summary Medial Clavicle Physeal Fractures, also known pseudodislocation of the sternoclavicular joint, are rare injuries to the medial physis of the clavicle in children. Diagnosis can be made with serendipity radiographic views but CT scan is the study of choice to differentiate from sternoclavicular dislocations. Treatment is generally nonoperative management. Rarely, surgical management is indicated with posterior displacement associated with airway or neurovascular compromise. Epidemiology Incidence rare injury Etiology 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 login to view 3 more bullets posterior displacement login to view 2 more bullets 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) login to view 1 more bullet 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 login to view 1 more bullet serendipity views ( beam at 40 deg cephalic tilt) login to view 4 more bullets Axial CT scan is the study of choice can differentiate from sternoclavicular dislocations can visualize mediastinal structures and injuries Treatment Nonoperative observation indications login to view 6 more bullets Operative closed reduction under anesthesia indications login to view 4 more bullets open reduction internal fixation indications login to view 2 more bullets postreduction management login to view 1 more bullet Technique Closed reduction in the operating room under anesthesia approach thoracic surgeon available reduction anterior dislocation login to view 4 more bullets posterior dislocation login to view 4 more bullets 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