Chapter 22: Clavicle and Scapula Fractures: Acromioclavicular and Sternoclavicular Injuries

Joshua M. Abzug, Peter M. Waters

Chapter Outline

Introduction to Midshaft Clavicle Fractures

The clavicle is the most commonly fractured bone in children, representing 5% to 15% of all pediatric fractures.109 The most common location for a clavicle fracture is the midshaft of the bone, accounting for up to 80% of fractures.109,112,116,123 Despite this high incidence, little literature exists regarding management and outcomes of pediatric clavicle fractures. Much of the literature cited throughout this chapter is therefore extrapolated from scientific studies performed regarding either adult or adolescent clavicle fractures. However, with the increasing trend for operative fixation in adults, more scientific investigations regarding the management of clavicle fractures in children are being performed. 

Assessment of Midshaft Clavicle Fractures

Mechanisms of Injury for Midshaft Clavicle Fractures

Clavicle fractures are frequent in children of all ages, from birth to skeletal maturity, with different mechanisms of injury resulting in the fracture based on age. Infants can sustain a clavicle fracture during the birthing process, especially those that are large for gestational age or those involved in difficult deliveries.15,60,78 Additional risk factors include a lower mean head to abdominal circumference ratio and a prior history of the mother having a previous child with macrosomia.60 
Neonatal clavicular fractures have been cited as one of the most frequent complications of natural delivery.30,67,70,81,113,122 However, there is no uniform screening method for determining whether or not a fracture occurred and therefore the exact incidence of neonatal clavicle fractures remains unknown. The incidence has been reported to be as high as 4.4%, but the true incidence may be even higher.81 Clavicle fractures due to birth trauma need to be distinguished from the rarer congenital pseudarthrosis of the clavicle, which is generally seen on the right side except in dextrocardia (Fig. 22-1). 
Figure 22-1
 
A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. (Courtesy of Joshua M. Abzug, MD.) B: Neonatal pseudarthrosis of the clavicle.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. (Courtesy of Joshua M. Abzug, MD.) B: Neonatal pseudarthrosis of the clavicle.
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Figure 22-1
A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. (Courtesy of Joshua M. Abzug, MD.) B: Neonatal pseudarthrosis of the clavicle.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. (Courtesy of Joshua M. Abzug, MD.) B: Neonatal pseudarthrosis of the clavicle.
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The anterior shoulder, typically the right side, is the most likely location where the clavicle fracture occurs, as babies are typically in the left occiput anterior (LOA) position.60 In addition, this is the most common side of injury in neonatal brachial plexus palsy. Therefore, when an infant sustains a clavicle fracture during the birthing process and limited motion is present about the affected extremity, it is unknown if the child has a concomitant brachial plexus injury or is not moving their arm secondary to the pain associated with the fracture, a so-called pseudopalsy. Once the fracture heals, typically in 1 to 3 weeks in a newborn, repeat assessment of the brachial plexus should be performed to distinguish pseudopalsy from a nerve injury. 
The exact mechanism for sustaining the clavicle fracture during the birthing process remains unknown. It is likely related to lateral compression of the shoulder girdle against the pelvis. However, neonatal clavicle fractures have also been shown to occur during cesarean sections.60 
Toddlers who sustain clavicle fractures may sustain the injury due to a fall from a height or injuries sustained during child abuse.22,70,114 In a series of children aged 4 years or younger, children abused had an incidence of clavicle fractures of approximately 4% compared to only about 1% in the control group.114 
School age clavicle fractures occurring in children are typically the result of a fall where the child sustains a lateral compressive force to the shoulder.131 Typical activities include falls off of playground equipment, falls from bicycles, and sporting activities. Alternatively, a direct blow to the clavicle can lead to fracture in a child; however, this mechanism is less common. The common fall onto an outstretched hand does not typically transmit enough force to the clavicle to sustain a fracture.64 
Adolescents sustain clavicle fractures due to similar mechanisms as school age children as well as due to high-energy mechanisms or competitive athletics. Motor vehicle and all-terrain vehicle (ATV) accidents are common high-energy mechanisms in adolescents that can result in either isolated clavicular fractures or clavicular fractures associated with polytrauma similar to adults.73,116 High-level competitive athletes also commonly sustain clavicle fractures due to collision sports, such as football, or much less commonly, due to repetitive, high-intensity training leading to a stress fracture.1 Specific sporting activities that can lead to stress fractures include rowing, diving, baseball, and gymnastics, among others.1,140,147 
The proposed mechanism leading to a clavicular stress fracture is excessive cyclic scapular protraction and retraction leading to clavicular fatigue.1 Excessive motion at the sternoclavicular and acromioclavicular (AC) joints transfers the forces to the clavicle itself, with the end result being these forces exceeding the ultimate tensile strength of the clavicle.1 This most commonly occurs in athletes who rapidly increase their training program. 

Associated Injuries with Midshaft Clavicle Fractures

Injuries that are associated with clavicle fractures depend on the age of the child with the fracture. Neonates can have a concomitant neonatal brachial plexus palsy. The most common type of neonatal brachial plexus palsy is an injury affecting C5 and C6 with resultant limited shoulder movement, elbow flexion, forearm supination, and wrist extension.46 Differentiation between a pseudopalsy, the child not moving their arm secondary to the clavicle fracture itself, and a concomitant neonatal brachial plexus palsy can be made by 3 to 4 weeks of age, as the pain from the fracture will be markedly decreased. Toddlers who sustain clavicle fractures as a result of nonaccidental trauma are likely to sustain concomitant fractures, such as fractures of the rib, tibia/fibula, humerus, or femur, intracranial bleeding, eye contusions, retinal hemorrhage, and burns.28,114 Lastly, adolescents involved in high-energy mechanisms of injury can have associated polytrauma including injury to surrounding structures or vital organs. Concomitant rib fractures, scapula fractures, pneumothorax, brachial plexus injury, or subclavian vessel injury may be present.64 Abdominal, head, spine, and/or lower extremity trauma can also occur. 

Signs and Symptoms of Midshaft Clavicle Fractures

Clavicle fractures in neonates commonly present after difficult deliveries with decreased active movement about the shoulder region, crying upon passive movement of the shoulder and entire upper extremity, swelling, crepitation, and an asymmetrical bony contour. The Moro (startle) reflex, (a newborn reflex in which a noise or sudden movement causes the baby to extend their neck, arms, and legs followed by pulling the arms and legs back in), may be decreased as well.60 Presence of limited digit motion or Horner syndrome (ptosis, miosis, and anhydrosis) indicates the presence of a more serious concomitant brachial plexus birth palsy with injury affecting the lower portions of the brachial plexus. 
Toddlers who sustain clavicle fractures associated with suspected abuse should undergo a complete head-to-toe survey, as if they were a trauma patient, looking for concomitant injuries and/or signs of abuse. This includes a thorough neurologic evaluation, an ophthalmologic examination, and a skeletal survey to look for corner fractures or additional fractures in various stages of healing. 
Examination of a child or adolescent with a clavicle fracture includes looking for deformity, swelling, and ecchymosis about the affected clavicle. Any tenting of the skin (Fig. 22-2) or open wounds should be noted. In addition, one should look at the lateral aspect of the shoulder for an abrasion or erythema, as this is most commonly the site of impact. Inspection may also demonstrate some drooping of the involved side as the scapula appears internally rotated and the shoulder appears shortened compared to the contralateral side. If significant swelling is present, this may be difficult to recognize.64 
Figure 22-2
Photographs depicting skin tenting from a displaced, segmental left diaphyseal clavicle fracture.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
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Figure 22-2
Photographs depicting skin tenting from a displaced, segmental left diaphyseal clavicle fracture.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
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Pain about the entire shoulder girdle is typically present, however significant tenderness to palpation is present overlying the fracture itself. Crepitus, with any attempt of active or passive range of motion, may be present. As noted above, concomitant injury to the brachial plexus may occur, especially the ulnar nerve because of its location adjacent to the middle third of the clavicle. Therefore, a thorough neurologic examination is required for all patients who sustain clavicular fractures. This includes assessing motor and sensory function throughout the entire upper extremity. It may be difficult to have a child in pain perform certain functions necessary to complete the neurologic evaluation; however, it is imperative to be patient and repeat the examination as often as necessary to obtain the necessary information. 
Because of the location of the subclavian vessel, a thorough vascular examination is also necessary, especially in patients involved in high-energy mechanisms of injury. The vessel can spasm or have a thrombosis from blunt trauma. Assessment of the radial pulse should be symmetric and if there is any concern for injury of the vessel, further diagnostic evaluation with advanced imaging should be performed. 

