Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Aug 10 2022

Distal Clavicle Physeal Fractures

Images clavicle physeal xray.jpg distal clavicle fracture pediatric.jpg distal clavicle fracture pediatric2.jpg
  • 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
1 of 50
1 of 4
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options