O1058: Skin Tenting Associated with Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results from the FACTS Multi-center Prospective Cohort Study

Background: Skin tenting is a commonly applied relative indication for operative treatment of clavicle fractures. However, the influence of this injury feature and optimal treatment for patients with skin tenting has been minimally investigated, particularly in adolescent populations, despite being the most affected epidemiologic sub-group. This study therefore sought to evaluate the outcomes of non-operatively and operatively treated clavicle fractures associated with skin tenting in the adolescent population.

Methods: 10-18 year-old patients with completely displaced mid-shaft clavicle fractures who received non-operative or operative treatment at one of eight participating institutions between 2013 and 2022 were screened for two categories of skin tenting at initial presentation: (1) ‘skin tenting’ or (2) ‘skin-at-risk for necrosis’ (described as tented, white, hypovascular). Additionally, demographic and fracture characteristics and treatment were recorded, and patients were followed for a minimum of one year. Return to sport (RTS) time, validated patient-reported outcomes (PROs: ASES, Quick DASH, and Marx shoulder activity), and complications were analyzed.

Results: Of the 768 prospectively enrolled adolescents with completely displaced midshaft clavicle fractures, the 92 (12%) patients who were reported to have ‘skin tenting’ or ‘skin-at-risk’ demonstrated greater age, comminution, shortening, and superior displacement, when compared to the 676 patients without tenting (Table 1). Of those with tenting, 32 (35%) were treated non-operatively (Non-Op), while 60 (65%) underwent open reduction and internal fixation (ORIF) (Table 2). Three Non-Op patients (9%) were converted to ORIF treatment at a mean of 20.0 days (range, 6-41 days) post-injury, due to increased symptoms or clinical concern. While non-operatively treated patients were, on average, less than one year younger than operative patients (Non-Op 14.5 years; ORIF 15.4 years, p=0.02), there were otherwise no significant differences between treatment cohort characteristics, including sex (Non-Op 81% males; ORIF 90% males, p=0.13), shortening (p=0.10), superior displacement (p=0.06), and comminution (p=0.20). The majority of patients provided PROs at 1 or 2 years post-treatment (64%), with no difference in response rates between treatment cohorts. There were no significant differences in RTS time, PRO scores, activity scores, or complications between the two cohorts (RTS: p=0.70, ASES: p=0.16, Quick DASH: p=0.07, Marx: p=0.26, complications: p=1.00).

Conclusion: In this prospective multi-center cohort study, the subset of adolescent clavicle fracture patients with skin tenting or skin-at-risk for necrosis showed no differences in complications, PROs or RTS, whether treated non-operatively and operatively. The reasons for these findings warrant further exploration, but may be due to early fracture settling, enhanced healing capacity, and bony remodeling potential that is unique to younger patients, and which may allow for tolerance of skin tenting without adverse effects. These data suggest that non-operative treatment with early observation may be associated with comparably good results, allowing for rare instances of conversion to operative treatment when clinically warranted.