Imaging and Other Diagnostic Studies for Midshaft Clavicle Fractures

Initial imaging of a suspected clavicle fracture includes plain radiographs of the clavicle in two projections. Typically, a standard anteroposterior (AP) radiograph and a 45-degree cephalic tilt view are obtained (Fig. 22-3). These images provide visualization of the shoulder girdle region as well as the upper lung fields, both of which should be assessed for additional injuries. However, if clinical suspicion is present for additional injuries, dedicated series of the suspected part(s) should be obtained. Rarely is advanced imaging necessary to evaluate the clavicle fracture as displacement, the fracture pattern, and any presence of comminution can be assessed on the plain films. In cases of high-energy mechanisms, the trauma team typically obtains a chest CT scan which can be used to further evaluate the clavicle fracture. 
Figure 22-3
Depiction of a 45-degree cephalic tilt to obtain an additional view of the clavicle.
Flynn-ch022-image003.png
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Classification of Midshaft Clavicle Fractures

Clavicle fractures are usually described based on the location of the fracture, the fracture pattern, and the presence or absence of displacement. Thus, clavicle fractures are either medial, midshaft, or lateral; nondisplaced or displaced; open or closed; comminuted or simple. Additional classification schemes have been proposed to evaluate adult clavicle fractures but none are widely utilized, as they are either purely descriptive of fracture location3 or cumbersome with multiple types and subtypes.43,123 

Outcome Measures for MIdshaft Clavicle Fractures

No outcome scores are specifically utilized to assess results following pediatric clavicle fractures. Outcome measures utilized are typically patient satisfaction, range of motion, pain, fracture union, and complications. Additional outcome measures assessed have included the Disability of the Arm, Shoulder, and Hand (DASH) Score, the QuickDASH, the simple shoulder test, and the Constant Shoulder Score. Radiographic criteria evaluating shortening and/or vertical displacement have also been utilized to assess results. 

Pathoanatomy and Applied Anatomy Relating to Midshaft Clavicle Fractures

The clavicle, also referred to as the collar bone, is an S-shaped bone that lies along the subcutaneous border of the anterior aspect of the shoulder girdle. An anterior convexity is present medially to permit the passage of the brachial plexus and axillary vessels from the neck region into the upper arm, whereas laterally there is an anterior concavity. 
Development of the clavicle begins at five and a half weeks' gestation via intramembranous ossification and by 8 weeks, the bone has developed into its S shape configuration.45 Postnatally, the clavicle continues to grow at a steady rate until age 12, increasing approximately 8.4 mm per year.92 After 12 years of age, the clavicle grows approximately 2.6 mm per year in females and 5.4 mm per year in males. Thus, 80% of the final clavicle length is reached by age 9 in females and age 12 in males.92 
Medially the clavicle articulates with the sternum, forming the sternoclavicular joint, whereas laterally the bone ends in an articulation with the acromion, forming the AC joint. The medial inferior aspect of the clavicle is the site of attachment of the costoclavicular ligament, whereas laterally on the inferior aspect there is the conoid tubercle and trapezoid line, the sites of attachment for the conoid and trapezoid ligaments, respectively. All of these ligaments slant posteriorly as they approach the clavicle and therefore when the clavicle elevates and the ligaments are put on stretch, the clavicle rotates posteriorly. In addition, these ligaments provide significant stability at both ends of the clavicle, thus making fractures in the middle third of the clavicle more likely. 
The pectoralis major originates from the medial aspect of the clavicle as well as the sternum and inserts onto the humerus at the intertubercular groove whereas the deltoid originates from the lateral aspect of the clavicle as well as the acromion and scapular spine to insert onto the humerus at the deltoid tuberosity. In addition, the sternocleidomastoid and sternohyoid muscles originate from the clavicle whereas the trapezius and subclavius insert onto the clavicle. 

Treatment Options for Midshaft Clavicle Fractures

Nonoperative Treatment of Midshaft Clavicle Fractures

Indications/Contraindications

The mainstay of treatment of pediatric and adolescent clavicle fractures is nonoperative, allowing the fracture to form callous and heal in situ, even if significant displacement is present (Fig. 22-4).8 It is well agreed upon that nondisplaced or minimally displaced fractures, defined as displacement less than 1.5 to 2 cm, should be treated nonoperatively. Fractures that should proceed directly to operative intervention include open fractures, fractures with associated skin tenting, and fractures with associated neurovascular injury (Table 22-1). 
Figure 22-4
 
A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remodeling with growth.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remodeling with growth.
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Figure 22-4
A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remodeling with growth.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a moderately displaced diaphyseal right clavicular fracture. B: Radiograph of the healed fracture with abundant callus formation, demonstrating the potential of remodeling with growth.
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Table 22-1
Midshaft Clavicle Fractures
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Table 22-1
Midshaft Clavicle Fractures
Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced fractures Open fractures
Minimally displaced fractures (<1.5–2 cm of displacement) Fractures associated with skin tenting
Fractures associated with neurovascular injury
X

Techniques

Nonoperative treatment of clavicle fractures is performed by immobilizing the child's shoulder girdle, typically with a sling. Alternatively, a figure-of-eight dressing or shoulder immobilizer can be utilized; however, these are more cumbersome and have not been shown to provide improved results. Neonates who sustain a clavicular fracture during the birthing process, can have immobilization performed utilizing a swath technique, such as placing Webril followed by an ACE bandage around the torso and arm. 
Follow-up radiographs are obtained at 4-week intervals until fracture union occurs. Once union is present and the child's motion and strength have returned to normal, the child is permitted to resume activities as tolerated. Calder et al. have suggested that follow-up radiographs are unnecessary in pediatric patients given the near universal expected fracture healing rate in a child. However, we routinely obtain radiographs until union is established to assess return to sports with decreased refracture risk.25 

Outcomes

Despite the high incidence of pediatric clavicle fractures and the fact that the vast majority of these fractures are treated nonoperatively, little data exist regarding the outcomes of these injuries. Union rates from 95% to 100% have been reported with nonoperative treatment.52,74,138 Most nondisplaced fractures have union by 4 to 8 weeks of time, whereas displaced fractures take longer, approximately 10 weeks.138 
Overall, the vast majority of patients have excellent outcomes and are able to return to their activities without limitations. A small percentage of patients treated nonoperatively with significant fracture displacement may have subjective complaints of pain with prolonged activity, easy fatigability, axillary pain, or drooping shoulders with bony prominence.138 Bae et al. evaluated a group of 16 patients with displaced (>2 cm) mid-diaphyseal clavicle fractures treated nonoperatively. All fractures united with no meaningful loss of shoulder motion or abduction–adduction strength by isokinetic testing. The vast majority of patients had low DASH and pain Visual Analog Scores (VAS) that were very low, means of 4.9 and 1.6 respectively. Only one patient out of 16 required a corrective osteotomy.8 The authors concluded that routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone. Further investigation is required to determine the risk factors and causes of pain and functional compromise in the minority of pediatric patients with symptomatic malunions. In contrast, the adult literature has shown that patients with significantly displaced midshaft fractures treated nonoperatively compared to plate fixation have significantly worse Constant shoulder scores, DASH scores, higher rates of nonunion, longer times to union, and more symptomatic malunions.26 

Operative Treatment of Midshaft Clavicle Fractures

Indications/Contraindications

Absolute indications for operative treatment of clavicle fractures in the pediatric and adolescent population is limited but includes open fractures, fractures with significant skin tenting/compromise (Fig. 22-5), comminuted fractures in which the central fragment is markedly displaced, and fractures associated with neurovascular injury. Additional relative indications may include floating shoulder injuries and fractures associated with polytrauma. Floating shoulder injuries involving midshaft clavicle fractures and fractures of the glenoid neck can be treated by ORIF of the clavicle alone as ligamentotaxis will reduce the other fracture via the coracoclavicular ligament.9 
Figure 22-5
Radiograph of a segmental right diaphyseal clavicle fracture causing skin tenting and subsequent compromise.
 
Note the vertical nature of the segmental fragment.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
Note the vertical nature of the segmental fragment.
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Figure 22-5
Radiograph of a segmental right diaphyseal clavicle fracture causing skin tenting and subsequent compromise.
Note the vertical nature of the segmental fragment.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
Note the vertical nature of the segmental fragment.
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Fractures with significant displacement that are treated nonoperatively in adults have been shown to subsequently heal with a malunion that can cause changes to shoulder mechanics. These alterations have been shown at times to lead to pain with overhead activities, decreased strength, and decreased endurance.58,93 Therefore, multiple studies have investigated the benefit of operative fixation versus nonoperative management of displaced midshaft clavicle fractures. A recent meta-analysis evaluating the results of randomized clinical trials that compared nonoperative and operative treatment in adults found a significantly higher nonunion and symptomatic malunion rate in the nonoperative group. In addition, patients treated with operative intervention had earlier functional return.94 It is unclear whether this data is transferable to the adolescent. Clearly the young child, especially less than age 8 years, has the potential to remodel a foreshortened, displaced fracture. 

