum that was closed over the top. So when we looked at plate and suture techniques in comparative fashion, we found similar time to radiographic healing, a little bit shorter time to return to sports with the sutures probably because some of those plate patients started to have pain and were indicated for hardware removal, loss of reduction in one case in each of the two cohorts, refracture in one plate case but no suture cases, 17% had pain after three months, warranting an unexpected hardware removal, though most of the removals of these plates were planned due to the young age and the likelihood of bone overgrowth, or hook plates are generally thought to be better removed, particularly in a young patient. So slightly more complications when taking those plate removal considerations. So overall, the indications for distal clavicle fractures in children are not well established, but our study shows posterior displacement may be a common finding in those who benefit from surgery. Our surgical treatment had acceptable results with low rates of complications. Plate fixation was successful, but high rates of removal of hardware, as we might expect, higher than mid-shaft clavicle fractures for these distal fractures. Suture-based fixation is a key takeaway of the study with low rates of displacement, high rates of healing, and negligible need for secondary surgery. Clearly more research is needed in prospective comparative fashion, and we're developing a new classification system and comparing this cohort to those non-operatively treated who might be a comparison group. Thank you.

distal clavicle fractures

AC joint injuries

pediatric patients

surgical decision-making

suture-based fixation