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Introduction
  • Description
    • a medial clavicle physeal injury is a rare injury to the medial physis of the clavicle in children.
      • also known as pseudodislocation of the sternoclavicular joint
      • usually treated conservatively
  • Epidemiology
    • rare injury
  • Pathophysiology
    • mechanism
      • fall onto an outstretched extremity
      • direct blow
      • child abuse a rare cause
    • pathoanatomy
      • considered a childhood equivalent to adult sternoclavicular separation
      • physeal sleeve and strong costoclavicular and sternoclavicular ligaments usually remain intact with injury . However, in series by Lee et al. of 40 patients treated operatively for a posterior sternoclavicular injury 50% were physeal fractures and 50% were actually sternoclavicular dislocations
      • anterior displacement
        • metaphyseal fragment may be sharp and palpable immediately beneath the skin
        • clavicular head of the sternocleidomastoid muscle is pulled anteriorly with the bone and spasms
        • patient's head may be tilted towards the affected side
      • posterior displacement
        • local swelling, tenderness, and depression of the medial end of the clavicle
        • innominate artery and vein, internal jugular vein, phrenic and vagus nerves, trachea, and esophagus may be injured with posterior displacement 
Anatomy
  • Clavicle osteology
    • 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 (intramembranous 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 the body (20-25yrs)
        • sternoclavicular dislocations in teenagers/young adults are usually physeal fracture-dislocations
Presentation
  • Symptoms
    • pain
    • dysfunction
    • anterior dislocation
      • deformity with a palpable bump
    • posterior dislocations
      • dyspnea or dysphagia
      • tachypnea and stridor
      • diminution or absence of distal pulses
      • paresthesias or paresis
  • Physical exam
    • palpation
      • prominence that increases with arm abduction and elevation
    • ROM and instability
      • decreased arm ROM
    • neurovascular
      • paresthesias in affected upper extremity
      • venous congestion or diminished pulse when compared with the contralateral side
Imaging
  • Radiographs
    • recommended views
      • AP
        • difficult to visualize on AP, and radiographs usually unreliable to assess for fracture and degree of displacement 
      • serendipity views ( beam at 40 deg cephalic tilt) 
        • anterior displacement
          • the affected clavicle is above the contralateral clavicle
        • posterior displacement
          • the affected clavicle is below the contralateral clavicle
  • Axial CT scan   
    • is the study of choice
    • can differentiate from sternoclavicular dislocations
    • can visualize mediastinal structures and injuries
Treatment
  • Nonoperative
    • observation
      • indications 
        • most asymptomatic injuries
          • will remodel and do not require intervention as the periosteal sleeve is intact 
        • anterior displacement
          • have good functional results treated nonoperatively
        • posterior displacement
          • if no injury to mediastinal structures
  • Operative
    • closed reduction under anesthesia
      • indications
        • acute posterior displacement with airway, esophageal, or neurovascular compromise
        • contraindications
          • late presenting posterior dislocations
            • closed reduction not attempted as medial clavicle may be adherent to vascular structures in the mediastinum
    • open reduction internal fixation
      • indications
        • failure of closed reduction with continued symptoms
        • chronic symptomatic posterior dislocations
      • postreduction management
        • obtain CT to confirm stability
Technique
  • Closed reduction in the operating room under anesthesia
    • approach
      • thoracic surgeon available
    • reduction
      • anterior dislocation
        • patient placed supine with a bolster under shoulders
        • longitudinal traction to both upper extremities and gentle posterior pressure to medial metaphyseal fragment applied
        • medial fragment may be grasped with a towel clip to help facilitate reduction
        • if unsuccessful, usually treated in a sling
      • posterior dislocation
        • patient placed supine position with a bolster under shoulders
        • longitudinal traction applied to arm with the shoulder adducted
        • a posteriorly directed force is applied to the shoulder while the medial end of the clavicle is grasped with a towel clip and brought anteriorly
        • if reduction fails, proceed to open reduction
  • Open Reduction Internal Fixation
    • approach
      • horizontal incision the over superior/medial clavicle
    • reduction
      • towel clip to reduce
    • fixation
      • sutures from medial clavicle to sternum/medial epiphysis
      • sutures preferred as may allow for MRI in the future
      • pin fixation should be avoided due to danger of migration
Complications
  • Persistent instability
    • incidence
      • rare in children as they have a high propensity to remodel
  • Laceration of subclavian artery or vein
    • incidence
      • rare
    • suggested by rapidly expanding hematoma
    • thick periosteum usually protective
    • treatment
      • repair of vessel
  • Pin migration
    • pin fixation around the clavicle should be avoided
 

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