Surgical Procedure for Midshaft Clavicle Fractures

Preoperative Planning

As with any procedure that will utilize implants, it is imperative to have the desired hardware available before proceeding to the operating room. Options for treatment of pediatric and adolescent clavicle fractures include anatomically designed clavicle plates, standard nonlocking and locking plates, and intramedullary devices including pins, wires, screws, and elastic nails. 
Intramedullary fixation has the potential benefits of requiring less soft tissue stripping at the fracture site, better cosmesis with smaller skin incisions, easier hardware removal, less potential for hardware irritation, and less bony weakness following hardware removal compared to plate fixation. However, the ability to resist torsional forces is less with intramedullary fixation compared to plating which can result in fracture of the intramedullary implant (Fig. 22-6). Furthermore, the potential for the intramedullary device to migrate is a major concern for many surgeons, thus limiting usage. 
Figure 22-6
Radiograph of a right midshaft clavicular fracture treated with an intramedullary elastic nail, which subsequently went on to fracture.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
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Figure 22-6
Radiograph of a right midshaft clavicular fracture treated with an intramedullary elastic nail, which subsequently went on to fracture.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
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If plate fixation is being planned, one must determine what the preferred location of the plate will be, anteroinferior or superior. Anteroinferior plates have the advantage of performing drilling in a posterosuperior direction, thus the drill is not directed toward the surrounding neurovascular structures. In addition, the plate is less prominent in this location. Superior placement of the plate is technically easier and allows for better resistance of the biomechanical forces acting to displace the fracture (Table 22-2). 
 
Table 22-2
ORIF of Midshaft Clavicle Fractures
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Table 22-2
ORIF of Midshaft Clavicle Fractures
Preoperative Planning Checklist
OR Table: Standard OR table capable of going into beach chair position
Position/positioning aids: Supine beach chair position with head and neck tilted away
Bump placed behind the scapula
Fluoroscopy location: Contralateral to fracture
Equipment: Surgeon's choice of implant
Tourniquet (sterile/nonsterile): None
Draping: Shoulder girdle, entire clavicle and ipsilateral limb is prepped and draped into the field to allow for visualization traction and manipulation
Medially the contralateral sternoclavicular joint should be included in the operative field
X

Positioning

Options for positioning during open reduction and internal fixation or intramedullary fixation of clavicle fractures include utilizing the beach chair position or having the patient supine. With either position, a bump is placed behind the scapula to aid in reducing the fracture. 

Surgical Approach(es)

Open reduction and internal fixation is performed via a direct surgical approach to the clavicle is performed by utilizing a skin incision that follows Langer lines. In an attempt to avoid wound problems, by having the incision directly over the plate, and to improve cosmesis, one can incise the skin on the inferior aspect of the clavicle.32 Once the skin is incised, electrocautery is utilized to divide the platysma, fascia, and periosteum in line with the skin incision. During this process, it is important to identify and protect the cutaneous supraclavicular nerves as they cross the clavicle. Subperiosteal dissection is then carried out to expose the fracture site while ensuring maintenance of the soft tissue attachments to any malrotated or segmental fracture fragments. 
Intramedullary fixation is performed by making a similar approach utilizing a small incision over the fracture site to expose only the ends of fracture fragments. An additional percutaneous incision is placed over the superolateral part of the clavicle to place the intramedullary device in an antegrade manner. 

Technique

Once the fracture site and fragments are exposed, bone holding forceps are utilized to reduce the fracture. If there is a segmental fracture, a separate interfragmentary screw may be used to reduce the fracture from three-parts to two-parts. The fracture is then anatomically reduced and clamped. Areas of comminution are accounted for. Either an anatomic clavicle plate or a small pelvic reconstruction plate is contoured to allow for rigid internal fixation. The plate is subsequently applied in the desired location and either direct visualization alone or fluoroscopic imaging in multiple planes is utilized to assess the reduction, screw placement and length. Following placement of the plate, the periosteum is closed while still protecting the supraclavicular nerves. Layered closure including a meticulous skin closure is then performed to reduce the chance of wound complications and permit the best cosmetic outcome possible. The patient is then placed in a sling or shoulder immobilizer. 
Intramedullary fixation is performed by exposing the fracture ends and then drilling the distal segment retrograde through the canal, exiting the posterior lateral cortex. Drilling of the medial segment is then performed, ensuring no violation of the anterior medial cortex occurs. The device can be placed retrograde through the canal to exit through the posterior-lateral hole and subsequently the skin. Fracture reduction can now be performed and the intramedullary device can be advanced antegrade across the fracture site. Many devices have mechanisms, such as washers or nuts, that can now be applied in an attempt to prevent migration of the device or allow for fracture compression. 

Author's Preferred Treatment of Midshaft Clavicle Fractures

The vast majority of pediatric and adolescent clavicle fractures are treated nonoperatively with immobilization for 3 to 4 weeks. Patients then undergo home or formal rehabilitation to restore range of motion and strength before resuming full activities. Operative treatment is performed for open fractures, fractures with skin compromise, fractures associated with neurologic or vascular injury, and significantly displaced fractures in athletes (Fig. 22-7). 
Figure 22-7
 
A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two.
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Figure 22-7
A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a displaced, segmental right diaphyseal clavicle fracture. B: Incision in line with Langer lines, ensuring protection of the supraclavicular cutaneous nerves as the exposure is performed. C: Plate placement on the superior aspect of the clavicle while preserving the supraclavicular cutaneous nerves. D: Postoperative radiograph of the anatomically reduced fracture. Note the interfragmentary screw that was utilized to convert this fracture from three fragments to two.
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We utilize the beach chair position and make our skin incision approximately 1 cm inferior to the clavicle. Following exposure of the fracture fragments, reduction is performed utilizing bone holding forceps. It is imperative to restore the length and contour of the clavicle during the reduction process. This may require utilization of smooth wires, suture, or interfragmentary screws. Once the reduction is near anatomic, the plate is applied on the superior aspect of the clavicle. During drilling and screw placement, we protect the surrounding neurovascular structures by placement of a malleable retractor inferior to the clavicle. Following plate placement, fluoroscopic imaging and/or direct visualization is utilized to assess the fracture reduction and screw lengths. The wound is then thoroughly irrigated and the periosteum closed. A meticulous subcuticular closure is then performed to obtain the best cosmetic result possible and decrease the chance of wound complications. Sterile dressings are applied followed by placement of the patient into either a sling or shoulder immobilizer. 

Postoperative Care for Midshaft Clavicle Fractures

Whether open reduction and internal fixation or intramedullary fixation is performed, the patient is placed in a sling or shoulder immobilizer for 3 to 4 weeks. At that point, clinical examination is utilized to assess tenderness at the fracture site and radiographs in two planes are obtained to assess bony healing. If the examination and radiographs are consistent with healing, the patient is permitted to begin range-of-motion activities followed by strengthening once the bone is fully healed. Full activity can be resumed once the range of motion and strength are returned to baseline levels. 

Potential Pitfalls and Preventive Measures for Midshaft Clavicle Fractures

The most dreaded intraoperative complication would be damage to a neurovascular structure or creation of a pneumothorax. Both of these exceedingly rare iatrogenic complications can be prevented by utilizing meticulous technique during the exposure of the fracture fragments and drilling/screw placement during the plate application. When exposing the fracture fragments, it is imperative to stay subperiosteal to create a layer between the bone and surrounding neurovascular structures. Subsequently, retractors can be placed in this layer and direct visualization can be utilized during the drilling and screw placement process to avoid damaging the neurovascular structures. 
Maintenance of soft tissue attachments to comminuted or malrotated small fragments will aid the surgeon in the reduction process. Furthermore, if these fragments are completely devoid of soft tissue attachments, devitalization may cause bony union to be delayed or not occur. 
Wound complications can be prevented by utilizing the inferior skin incision rather than a direct approach to the clavicle. In addition, a meticulous closure at the end of the procedure will permit the best cosmetic outcome while minimizing the chance of wound issues. 

