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 displacing forces login to view 4 more bullets open fractures buttonhole through platysma Associated injuries are rare but include neurovascular injury brachial plexus injury associated topics on orthobullets pediatric login to view 3 more bullets adolescent and adult login to view 3 more bullets Relevant Anatomy Acromioclavicular Joint Anatomy AC joint stability static stabilizers acromioclavicular ligament login to view 3 more bullets coracoclavicular ligaments (trapezoid and conoid) login to view 2 more bullets 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 login to view 1 more bullet Treatment Nonoperative observation / care with lifting indications login to view 1 more bullet outcomes login to view 1 more bullet sling or shoulder immobilizer with progressive motion indications login to view 2 more bullets outcomes login to view 2 more bullets Operative open reduction internal fixation indications login to view 8 more bullets 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 login to view 2 more bullets others login to view 3 more bullets approach beach chair or supine direct superior vs anterior incision postoperative rehabilitation early login to view 1 more bullet late login to view 2 more bullets Complications Nonoperative treatment nonunion/malunion are rare Operative treatment hardware prominence (up to 59%) plate removal is commonly performed discomfort anterior chest wall numbness refracture infection/ wound dehiscence(~5%)