summary Clavicle Shaft Fractures are common pediatric fractures that most commonly occur due to a fall on an outstretched arm or direct trauma to lateral aspect of shoulder. Diagnosis can be made with plain radiographs. Treatment is generally nonoperative management with a sling. Surgical management is indicated for open fractures or those associated with impending soft tissue compromise. Epidemiology Incidence common; 15% pediatric upper extremity injuries Demographics birth fractures 0.5% normal deliveries;1.6% breech deliveries traumatic most often seen in active patients Etiology Pathophysiology mechanism fall on an outstretched arm or direct trauma to lateral aspect of shoulder birth fractures (account for 90% of obstetric fractures) if there is no history of trauma consider congenital pseudarthrosis of clavicle (typically on right except in patients with dextrocardia) pathoanatomy displacing forces medial fragment displaces posterosuperior due to pull of the sternocleidomastoid muscle lateral fragment displaces inferomedially due to pull of pectoralis and weight of arm open fractures buttonhole through platysma Associated injuries are rare but include neurovascular injury brachial plexus injury associated topics on orthobullets pediatric medial clavicle physeal injury clavicle shaft fracture - pediatric (80%) distal clavicle physeal injury adolescent and adult sternoclavicular dislocation clavicle shaft fracture distal third clavicle fracture Relevant Anatomy Acromioclavicular Joint Anatomy AC joint stability static stabilizers acromioclavicular ligament provides anterior/posterior stability has superior, inferior, anterior, and posterior components superior ligament is strongest, followed by posterior coracoclavicular ligaments (trapezoid and conoid) provides superior/inferior stability conoid ligament is strongest capsule dynamic stabilizers deltoid and trapezius Classification Allman Classification Type I Middle third (most common) Type II Distal to the coracoclavicular ligaments (lateral 1/3) Type III Proximal (medial) third Presentation Symptoms pain Physical exam deformity perform neurovascular exam tenting of skin, assess if skin is at risk (impending open fracture) Imaging Radiographs views sitting/standing upright, standard AP view of bilateral shoulders additional views 15° cephalic tilt (ZANCA view) determine superior/inferior displacement may consider having the patient hold 5 to 10 lbs weight in affected hand Treatment Nonoperative observation / care with lifting indications newborn birth fractues outcomes union occurs at approx 1 wk sling or shoulder immobilizer with progressive motion indications <12 years of age due to high remodeling potential almost all fractures in this age group are treated nonoperatively outcomes nonunion/malunion rare in <12 yo may have prominent area of callous which generally becomes less apparent over 6-12 mo Operative open reduction internal fixation indications controversial shortening of > 2cm not an indication in children < 12 yo due to remodeling potential controversial in adolescent fractures absolute open fxs displaced fracture with soft-tissue at risk from tenting subclavian artery or vein injury Techniques Sling Immobilization technique sling or figure-of-eight (prospective studies have not shown difference between sling and figure-of-eight braces) or shoulder immobilizer after 2-4 weeks begin gentle range of motion exercises strengthening exercises begin at 6-10 weeks no attempt at reduction should be made Open Reduction, Plate and Screw Fixation equipment most common limited contact precontroured, dynamic compression plate k-wires for preliminary fixation others 3.5mm reconstruction plate locking plates specially designed intramedulary rods approach beach chair or supine direct superior vs anterior incision postoperative rehabilitation early sling for 7-10 days followed by active motion late strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union full activity including sports at ~ 3 month Complications Nonoperative treatment nonunion/malunion are rare Operative treatment hardware prominence (up to 59%) plate removal is commonly performed discomfort anterior chest wall numbness refracture infection/ wound dehiscence(~5%)