Updated: 8/10/2022

Distal Clavicle Physeal Fractures

Review Topic
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  • summary
    • Distal Clavicle Physeal Fractures are rare injuries to the distal physis of the clavicle in skeletally immature patients.
    • 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
      • rare injury
        • accounting for only 5%-10% of clavicle fractures in children
  • Etiology
    • Pathophysiology
      • mechanism
        • fall onto an outstretched extremity or onto side of the shoulder.
        • direct blow
        • child abuse (rare cause)
      • pathoanatomy
        • considered a childhood equivalent to adult AC separation
        • periosteum usually remains intact with injury
        • clavicle displaces away from physis and periosteal sleeve
          • both of which remain attached to the AC and CC ligaments
  • Anatomy
    • Clavicle osteology
      • S-shaped bone
      • medial clavicle is connected to the axial skeleton via the sternoclavicular joint
      • lateral clavicle is connected to the scapula via the acromioclavicular joint
    • Clavicle ossification
      • overview
        • first bone to ossify in the fifth week in utero
        • physes are the last to close
      • central clavicle
        • initial growth via intramembranous ossification from the ossification center in the central portion of the clavicle (<5 years)
      • distal clavicle
        • continued growth via secondary ossification at lateral physis
        • lateral epiphysis does not ossify until age 18 years
      • medial clavicle
        • approximately 80% of clavicular growth occurs at the medial physis (secondary ossification)
        • medial epiphysis does not begin to ossify until 18 to 20 years
        • last physis to close in body (20-25yrs)
          • thus sternoclavicular dislocations in teenagers/young adults are usually physeal fracture-dislocations
    • Coracoclavicular (CC) ligaments
      • provide vertical stability
      • composed of
        • trapezoid ligaments
          • 2 cm from AC joint
        • conoid ligaments
          • 4 cm from AC joint
    • Acromioclavicular (AC) ligaments
      • provide horizontal stability
  • Classification
      • Rockwood Classification
      • Type
      • Definition
      • Image
      • Type I
      • Sprain of the AC ligaments, periosteal tube intact
      • Type II
      • Partial disruption of the periosteal tube
      • Type III
      • Large split in the periosteal tube with superior displacement
      • Type IV
      • Large split in the periosteal tube with posterior displacement of the lateral clavicle through trapezius
      • Type V
      • Complete disruption of the periosteal tube with displacement through the deltoid and trapezius
      • Type VI
      • Inferior dislocation of the distal clavicle below the coracoid
  • Presentation
    • Symptoms
      • pain
    • Physical exam
      • common
        • ecchymosis in older children
        • tenderness at the distal clavicle
        • deformity at distal clavicle
      • rare
        • skin tenting may be present
        • pseudo-paralysis of the affected ipsilateral extremity may be present in newborns
          • reflexes remain intact following isolated clavicle fractures
            • can help differentiate from brachial plexus injuries
  • Imaging
    • Radiographs
      • initial views
        • AP +/- Zanca
          • for intra-articular injury
        • axillary lateral
          • to define a Type-IV injury
      • later findings
        • intact periosteal sleeve forms a "new" lateral clavicle inferior to the superiorly displaced medial fragment.
  • Treatment
    • Nonoperative
      • sling management
        • indications
          • indicated in most cases, especially if periosteum is intact
            • a new clavicle will form within the intact periosteal sleeve resulting in a Y shaped clavicle
            • the displaced clavicle will typically reabsorb with time and growth
    • Operative
      • surgical reduction
        • absolute indications (rare)
          • open fractures
          • significant skin compromise
          • displaced intra-articular extension
          • a/w neurovascular injuries requiring surgery
        • relative
          • severely displaced fractures in older patients with nearly closed physis
          • displaced and entrapped fragment in trapezius
          • floating shoulder injuries
          • some Type III fractures in patients approaching skeletal maturity
          • types IV, V, and VI may need open reduction with repair of periosteal sleeve
  • Complications
    • Laceration of subclavian artery or vein
      • rare
      • diagnosed by rapidly expanding hematoma
      • thick periosteum usually protective
      • treatment = vascular repair
    • Nonunion
      • rare
      • seen after attempts at open reduction
      • treatment
        • surgical fixation with iliac crest bone grafting
    • Pin migration
      • pin fixation around the clavicle should be avoided

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(OBQ10.94) A 6-year-old patient sustains an injury to his shoulder after falling from his bicycle. A radiograph is shown in Figure A. What is the preferred treatment in this patient?

QID: 3182

Closed reduction and pinning of the fracture



Open reduction and plating



Sling immobilization



Coracoclavicular ligament reconstruction



Open reduction and suture fixation



L 1 C

Select Answer to see Preferred Response

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