Treatment-Specific Outcomes for Midshaft Clavicle Fractures

The majority of available data for the treatment of pediatric and adolescent midshaft clavicle fractures is retrospective in nature involving preadolescents and adolescents. Mehlman et al. performed a retrospective review of 24 children with a mean age of 12 years who underwent operative treatment of completely displaced clavicle shaft fractures. In their series, there were no nonunions and no infections. Twenty-one of the 24 patients were able to return to unrestricted sports activity. Three complications were reported including two patients who had scar sensitivity and one patient who had a transient ulnar nerve neurapraxia. All patients underwent hardware removal on an elective basis.95 
Namdari et al. also performed a retrospective review of 14 skeletally immature patients who underwent open reduction and internal fixation of displaced midshaft clavicle fractures. No nonunions occurred in the cohort but eight patients had numbness about the surgical site. Four patients had their hardware removed.101 
Vander Have et al. have performed the only comparative study to date evaluating nonoperative versus operative treatment of midshaft clavicle fractures in adolescents. The authors retrospectively reviewed 43 fractures of which 25 were treated nonoperatively and 17 were treated operatively. No nonunions occurred in either group but five symptomatic malunions occurred in the nonoperative group, four of which were treated with a corrective osteotomy. All complications in the operative group were related to prominence of the hardware. Return to full activities occurred faster, by approximately 4 weeks, in the operative group compared to the nonoperative group.138 
Although the Vander Have study showed a high rate (20%) of symptomatic malunion, with many requiring corrective osteotomy, in the nonoperative group, Bae et al. have recently reported that the vast majority of significantly displaced (>2 cm) diaphyseal clavicle fractures treated nonoperatively result in an asymptomatic malunion that does not require corrective osteotomy. Of the 16 fractures studied, all united in a malunited position with only one requiring a corrective osteotomy. The mean DASH score was low at 4.9 and the mean pain VAS was 1.6. No significant loss of strength or motion was present.8 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Midshaft Clavicle Fractures

Patients who have prominence of their hardware can be successfully treated by removal of their hardware.95,101,138 If a patient initially treated by nonoperative measures develops a symptomatic malunion, corrective osteotomy has been shown to be successful in eliminating symptoms (Fig. 22-8).138 In the Vander Have series, all patients who underwent corrective osteotomy of their malunion went on to union and resolution of their symptoms.138 Only one nonunion has been reported in the pediatric and adolescent literature to date.107 Treatment can be successfully performed by subsequent open reduction and internal fixation with a stable construct. On rare occasion, a vascularized bone or corticoperiosteal flap may be necessary (Fig. 22-9, Table 22-3). 
Figure 22-8
 
A: Intraoperative photograph depicting the mid diaphyseal malunion. B: Intraoperative photograph showing the osteotomy has been performed in the plane of maximal deformity. C: Intraoperative photograph following reduction and plating of the malunion.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Intraoperative photograph depicting the mid diaphyseal malunion. B: Intraoperative photograph showing the osteotomy has been performed in the plane of maximal deformity. C: Intraoperative photograph following reduction and plating of the malunion.
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Figure 22-8
A: Intraoperative photograph depicting the mid diaphyseal malunion. B: Intraoperative photograph showing the osteotomy has been performed in the plane of maximal deformity. C: Intraoperative photograph following reduction and plating of the malunion.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Intraoperative photograph depicting the mid diaphyseal malunion. B: Intraoperative photograph showing the osteotomy has been performed in the plane of maximal deformity. C: Intraoperative photograph following reduction and plating of the malunion.
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Figure 22-9
Radiograph of a healed clavicle fracture following treatment of a symptomatic nonunion with a vascularized fibula graft.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
View Original | Slide (.ppt)
Figure 22-9
Radiograph of a healed clavicle fracture following treatment of a symptomatic nonunion with a vascularized fibula graft.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
View Original | Slide (.ppt)
X
 
Table 22-3
ORIF of Midshaft Clavicle Fractures
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Table 22-3
ORIF of Midshaft Clavicle Fractures
Surgical Steps
  1.  
    Skin incision approximately 1 cm inferior to the clavicle in line with Langer lines
  2.  
    Electrocautery through platysma, fascia, and periosteum directly onto the clavicle while avoiding injury to the supraclavicular cutaneous nerves
  3.  
    Expose fracture site in a subperiosteal manner while preserving soft tissue attachments to malrotated and comminuted fragments
  4.  
    Reduce fracture fragments utilizing bone holding forceps
  5.  
    Apply plate in desired location
  6.  
    Assess reduction and screw lengths with direct visualization or fluoroscopic imaging in multiple planes
  7.  
    Close periosteum
  8.  
    Meticulous skin closure
  9.  
    Apply sling or shoulder immobilizer
Intramedullary Fixation of Midshaft Clavicle Fractures
Surgical Steps
  1.  
    Skin incision overlying the fracture site in line with Langer lines
  2.  
    Electrocautery through fascia and periosteum directly onto the clavicle while avoiding injury to the supraclavicular cutaneous nerves
  3.  
    Expose fracture site in a subperiosteal manner while preserving soft tissue attachments to malrotated and comminuted fragments
  4.  
    Drill the medial segment of the fracture in preparation for device placement while ensuring no violation of the anterior medial cortex occurs
  5.  
    Drill distal fragment medullary canal and then posterior lateral cortex so that the drill can be visualized just beneath the skin
  6.  
    Make a percutaneous skin incision where the drill is tenting the skin
  7.  
    Place intramedullary device in a retrograde manner through fracture site to exit through posterior lateral skin incision
  8.  
    Reduce fracture fragments
  9.  
    Advance device antegrade across the fracture
  10.  
    Place device-specific mechanisms, if available, to prevent migration or permit compression
  11.  
    Close periosteum
  12.  
    Meticulous skin closure
  13.  
    Apply sling or shoulder immobilizer
X

Summary, Controversies, and Future Directions Related to Midshaft Clavicle Fractures

The vast majority of pediatric and adolescent midshaft clavicle fractures can be treated successfully with nonoperative measures. Open reduction and internal fixation should be performed for open fractures, fractures with skin compromise, and fractures with nerve or vascular injury. In addition, recent literature has suggested a faster return to activities utilizing open reduction and internal fixation of markedly displaced (>2 cm) or segmental fractures in older patients. Future prospective studies will need to be performed to determine the potential benefits and complications of operative fixation versus nonoperative treatment in adolescents. 

Introduction to Distal Clavicle Fractures

Distal clavicle fractures account for 10% to 30% of all clavicle fractures, thus making it the second most common site for a clavicle fracture.124 Minimal studies exist regarding the treatment and outcomes of these fractures for pediatric and adolescent patients. Therefore, the information presented here will mainly be extrapolated from the adult literature and our experience. 

Assessment of Distal Clavicle Fractures

Mechanisms of Injury for Distal Clavicle Fractures

Akin to midshaft clavicle fractures, distal clavicle fractures are typically the result of a direct blow to the shoulder girdle or a fall onto the distal aspect of the clavicle.124,131 Direct blows typically occur in adolescents involved in collision-type sports such as football or lacrosse. When a fall is the mechanism of injury, direct contact from the ground is made against the acromion with the arm typically held in an adducted position. The force is transmitted from the acromion across the AC joint to the distal end of the clavicle. 

Associated Injuries with Distal Clavicle Fractures

Common injuries associated with distal clavicle fractures include additional fractures about the shoulder girdle including proximal humerus and scapular fractures, thus constituting a floating shoulder-type injury. In addition, rib fractures, lung injuries including contusions, and brachial plexus injuries may occur concomitantly. Lastly, cervical spine injuries must be ruled out in collision or high-energy mechanisms of injury. 

Signs and Symptoms of Distal Clavicle Fractures

Patients who sustain distal clavicle fractures present with pain about the involved shoulder especially with any attempt at movement of the arm. Paresthesias may be present if a concomitant brachial plexus injury occurred or there is swelling causing injury to the supraclavicular nerves. 
Physical examination should begin by observing for obvious swelling, ecchymosis, and/or skin tenting. Palpation of the entire upper extremity, hemithorax, and cervical spine should be performed to identify the location of maximal tenderness as well as additional areas that may have sustained a concomitant injury. A complete neurovascular examination should be performed to evaluate for rare brachial plexus injury. Patients involved in high-energy mechanisms should have a complete head-to-toe survey performed by the orthopedic physician as well as either a member of the trauma team or the emergency room physician. 

Imaging and Other Diagnostic Studies for Distal Clavicle Fractures

Initial imaging should be performed by obtaining plain radiographs of the shoulder including a true AP view and an axillary lateral view. In addition, a Zanca view can be obtained to better assess the AC joint for intra-articular involvement. This is performed by aiming the x-ray beam in 10 to 15 degrees of cephalic tilt.149 A CT scan will be diagnostic of intra-articular fractures, which may require operative intervention for best results. 

