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https://upload.orthobullets.com/topic/4122/images/distal clavicle physeal xray.jpg
https://upload.orthobullets.com/topic/4122/images/peds clavicle fx periosteal sleeve.jpg
https://upload.orthobullets.com/topic/4122/images/healing distal clavicle fracture pediatric.jpg
https://upload.orthobullets.com/topic/4122/images/healing distal clavicle fracture pediatric2.jpg
https://upload.orthobullets.com/topic/4122/images/distal_clavicle.jpg
Introduction
  • Epidemiology
    • rare injury accounting for only 5%-10% of clavicle fractures in children
  • Pathophysiology
    • mechanism
      • Fall onto an outstretched extremity or the side of the shoulder.
      • Direct blow
    • 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
    • is an S-shaped bone whose medial end is connected to the axial skeleton via the sternoclavicular joint and lateral end is connected to the scapula via the acromioclavicular joint
  • Clavicle ossification
    • overview
      • first bone to ossify in the fifth week in utero
    • central clavicle
      • initial growth (<5 years) occurs from the ossification center in the central portion of the clavicle (Intramembrenous Ossification)
    • distal clavicle
      • continued growth occurs at the medial and lateral epiphyseal plates
      • lateral epiphysis does not ossify until age 18 years
    • medial clavicle
      • approximately 80% of clavicular growth occurs at the medial physis
      • does not begin to ossify until 18 to 20 years
      • last physis to close in body (20-25yrs)
        • sternoclavicular dislocations in teenagers/young adults are usually physeal fracture-dislocations
Classification
 
 Classification
Type I  • Minimally displaced with intact AC and CC ligaments.
 
Type IIA  • Clavicle displaced superiorly with fracture medial to CC ligament.
 
Type IIB  • Clavicle displaced superiorly with tear of Conoid ligament.  




Presentation
  • Symptoms
    • pain
    • dysfunction
    • 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, which can help differentiate from brachial plexus injuries
Imaging
  • Radiographs
    • recomended views
      • obtain AP and Zanca view to help define injury 
    • 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, and the displaced clavicle will typically reabsorb with time and growth
  • Operative
    • surgical reduction
      • indications (rarely indicated and controversial)
        • open fractures
        • severly displaced fractures in older patients with near closed physis
        • some Type II fractures
Complications
 

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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? Review Topic

QID: 3182
FIGURES:
1

Closed reduction and pinning of the fracture

1%

(15/1018)

2

Open reduction and plating

0%

(4/1018)

3

Sling immobilization

93%

(949/1018)

4

Coracoclavicular ligament reconstruction

1%

(9/1018)

5

Open reduction and suture fixation

4%

(37/1018)

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