Courtesy: Kaye Wilkins MD, Prof Lynn Staheli MD

Sternoclavicular Injuries

Key concept

• Usually represent Salter Harris Type I or II physeal injuries of the medial clavicle rather than true sternoclavicular dislocations.
• Medial clavicular physis is the last epiphysis to ossify and fuse at 20 to 25 years.
• Ligaments are stronger than the physis, so failure occurs through the physis.

Pathology

• Injury occurs through the physis.
• Epiphysis remains in place.
• Metaphysis displaces.
• Intact periosteum allows excellent healing.

Mechanism

• Direct blow to the shoulder.
• Anterior force causes anterior displacement.
• Posterior force causes posterior displacement.

Clinical features

Anterior displacement

• Visible swelling and prominence.
• Local pain.
• Usually benign.

Posterior displacement

• Subtle swelling or depression.
• Dyspnea.
• Dysphagia.
• Venous congestion.
• Facial swelling.
• Risk of mediastinal compression.

Imaging

• Standard radiographs have limited value.
• Serendipity view uses a 40 degree cephalad beam.
• CT scan is the investigation of choice.

Treatment

Anterior displacement

• Usually treated conservatively.
• Closed reduction if required.
• Sling for immobilization.

Posterior displacement

• Orthopedic emergency.
• Urgent closed reduction under general anesthesia.
• Towel clip traction may be required.
• Open reduction if unstable.

Late asymptomatic injuries

• Observation is usually sufficient because remodeling is excellent.

Clavicle Shaft Fractures

General principles

• Very common in children.
• Excellent healing potential.
• Nonunion is rare.

Age related pattern

• Infants usually have minimal displacement.
• Children 1 to 4 years commonly sustain greenstick fractures.
• Children older than 5 years usually have complete displaced fractures.

Treatment

• Sling is the preferred treatment.
• Figure of eight brace is generally unnecessary.

Healing

• Week 1: Pain and deformity are prominent.
• Week 2: Pain decreases.
• Week 3: Callus forms and activity improves.

Indications for surgery

• Open fracture.
• Skin tenting.
• Neurovascular injury.
• Floating shoulder.
• Symptomatic nonunion.

Fixation options

• Plate and screws.
• Elastic intramedullary nail.

Distal Clavicle Injuries

Key concept

• Represent periosteal sleeve injuries rather than true acromioclavicular dislocations.

Pathology

• Periosteum remains intact.
• Coracoclavicular ligaments remain attached.
• Medial clavicle displaces.
• New clavicle forms within the periosteal sleeve.

Treatment

• Type I to III injuries are treated with a sling.
• Type IV to VI injuries usually require surgery.
• Selected symptomatic athletes with Type III injuries may benefit from surgery.

Proximal Humerus Fractures

Key concept

• Excellent remodeling potential.
• Proximal humeral physis contributes about 80 percent of humeral growth.

Muscle forces

Proximal fragment

• Rotator cuff causes abduction and external rotation.

Distal fragment

• Pectoralis major causes adduction and medial displacement.

Age pattern

• Younger children usually sustain metaphyseal fractures.
• Older children more commonly sustain physeal fractures.

Treatment

• Most fractures are treated nonoperatively with a sling.
• Significant deformity remodels well in younger children.

Indications for surgery

• Open fracture.
• Neurovascular injury.
• Failed closed reduction.
• Older child with severe displacement.
• High demand athlete.

Fixation options

• Percutaneous Kirschner wires.
• Retrograde elastic intramedullary nails.
• Cannulated screws in older adolescents.

Complications

• Malunion causing impingement.
• Reduced range of motion.

Metaphyseal Versus Physeal Fractures

Physeal fractures

• Greater rotational deformity.
• Stronger muscle deforming forces.
• Good remodeling.

Metaphyseal fractures

• Less rotational deformity.
• Less muscle displacement.
• Excellent remodeling.

Special Points

Always assess

• Neurovascular status.
• Shoulder dislocation.
• Coracoid fracture.
• Brachial plexus injury.

Floating shoulder

• Combination of clavicle and scapular neck fracture.
• Usually requires stabilization of the clavicle.

Exam Pearls

• Sternoclavicular injury in children is usually a physeal injury rather than a true dislocation.
• Posterior sternoclavicular injury is life threatening.
• Most clavicle fractures are treated nonoperatively.
• Distal clavicle injuries are periosteal sleeve injuries.
• Proximal humerus has the greatest remodeling potential in the body.
• Surgery for proximal humerus fractures is rarely required except in older children with severe displacement.