Classification of Distal Clavicle Fractures

The most commonly utilized classification scheme for distal clavicle fractures is that proposed by Neer and modified by Craig.33,104 This classification scheme includes five types based on the relationship of the fracture line to the coracoclavicular ligaments, the AC ligaments, and the physis. Most lateral clavicle fractures in the skeletally immature are periosteal disruptions in which the bone displaces away from the periosteal sleeve whereas the ligaments remain attached to the intact inferior portion of the periosteum. 
Type I fractures occur distal to the coracoclavicular ligaments but do not involve the AC joint. Minimal displacement occurs due to the proximal fragment being stabilized by the intact coracoclavicular ligaments and the distal fragment being stabilized by the AC joint capsule, the AC ligaments, and the deltotrapezial fascia. 
Type II fractures are subdivided into type IIA and type IIB fractures, with type IIA fractures occurring medial to the coracoclavicular ligaments and type IIB fractures occurring between the coracoclavicular ligaments with concomitant injury to the conoid ligament. In type IIA injuries, the proximal fragment loses the stability provided by the coracoclavicular ligaments and displaces superiorly out of the periosteal sleeve. In contrast, the distal fragment remains stable because of the attachments of the AC joint capsule, AC ligaments, and the coracoclavicular ligament(s). This remains true for type IIB fractures as well, because even though the conoid ligament is disrupted, the trapezoid ligament remains attached. 
Type III fractures occur distal to the coracoclavicular ligaments and extend into the AC joint. As these fractures do not disrupt the ligamentous structures, minimal displacement is the norm. 
Type IV fractures occur in skeletally immature patients and involve a fracture medial to the physis. The epiphysis and physis remain uninjured and attached to the AC joint. However, significant displacement can occur between the physis and metaphyseal fragment, as the coracoclavicular ligaments are attached to the physis. This is especially true if the periosteal sleeve is disrupted. In essence, this is analogous to a type IIA fracture. 
Type V fractures have a fracture line that leaves a free-floating inferior cortical fragment attached to the coracoclavicular ligaments with an additional fracture line dividing the distal clavicle from the remainder of the clavicle. Therefore, neither the proximal nor distal fragment is attached to the coracoclavicular ligaments. The end result is instability with the potential for significant displacement of the distal end of the proximal fragment. 

Outcome Measures for Distal Clavicle Fractures

No specific outcome score exists in isolation for distal clavicle fractures. Therefore, outcomes are described based on union rates and subjective patient outcomes. Adult-oriented outcome measures have been individually utilized in various studies, including the Constant Score, the American Shoulder and Elbow Surgeons (ASES) score, and the Medical Outcomes Study 36-Item Short Form. However these have not been used universally and none of them have been validated in the pediatric or adolescent populations. 

Pathoanatomy and Applied Anatomy Relating to Distal Clavicle Fractures

The distal aspect of the clavicle forms the articulation with the scapula via the AC joint. Ligamentous connections between this portion of the clavicle and the scapula include the AC ligaments and coracoclavicular ligaments. The coracoclavicular ligaments include the trapezoid ligament, located more laterally with an attachment to the distal clavicle approximately 2 cm from the AC joint, and the conoid ligament, located more medially with an attachment to the distal clavicle approximately 4 cm from the AC joint.120 The presence of these ligamentous attachments and the acromioclavicular joint capsule permit fluid scapulothoracic motion.11 
Stability of the clavicle in the horizontal/AP plane is provided by the AC ligaments whereas stability in the vertical/superoinferior plane is provided by the coracoclavicular ligaments.44 This stability permits the definition of the coracoclavicular space, the space between the coracoid process and the undersurface of the clavicle, which should be 1.1 to 1.3 cm.16 

Treatment Options for Distal Clavicle Fractures

Nonoperative Treatment of Distal Clavicle Fractures

Indications/Contraindications

The majority of distal clavicle fractures in the pediatric and adolescent population can be managed nonoperatively with immobilization alone as long as significant displacement is not present. Typically, this is universally true for type I and type III fractures. However, types II, IV, and V fractures may have significant displacement with subsequent skin tenting or instability present about the shoulder girdle. Contraindications to nonsurgical management include open fractures, fractures associated with skin compromise, and fractures with concomitant neurovascular injury requiring surgical intervention. Displaced fractures in the pediatric and adolescent population (types II, IV, and V) should be treated on an individual basis depending on the patient's age, the amount of displacement, and the patient's activities (Table 22-4). 
 
Table 22-4
Midshaft Clavicle Fractures
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Table 22-4
Midshaft Clavicle Fractures
Potential Pitfalls and Preventions
Pitfall Prevention
Neurovascular injury/pneumothorax Utilize subperiosteal dissection
Place retractors inferiorly when drilling from superior to inferior direction
Delayed union/nonunion Maintain soft tissue attachments to comminuted or malrotated fragments
Malunion Maintain soft tissue attachments to comminuted or malrotated fragments
Anatomically reduce and stabilize segmental fractures
X

Techniques

Patients are placed in either a sling or shoulder immobilizer for approximately 3 to 4 weeks and then allowed to begin active range of motion. Radiographs are taken at the 3- to 4-week follow-up visit to ensure adequate healing is occurring and there has been no further displacement. 

Outcomes

Nonoperative treatment of nondisplaced or minimally displaced distal clavicle fractures typically has excellent outcomes with successful union occurring and patients able to return to full activities. However, types I and III fractures have been shown to go on to delayed-onset symptomatic AC joint arthrosis in the adult literature.103 
Treatment of significantly displaced distal clavicle fractures is somewhat controversial due to a relatively high nonunion rate reported in the adult literature. In a retrospective review performed by Neer,102 he documented that all patients with type II distal clavicle fractures treated nonoperatively, had either a delayed union (67%) or a nonunion (33%). Edwards et al.37 treated 20 patients with type II distal clavicle fractures nonoperatively and had a 45% delayed union rate and a 30% nonunion rate. Additional studies have shown similar nonunion rates ranging from 25% to 44% for type II fractures treated nonoperatively.110,124,125,127 In contrast, all type II fractures treated surgically with open reduction and internal fixation have gone on to union.37,102,127 

Operative Treatment of Distal Clavicle Fractures

Indications/Contraindications

Absolute indications for operative treatment of distal clavicle fractures include open fractures, fractures with significant skin compromise, displaced intra-articular extension, and fractures with associated neurovascular injuries that require operative intervention. Additional relative indications may include significantly displaced fractures in competitive athletes and adolescents, entrapment in the trapezius muscle, floating shoulder-type injuries, and patients with polytrauma. 

Surgical Procedure for Distal Clavicle Fractures

Preoperative Planning

It is necessary to determine preoperatively what the plan for fixation is going to be as numerous techniques can be performed to stabilize the distal clavicle. Ideally, multiple options are available at the time of surgical intervention including various nonabsorbable suture options, Dacron tape, and locking plates, such as anatomic clavicle plates and hook plates. The position the patient will be in during the procedure needs to be discussed with the anesthesiologist and operating room staff, especially if the beach chair position is being utilized (Table 22-5). 
 
Table 22-5
Midshaft Clavicle Fractures
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Table 22-5
Midshaft Clavicle Fractures
Common Adverse Outcomes and Complications
Hardware prominence
Malunion
Nonunion
Wound complications
X

Positioning

The patient can be positioned in either the beach chair position with the head and neck tilted away or supine on a radiolucent table. With either position, a bump should be placed behind the scapula. The entire shoulder girdle, beginning at the medial edge of the clavicle, and entire limb should be prepped and draped in the operative field to allow for movement of the limb which facilitates fracture reduction and fixation. A sterile area above the shoulder adjacent to the head is maintained to allow for the surgeon to work both inferior and superior to the clavicle and shoulder. 

Surgical Approach(es)

A slightly curved incision in Langer skin lines over the distal third of the clavicle and AC joint should be made. Once the skin is divided, the subcutaneous tissue, fascia, and periosteum are incised to maintain a thick flap. Subperiosteal dissection is then carried out from nonfractured clavicle out to the fracture site to expose the fracture fragments. 

Technique

Fixation with low-profile anatomic distal locking plates or hook plates can be utilized for skeletally mature adolescents as appropriate (Fig. 22-10). Younger patients may require utilization of modular hand instrumentation or mini-fragment locking plates (Synthes, Inc., West Chester, PA). Distal radius plate fixation has also been suggested by placement of the 2.4-mm locking screws in the distal clavicle fragment.68 
Figure 22-10
 
A: Radiograph of a displaced intra-articular lateral clavicle fracture where the lateral aspect of the medial fragment was entrapped in the trapezius muscle. B: Postoperative radiograph demonstrating fixation utilizing a hook plate. Removal of the implant is planned.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a displaced intra-articular lateral clavicle fracture where the lateral aspect of the medial fragment was entrapped in the trapezius muscle. B: Postoperative radiograph demonstrating fixation utilizing a hook plate. Removal of the implant is planned.
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Figure 22-10
A: Radiograph of a displaced intra-articular lateral clavicle fracture where the lateral aspect of the medial fragment was entrapped in the trapezius muscle. B: Postoperative radiograph demonstrating fixation utilizing a hook plate. Removal of the implant is planned.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Radiograph of a displaced intra-articular lateral clavicle fracture where the lateral aspect of the medial fragment was entrapped in the trapezius muscle. B: Postoperative radiograph demonstrating fixation utilizing a hook plate. Removal of the implant is planned.
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The implant choice will depend on the age and size of the patient, as well as the size and location of the fracture fragments. Larger patients and fragments will permit fixation with low-profile locking plates, whereas smaller fragments may require fixation with suture, Kirschner wire fixation, or even a hook plate. Kirschner wire fixation should be supplemented with a dorsal tension band, utilizing either suture or wire. Threaded wires are used to lessen the risk of migration.6,69,82,87 
Additional fixation of the coracoclavicular ligaments has been suggested to decrease the chance of nonunion in adults. This has been performed utilizing suture or Dacron tape with or without additional fixation.47,143 In addition, arthroscopic techniques, utilizing suture, the Tightrope system (Arthrex, Naples, FL) or a double-button device, to stabilize the coracoclavicular ligaments have also been reported in adults.14,29,111,117 Some authors have proposed placement of a screw between the coracoid and clavicle, however this requires screw removal following fracture union.10,37,39,65,86,148 Neither of these techniques are used very often in children or adolescents because of the periosteal insertion of the ligaments. Once the periosteum is repaired, the ligaments usually are stable (Table 22-6). 
 
Table 22-6
Distal Clavicle Fractures
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Table 22-6
Distal Clavicle Fractures
Nonoperative Treatment
Indications Relative Contraindications
Nondisplaced and minimally displaced fractures (type I and type III fractures) Open fractures
Fractures with associated skin compromise
Fractures with concomitant neurovascular injury requiring surgical intervention
X

Author's Preferred Treatment of Distal Clavicle Fractures

Our preferred technique is to treat the vast majority of distal clavicle fractures in the pediatric and adolescent populations with nonoperative measures. Patients are placed into a sling or shoulder immobilizer for 3 to 4 weeks and then advanced to active range of motion, presuming union has occurred. Operative intervention is reserved for open fractures, fractures with skin compromise, fractures with associated neurovascular injury requiring operative intervention, displaced intra-articular fractures and significantly displaced fractures, especially those displaced posteriorly with entrapment in trapezius muscle. 
A direct approach to the fracture site is performed utilizing a Langer skin line. Following sharp incision of the skin, electrocautery is utilized to divide the subcutaneous tissue, fascia, and periosteum. A freer elevator or similar blunt instrument is then used to elevate the periosteum off of the clavicle while preserving the AC and coracoclavicular ligament attachments. The fracture fragments are then exposed and irrigated free of hematoma and debris in preparation for reduction. 
Fixation of a distal clavicle fracture is ideally performed utilizing a plate and screw construct, assuming there is enough bone laterally for stable fixation. In older adolescents, we utilize anatomically contoured distal clavicular locking plates when feasible. If the fragment is too small for these implants, we attempt to perform fixation utilizing mini-fragment or modular hand-locking plates (Synthes, Inc., West Chester, PA). We do not routinely supplement our plate fixation with suture around the coracoid and clavicle unless the fixation was marginal. The periosteal repair is generally sufficient for ligamentous and soft tissue stability. 
If plate fixation is not an option, interosseous suture fixation of the fracture fragments is performed (Fig. 22-11). We have not found it necessary to place suture around the coracoid and clavicle to obtain union in the pediatric and adolescent populations. Hook plates are only utilized as a last resort, as they require a second procedure for removal. However, they are available during all procedures, in case adequate fixation is unable to be obtained without them. Generally the hook plate would be used in an appropriately sized adolescent. 
Figure 22-11
 
A, B: Preoperative AP and Scapula Y views of a displaced lateral clavicle fracture. C: Intraoperative photograph depicting the incision along Langer skin lines overlying the distal part of the clavicle and acromion. D: Intraoperative photograph showing fixation of the fracture utilizing interosseous suture.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A, B: Preoperative AP and Scapula Y views of a displaced lateral clavicle fracture. C: Intraoperative photograph depicting the incision along Langer skin lines overlying the distal part of the clavicle and acromion. D: Intraoperative photograph showing fixation of the fracture utilizing interosseous suture.
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Figure 22-11
A, B: Preoperative AP and Scapula Y views of a displaced lateral clavicle fracture. C: Intraoperative photograph depicting the incision along Langer skin lines overlying the distal part of the clavicle and acromion. D: Intraoperative photograph showing fixation of the fracture utilizing interosseous suture.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A, B: Preoperative AP and Scapula Y views of a displaced lateral clavicle fracture. C: Intraoperative photograph depicting the incision along Langer skin lines overlying the distal part of the clavicle and acromion. D: Intraoperative photograph showing fixation of the fracture utilizing interosseous suture.
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Postoperative Care

Postoperatively, patients are placed in a sling or shoulder immobilizer for 4 to 6 weeks. Postoperative mobilization is dependent on age and psychological maturity of the patient as well as rigidity of the fixation. When safe, immobilization is removed several times a day for pendulum exercises. Following union of the fracture, active shoulder range of motion and strengthening is initiated. Contact sports participation is usually avoided for 3 months. 

Potential Pitfalls and Preventive Measures for Distal Clavicle Fractures

Nonunion or hardware failure can occur if there is inadequate fixation of the distal clavicular fragment or excessive activity early. In addition, it is imperative to avoid screw penetration into the AC joint, which can be assessed with direct visualization and/or utilizing fluoroscopy in multiple planes. 

Treatment-Specific Outcomes for Distal Clavicle Fractures

Operative treatment of distal clavicle fractures has excellent results with regard to union rates, especially in children and adolescents. The main concern is hardware complications. Utilization of smooth wires about this region has led to migration of the wires into areas including the lung, abdomen, spine, trachea, and vascular structures. Avoid smooth wires if possible; leave them out of skin and remove them early if used.85,118,137 Furthermore, tension band wiring is prone to symptomatic hardware requiring a second procedure for removal. Using ethibond suture as a tension band lessens the risk of hardware irritation but suture granulomas can also be irritating and require subsequent removal at times.79 
Union rates with plate fixation have been reported to be as high as 100%.25,45 Studies comparing techniques for treatment of very distal fractures have found that hook plate usage in adults yields better results with regard to return to work and sports participation while having a lower complication rate.42,79 However, we would advocate removal of the hook plate in an adolescent when the fracture is healed to avoid secondary complications. 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Distal Clavicle Fractures

The most common complication of treatment of distal clavicle fractures is related to symptomatic hardware, which is easily remedied by removal of hardware. Nonunion and symptomatic malunions are best managed by performing open reduction and internal fixation of the fracture. If necessary, the distal fragment can be excised and the AC joint can be reconstructed utilizing a modified Weaver–Dunn procedure, where the coracoacromial ligament is transferred to the distal end of the remaining clavicle (Table 22-7).5 
 
Table 22-7
ORIF of Distal Clavicle Fractures
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Table 22-7
ORIF of Distal Clavicle Fractures
Preoperative Planning Checklist
OR Table: Standard operating room table capable of being put into beach chair position
Position/positioning aids: Beach chair position with head and neck tilted away or supine
Bump placed behind the scapula. Leave plenty of sterile standing space above the shoulder adjacent to the head
Fluoroscopy location: Contralateral side of fracture
Equipment: Nonabsorbable suture, Dacron tape, anatomic clavicle plates, hook plates, mini fragment or modular hand locking plates
Tourniquet (sterile/nonsterile): None
Draping: Entire shoulder girdle region and ipsilateral limb is prepped and draped into the field to allow for traction and manipulation
Medially the contralateral sternoclavicular joint should be included in the operative field
X

Summary, Controversies, and Future Directions Related to Distal Clavicle Fractures

The majority of literature available on distal clavicle fractures is for the adult population. Typically, if a child or adolescent sustains a fracture in this region, immobilization alone is sufficient to obtain a successful outcome. In older adolescents and highly competitive athletes, operative intervention may be warranted. Utilization of a plate and screw construct typically yields excellent results with a rapid return to function, a very high union rate, and a low complication rate. Further studies evaluating the treatment and outcomes of these fractures in adolescents are needed. 

Introduction to Scapula Fractures

Scapula fractures are uncommon accounting for 1% of all fractures in adults with an even lower incidence in children.51,134 Fractures involving the scapular body are most common accounting for approximately 45% of fractures. The remainder of fractures involve the glenoid neck (25%), glenoid cavity (10%), acromion process (8%), coracoid process (7%), and scapular spine (5%).91,134 Very rarely, scapulothoracic dissociation can occur and has been reported in two separate case reports involving children, one child 8 years old and the other 11 years old.4,106 Because of the low incidence of scapular fractures, mostly case report and retrospective small case series literature exist on their treatment and outcomes in the pediatric and adolescent populations. 

