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 trapezoid ligaments 2 cm from AC joint conoid ligaments 4 cm from AC joint Acromioclavicular (AC) ligaments provide horizontal stability Classification Rockwood Classification 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 ecchymosis in older children Physical exam tenderness and deformity at the distal clavicle 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 suggested 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
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 FIGURES: A Type & Select Correct Answer 1 Closed reduction and pinning of the fracture 2% (34/1610) 2 Open reduction and plating 1% (14/1610) 3 Sling immobilization 92% (1488/1610) 4 Coracoclavicular ligament reconstruction 1% (16/1610) 5 Open reduction and suture fixation 3% (51/1610) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK