Updated: 6/12/2021

Clavicle Shaft Fracture - Pediatric

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  • summary
    • Clavicle Shaft Fractures are common pediatric fractures that most commonly occur due to a fall on an outstretched arm or direct trauma to lateral aspect of shoulder.
    • Diagnosis can be made with plain radiographs.
    • Treatment is generally nonoperative management with a sling. Surgical management is indicated for open fractures or those associated with impending soft tissue compromise. 
  • Epidemiology
    • Incidence
      • common; 15% pediatric upper extremity injuries
    • Demographics
      • birth fractures
        • 0.5% normal deliveries;1.6% breech deliveries
      • traumatic
        • most often seen in active patients
  • Etiology
    • Pathophysiology
      • mechanism
        • fall on an outstretched arm or direct trauma to lateral aspect of shoulder
        • birth fractures (account for 90% of obstetric fractures)
        • if there is no history of trauma consider congenital pseudarthrosis of clavicle (typically on right except in patients with dextrocardia)
      • pathoanatomy
        • displaced fractures
          • the sternocleidomastoid muscle pulls the medial fragment posterosuperiorly
          • pectoralis and weight of arm pull the lateral fragment inferomedially
        • open fractures buttonhole through platysma
    • Associated injuries
      • are rare but include
        • neurovascular injury
        • brachial plexus injury
      • associated topics on orthobullets
        • pediatric
          • medial clavicle physeal injury
          • clavicle shaft fracture - pediatric (80%)
          • distal clavicle physeal injury
        • adolescent and adult
          • sternoclavicular dislocation
          • clavicle shaft fracture
          • distal third clavicle fracture
  • Relevant Anatomy
    • Acromioclavicular Joint Anatomy
    • AC joint stability
      • static stabilizers
        • acromioclavicular ligament
          • provides anterior/posterior stability
          • has superior, inferior, anterior, and posterior components
            • superior ligament is strongest, followed by posterior
        • coracoclavicular ligaments (trapezoid and conoid)
          • provides superior/inferior stability
          • conoid ligament is strongest
        • capsule
      • dynamic stabilizers
        • deltoid and trapezius
  • Classification
    • Allman Classification
      Type I
      Middle third (most common)
      Type II
      Distal to the coracoclavicular ligaments (lateral 1/3)
      Type III
      Proximal (medial) third
  • Presentation
    • Symptoms
      • pain
    • Physical exam
      • deformity
      • perform neurovascular exam
      • tenting of skin, assess if skin is at risk (impending open fracture)
  • Imaging
    • Radiographs
      • views
        • sitting/standing upright, standard AP view of bilateral shoulders
      • additional views
        • 15° cephalic tilt (ZANCA view) determine superior/inferior displacement
          • may consider having the patient hold 5 to 10 lbs weight in affected hand
  • Treatment
    • Nonoperative
      • observation / care with lifting
        • indications
          • newborn birth fractues
        • outcomes
          • union occurs at approx 1 wk
      • sling or shoulder immobilizer with progressive motion
        • indications
          • <12 years of age
            • due to high remodeling potential almost all fractures in this age group are treated nonoperatively
        • outcomes
          • nonunion/malunion rare in <12 yo
          • may have prominent area of callous which generally becomes less apparent over 6-12 mo
    • Operative
      • open reduction internal fixation
        • indications
          • controversial: adolescent fractures with significant shortening(>2cm)
          • absolute
            • open fxs
            • displaced fracture with soft-tissue at risk from tenting
            • subclavian artery or vein injury
  • Techniques
    • Sling Immobilization
      • technique
        • sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces) or shoulder immobilizer
        • after 2-4 weeks begin gentle range of motion exercises
        • strengthening exercises begin at 6-10 weeks
        • no attempt at reduction should be made
    • Open Reduction, Plate and Screw Fixation
      • equipment
        • most common
          • limited contact precontroured, dynamic compression plate
          • k-wires for preliminary fixation
        • others
          • 3.5mm reconstruction plate
          • locking plates
          • specially designed intramedulary rods
      • approach
        • beach chair or supine
        • direct superior vs anterior incision
    • Postoperative Rehabilitation
      • early
        • sling for 7-10 days followed by active motion
      • late
        • strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
        • full activity including sports at ~ 3 month
  • Complications
    • Nonoperative treatment
      • nonunion/malunion are rare
    • Operative treatment
      • hardware prominence (up to 59%) (Li et al JPO 2018); plate removal commonly performed
      • discomfort
      • anterior chest wall numbness
      • refracture
      • infection/ wound dehiscence(~5%)

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