Assessment of Scapula Fractures

Mechanisms of Injury for Scapula Fractures

When scapula body fractures occur in children they are likely the result of either high-energy mechanisms, such as a fall from a height or motor vehicle accidents, or the result of nonaccidental injury.22 Bullock et al.22 showed that scapula fractures had the highest risk of abuse for any fracture other than rib/sternum fractures and when they were present, they were more than twice as likely to be associated with child abuse than not. 
Glenoid fractures most commonly occur due to a direct force on the lateral shoulder, such as occurs during a fall or a collision sport. The force is transmitted to the humeral head, which then is driven into the glenoid surface.24 An alternative mechanism of injury is a fall onto a flexed elbow.84 The position of the arm at the time of injury will determine whether an anterior or posterior rim fracture occurs.98 
Acromion fractures occur due to a direct blow to the lateral aspect of the shoulder, which typically occurs during a fall or a collision in sport.91 It is imperative to recognize that complete failure of the epiphyses to fuse is a normal anatomic variant known as os acromiale, and should not be mistaken for a fracture.83 If necessary, comparison radiographs with the contralateral side can be obtained to evaluate for this. 
Coracoid fractures occur due to the pull of either the AC ligaments or the conjoint tendon. When the AC ligaments avulse the coracoid from the remainder of the scapula, the fracture occurs at the physis through the base of the coracoid and upper quarter of the glenoid.57 In contrast, when the conjoint tendon avulses the coracoid from the scapula, the fracture occurs through the tip of the coracoid.34 

Associated Injuries with Scapula Fractures

Whether scapula fractures occur due to high-energy mechanisms or nonaccidental trauma, associated injuries are common, including life-threatening injuries. Such injuries include closed head injuries, pneumo- or hemothorax, rib fractures, ruptured viscera, and concomitant long-bone fractures.51,62,134 Almost half of all children admitted to the hospital for nonaccidental trauma have at least one fracture and approximately one-third had a diagnosis of contusion.22 Concomitant neurovascular injury may also occur involving the brachial plexus, subclavian artery/vein, or axillary vessels. Lastly, additional fractures or dislocations can occur about the shoulder girdle, leading to a floating shoulder. 

Signs and Symptoms of Scapula Fractures

Because of the large amount of force required to sustain a scapula fracture, a complete head-to-toe survey should be performed by either the trauma team or emergency room physician. Associated rib fractures or lung injury may cause difficulty breathing, whereas ruptured viscera will lead to an acute abdomen. In cases of suspected nonaccidental trauma, a complete evaluation needs to be performed including a head CT scan, an ophthalmologic examination, a skeletal survey, and a social work consultation. 
Patients with scapula fractures will often complain of significant pain about their chest, back, and shoulder region. Numbness may be present because of concomitant brachial plexus injury or significant swelling. Observation for significant swelling and ecchymosis should begin the examination. Subsequently, a complete neurovascular examination of the involved upper extremity is necessary. Palpation should then be performed to determine the location of maximal tenderness as well as additional areas of tenderness, as concomitant shoulder girdle fractures can be present. A secondary survey should be performed by the orthopedic surgeon to ensure there are no additional musculoskeletal injuries. 

Imaging and Other Diagnostic Studies for Scapula Fractures

Scapula fractures may initially be discovered on the chest x-ray obtained during the trauma work-up; however, additional imaging is necessary to fully evaluate the fracture. Plain radiographs including true AP and lateral scapula views as well as a glenohumeral axillary view should be obtained when a scapula fracture is suspected. In addition, because of the significant amount of overlying bony and soft tissue structures, a CT scan will enable the surgeon to fully understand the fracture pattern. The addition of reconstructions, including three-dimensional reconstructions, will aid in preoperative planning if operative intervention is being considered. 

Classification of Scapula Fractures

Scapula fractures are classified according to the fracture location within the scapula; body, glenoid cavity, glenoid neck, acromion, or coracoid. In addition, scapulothoracic dissociation is a term utilized to describe complete separation of the scapula from the posterior chest wall. 
Glenoid neck fractures are further classified based on their displacement and angulation. A type I fracture is displaced less than 1 cm and angulated less than 40 degrees, whereas a type II fracture has more than 1 cm of displacement and is angulated greater than 40 degrees.50 Type I fractures account for 90% of glenoid neck fractures.2,150 
Glenoid cavity fractures are classified into six types based on the location of the fracture within the glenoid cavity and their severity (Fig. 22-12).49,61 Type I fractures involve either the anterior (type Ia) or posterior (type Ib) aspect of the glenoid rim. Type II fractures have a transverse fracture line that divides the superior and inferior aspects of the glenoid and then exits inferiorly through the lateral scapular border. Types III and IV fractures also begin with a fracture line dividing the superior and inferior aspects of the glenoid, but type III fractures exit superiorly near or through the scapular notch and type IV fractures exit medially through the medial border of the scapula. Type V fractures have more than one fracture line involving a combination of types II to IV and are further subclassified into a, b, and c. Type Va fractures are a combination of type II and IV fractures; type Vb fractures are a combination of types III and IV fractures; and type Vc fractures are a combination of types II, III, and IV fractures. Lastly, type VI fractures are severely comminuted fractures. 
Figure 22-12
Schematic depicting the six types of glenoid cavity fractures.
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Outcome Measures for Scapula Fractures

No specific outcome measures exist for the evaluation of scapula fractures. Results in the adult literature utilize subjective complaints of pain, fracture displacement, residual deformity, nonunion, and development of posttraumatic arthritis as determinants for success.38,72,77,89,108 Specific pediatric outcomes have not been developed but the goals of outcome are the same: Restoration of motion, function, and strength without long-term limitations and/or pain. 

Pathoanatomy and Applied Anatomy Relating to Scapula Fractures

The scapula is a flat bone on the posterior aspect of the chest wall, covered almost entirely by muscle due to it having 17 muscular attachments on it. Only the dorsal aspect of the scapular spine and acromion are subcutaneous, thus the remainder of the bone is deep and well protected from low-energy mechanisms of injury. Three articulations occur with the scapula; the acromion articulates with the clavicle at the AC joint; the proximal humerus articulates with the glenoid at the glenohumeral joint; and the posterior chest wall articulates with the anterior scapula to make up the scapulothoracic articulation. 

Treatment Options for Scapula Fractures

Nonoperative Treatment of Scapula Fractures

Indications/Contraindications

The vast majority of scapula fractures can be treated nonoperatively with immobilization alone, no matter what part of the scapula the fracture involves. Exceptions include open fractures, fractures with associated neurovascular injuries requiring operative intervention, scapulothoracic dissociation, large glenoid rim fractures with associated proximal humerus subluxation/dislocation, type II glenoid neck fractures, and glenoid cavity fractures with displacement greater than 5 mm.2,4,72,106 All of these are very rare in children but need not be missed (Table 22-8). 
 
Table 22-8
ORIF of Distal Clavicle Fractures
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Table 22-8
ORIF of Distal Clavicle Fractures
Surgical Steps
  1.  
    Skin incision over distal 1/3 of clavicle and acromion in line with Langer lines
  2.  
    Electrocautery through subcutaneous tissue, fascia, and periosteum directly onto the clavicle
  3.  
    Expose fracture site in a subperiosteal manner while preserving the acromioclavicular and coracoclavicular ligaments
  4.  
    Reduce fracture fragments with reduction clamps and temporary Kirschner wire fixation if necessary
  5.  
    Apply plate on superior aspect of clavicle
  6.  
    Assess reduction and screw lengths with direct visualization and/or fluoroscopic imaging in multiple planes
  7.  
    Repair periosteum to tighten coracoclavicular and acromioclavicular ligaments. Rarely apply supplemental fixation to coracoclavicular ligaments utilizing suture around coracoid and clavicle if fixation is marginal
  8.  
    Irrigate wound and close periosteum
  9.  
    Meticulous skin closure with absorbable suture
  10.  
    Apply sling or shoulder immobilizer
X

Techniques

A sling or shoulder immobilizer is utilized for 3 to 6 weeks depending on patient, injury severity, and healing. When there is sufficient healing and reduction in pain, rehabilitation progresses from pendulum exercises to full range of motion and strengthening. Return to sports is usually 8 to 12 weeks after injury. 

Outcomes

No large studies exist regarding the outcomes of children treated for scapula fractures. In the adult literature, the vast majority of patients obtain fracture union and have minimal to no pain with good functional outcomes expected.51,108 Similarly most reports indicate children do well with this rare injury. 

Operative Treatment of Scapula Fractures

Indications/Contraindications

Operative indications for scapula fractures are limited in the pediatric and adolescent populations but include open fractures, fractures with associated neurovascular injuries requiring operative intervention, scapulothoracic dissociation, large glenoid rim fractures with associated proximal humerus subluxation/dislocation, type II glenoid neck fractures, coracoid process fractures with greater than 2 cm of displacement, and glenoid cavity fractures with displacement greater than 5 mm.2,4,72,106 Floating shoulder injuries involving the midshaft of the clavicle and the glenoid neck can be treated by ORIF of the clavicle as the glenoid neck will reduce via ligamentotaxis provided by the intact coracoclavicular ligament.9 Similarly, floating shoulder injuries involving fractures of the glenoid neck, midshaft of the clavicle, and scapula spine will heal by ORIF of the clavicle and scapula spine due to ligamentotaxis provided by the intact coracoclavicular and/or coracoacromial ligaments.9 Nonoperative management with immobilization should be used for the remainder of injuries. 

