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