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Updated: Jun 12 2021

Medial Clavicle Physeal Fracture

  • 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
          • 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 may actually be 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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