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 login to view 1 more bullet 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) login to view 1 more bullet Coracoclavicular (CC) ligaments provide vertical stability composed of trapezoid ligaments login to view 1 more bullet conoid ligaments login to view 1 more bullet 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 login to view 2 more bullets Imaging Radiographs initial views AP +/- Zanca login to view 1 more bullet axillary lateral login to view 1 more bullet later findings intact periosteal sleeve forms a "new" lateral clavicle inferior to the superiorly displaced medial fragment. Treatment Nonoperative sling management indications login to view 3 more bullets Operative surgical reduction absolute indications (rare) login to view 4 more bullets relative login to view 5 more bullets 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