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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?
Closed reduction and pinning of the fracture
Open reduction and plating
Coracoclavicular ligament reconstruction
Open reduction and suture fixation
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The history and radiograph depict a patient that has sustained an oblique fracture of the distal clavicle with superior displacement of the medial fragment. The preferred treatment is sling immobilization.
Distal clavicle physeal fractures are fairly rare in the pediatric population. The robust periosteum remains intact while the clavicle displaces. The regenerative capacity is high with an intact periosteum. The coracoclavicular (CC) ligaments remain attached to the periosteum and new bone fills any remaining bony gaps within the periosteal sleeve. Most of these injuries can be managed conservatively. Surgical intervention is rarely indicated, even with significantly displaced injuries.
Nenopoulos et al. retrospectively reviewed 75 pediatric patients treated for distal clavicular injuries. The majority of patients (63/75) were treated conservatively. They indicate that results from conservative measures yielded excellent outcomes. Surgical intervention could be considered in patients greater than 8 years, to optimize cosmetic results.
Answers 1, 2, 4, 5: Operative intervention is rarely indicated for distal clavicular injuries in the pediatric population.
Nenopoulos SP, Gigis IP, Chytas AA, Beslikas TA, Nenopoulos AS, Christoforidis JE
Injury. 2011 Apr;42(4):376-80. PMID: 21055749 (Link to Abstract)
Nenopoulos, INJURY 2011
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