Clavicle Fractures

Introduction
Epidemiology
incidence
clavicle fractures make up ~4% of all fractures

demographics
often seen in young active patients

Pathophysiology
mechanism
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma

pathoanatomy
in displaced fractures, the sternocleidomastoid
muscle pulls the medial fragment posterosuperiorly,
while pectoralis and weight of arm pull the lateral
fragment inferomedially
open fractures buttonhole through platysma

 Associated injuriesare rare but include

ipsilateral scapular fracture
scapulothoracic dissociation
should be considered with significantly displaced
fractures

rib fracture
pneumothorax
neurovascular injury

Pediatric Clavicle fractures, fracture

patterns include
medial clavicle physeal injury
distal clavicle physeal injury

Medial Clavicle Physeal

Fractures
Suspect in any young individual(< 25
yrs) with a medial clavicle or
sternoclavicular injury
Usually Salter-Harris Type I or II

Imaging
Radiographs
difficult to visualize on AP
obtainserendipity views(beam at 40 deg
cephalic tilt)
anterior dislocation/fxs - affected clavicle is above
contralateral clavicle
posterior dislocation/fxs - affected clavicle is below
contralateral clavicle

CT scan
is study of choice
can differentiate fromsternoclavicular
dislocations
can visualize mediastinal structures and
injuries

Treatment
Nonoperative
observation
controversial
most asymptomatic injuries will remodel and do not require intervention

closed reduction in operating room under anesthesia

indications
anterior displaced physeal fx
indications are not well established
posterior displaced physeal fx
hoarsness
blunt or direct trauma to subclavian vessels
thoracic outlet syndrome
pneumothorax

technique
approach
thoracic surgeon available
reduction
traction and abduction of arm, while applying direct pressure
posterior displaced fractures usually requiresterile towel clipfor manipulation
convert to open
if irreducible by closed means, consider open approach

postreduction
immobilization
figure of 8 harness for 3-4 weeks (anterior displaced)

 Operative
open reduction
indications
rarely needed
unreducible and symptomatic in a patient > 23 yrs
old

Distal Clavicle Physeal

Fractures
Rare injury accounting for only 5% of
clavicle fractures in children

considered a childhood equivalent to adult

AC separation

Pathoanatomy
periosteum usually remains intact with injury
clavicle displaces away from physis and
periosteal sleeve, both of which remain
attachedto the AC and CC ligaments

Presentation
Symptoms
pain, dysfunction, ecchymosis in older
children

Physical exam
pseudo-paralysis of the affected ipsilateral
extremity may be present in newborns
reflexes remainintact following isolated clavicle
fractures, which can help differentiate from
brachial plexus injuries

Imaging

Radiographs
obtain AP and serendipity view to help define
injury

Treatment
Nonoperative
sling management
indicated in most cases, especially if
periosteum is intact. A new clavicle will form
within the intact periosteal sleeve, and the
displaced clavicle will typically reabsorb with
time and growth

Operativesurgical reduction
indications (rarely indicated)
open fractures
severly displaced fractures in older patients with
near closed physis