Surgical Procedure for Scapula Fractures

Preoperative Planning

The position of the patient and necessary implants will depend on which part of the scapula is fractured. Typically, it is necessary to utilize plates that can be bent and twisted to match the shape of the scapula. Advanced imaging with three-dimensional reconstruction is helpful in planning for open reduction and internal fixation of scapula fractures (Table 22-9). 
 
Table 22-9
Distal Clavicle Fractures
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Table 22-9
Distal Clavicle Fractures
Potential Pitfalls and Preventions
Pitfall Prevention
Nonunion/hardware failure Ensure adequate fixation in distal fragment
Supplement fixation with suture and prolonged immobilization until healed
Screw penetration into acromioclavicular joint Directly visualize joint and utilize fluoroscopy in multiple planes following plate fixation
X

Positioning

Patient positioning will depend on the location of the fracture within the scapula and subsequently the approach being utilized. If anterior exposure is necessary, the patient is placed in the beach chair position and a standard deltopectoral approach is performed. Posterior exposure is performed by having the patient in the lateral decubitus position in a bean bag, allowing the shoulder and trunk to droop slightly forward. 

Surgical Approach(es)

Anterior access to the glenoid and coracoid is performed through a standard deltopectoral approach. An incision is made along the deltopectoral groove from the coracoid proximally and carried 10 to 15 cm distally. Sharp dissection is carried out through the skin and the cephalic vein is identified in the deltopectoral groove. Subsequently, the deltoid is retracted laterally and the pectoralis major medially. The cephalic vein can be taken in either direction. Deep, the short head of the biceps and the coracobrachialis are identified and retracted in a medial direction. Access to the anterior aspect of the shoulder joint is now easily obtained. Typically, to have adequate exposure of the glenoid, the subscapularis must be taken down and a retractor placed in the glenohumeral joint to retract the humeral head. 
If a posterior approach to the glenoid is being performed, a vertical incision is made overlying the posterior glenoid and full-thickness skin flaps are raised. Exposure of the glenoid is performed by splitting the deltoid longitudinally in line with its fibers. The infraspinatus and teres minor are now visible. These muscles can be partially or completely detached, or the interval between them can be utilized, depending on the amount of exposure necessary. Alternatively, a transverse incision can be performed along the length of the scapula spine, extending to the posterior corner of the acromion. The deltoid is then detached from its origin on the scapular spine and the plane between the deltoid and infraspinatus is identified and developed. Identification of the teres minor is now performed and the plane between the teres minor and infraspinatus is developed. By retracting the infraspinatus superiorly and the teres minor inferiorly, the posterior aspect of the glenoid and scapula neck is now exposed. The glenohumeral joint capsule can be incised longitudinally along the edge of the scapula to gain access to the joint. 

Technique

Displaced glenoid neck fractures are approached through the posterior approach with placement of a plate along the posterior aspect of the glenoid and extending down along the lateral angle of the scapula. Operative treatment of type Ib, type II, and type IV glenoid cavity fractures is also performed via a posterior approach. The infraspinatus can remain attached during fixation of type Ib fractures whereas detachment is necessary for types II and IV fractures. Fixation of type Ib fragments is typically performed utilizing two interfragmentary screws whereas types II and IV fractures typically require plate and screw fixation. 
An anterior deltopectoral approach is utilized to perform ORIF of types Ia and III glenoid cavity fractures as well as coracoid fractures displaced greater than 2 cm. Fixation is achieved with interfragmentary screws for type Ia and large coracoid process fractures if the fragment is large enough whereas plate and screw fixation is typically necessary for type III fractures. Alternatively, suture anchors can be utilized to stabilize type Ia fragments and small coracoid process fractures can be reattached with the conjoint tendon utilizing heavy nonabsorbable suture placed in a Bunnell fashion through the tendon and passed through a drill hole in the intact coracoid process. Arthroscopic fixation of type Ia fractures can also be performed by utilizing suture anchor fixation to the intact labral attachment of the fragment (Table 22-10).133 
 
Table 22-10
Distal Clavicle Fractures
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Table 22-10
Distal Clavicle Fractures
Common Adverse Outcomes and Complications
Hardware prominence
Hardware migration
Nonunion
Symptomatic malunion
X

Author's Preferred Treatment for Scapula Fractures

The vast majority of pediatric and adolescent scapula fractures are treated nonoperatively with immobilization for 3 to 4 weeks followed by pendulum exercises and progressed to active range of motion as tolerated. This includes scapula body fractures, acromion fractures, coracoid process fractures, and glenoid neck and cavity fractures without significant displacement. Operative treatment is reserved for open fractures and glenoid cavity fractures with significant size and/or displacement leading to glenohumeral subluxation/dislocation. Coracoid process fractures displaced greater than 2 cm are also treated with open reduction and internal fixation. 
Our preference is to perform arthroscopic reduction of type Ia glenoid cavity fractures and open reduction and internal fixation for the remainder of glenoid cavity fractures and glenoid neck fractures requiring operative fixation. We routinely obtain three-dimensional CT scans to aid in preoperative planning and determination of the best surgical approach to utilize based on the fracture pattern. 

Postoperative Care for Scapula Fractures

Postoperatively, patients are placed in a sling or shoulder immobilizer for 3 to 6 weeks. Subsequently, pendulum exercises are performed followed by advancement to active range of motion based on radiographic union and pain. Strengthening and contact sports are not permitted for a minimum of 3 months postoperatively. 

Potential Pitfalls and Preventive Measures for Scapula Fractures

Care must be taken during ORIF when retracting structures about the shoulder region as vigorous retraction can damage neurovascular structures. For example, the musculocutaneous nerve is at risk during excessive medial retraction about the glenohumeral joint/coracoid. 
It is necessary to obtain a near-anatomic reduction of the articular surface during ORIF of glenoid cavity fractures as residual displacement greater than 2 mm leads to poorer outcomes.72,89 Furthermore, failure to reduce large glenoid cavity fragments may lead to persistent glenohumeral subluxation/dislocation (Table 22-11). 
 
Table 22-11
Scapula Fractures
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Table 22-11
Scapula Fractures
Potential Pitfalls and Preventions
Pitfall Prevention
Neurovascular injury Avoid overvigorous retraction
Persistent glenohumeral subluxation/dislocation Obtain near anatomic (<2 mm incongruity) of glenoid cavity fragments
X

Treatment-Specific Outcomes for Scapula Fractures

No data exists regarding the outcomes of pediatric and adolescent patients treated with ORIF for scapula fractures. The adult literature has demonstrated that the results of operative fixation of glenoid cavity fractures depend on near-anatomic restoration of joint alignment. If residual incongruity is less than 2 mm, good-to-excellent results can be expected for 80% to 90% of patients. Furthermore, posttraumatic arthritis will be minimal.72,89 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Scapula Fractures

Nonunion and symptomatic malunion can occur following treatment of scapular body fractures nonoperatively.40,88,97 Nonunions can be addressed by performing open reduction and internal fixation with good-to-excellent results expected. In addition, significant displacement associated with glenoid neck fractures has been shown to be a poor prognostic indicator. Therefore, fixation of fractures with more than 1 cm of displacement or angulation greater than 40 degrees will yield improved outcomes.38,77,108 Lastly, large glenoid rim fractures should be addressed operatively to prevent subluxation/dislocation of the glenohumeral joint (Table 22-12). 
 
Table 22-12
Scapula Fractures
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Table 22-12
Scapula Fractures
Common Adverse Outcomes and Complications
Nonunion
Symptomatic malunion
Glenohumeral subluxation/dislocation
X

Summary, Controversies, and Future Directions Related to Scapula Fractures

Scapula fractures are rare injuries that occur due to high-energy mechanisms or nonaccidental trauma. Conservative treatment with immobilization yields excellent outcomes in the vast majority of cases. However it is important to recognize fractures that can potentially lead to adverse outcomes and complications. Advanced imaging with CT scans, including three-dimensional reconstruction, can aid the surgeon by providing better understanding of the fracture pattern. Operative fixation should be performed for fractures about the glenoid with significant displacement or those leading to glenohumeral subluxation/dislocation. Because of the rarity of these fractures, it is likely that future multicenter studies will be necessary to provide information regarding the best treatments and their outcomes for pediatric and adolescent scapula fractures. 

Introduction to Acromioclavicular Dislocations

While AC dislocations are common in adults, they are rare in children. Injuries that appear to disrupt the AC joint in a child may actually be an epiphyseal separation of the distal clavicle termed a “pseudodislocation,” rather than a true AC joint disruption.126 However, adolescents can sustain true AC dislocations, especially those involved in competitive sports participation.35,71 Treatment of these injuries, especially complete dislocations, remains somewhat controversial and is based on individual patient demands. 

Assessment of Acromioclavicular Dislocations

Mechanisms of Injury for Acromioclavicular Dislocations

Acromioclavicular joint injuries typically occur due to a direct blow to the acromion with the shoulder adducted, as can occur during collision sports, or due to a fall onto the superolateral aspect of the shoulder. The result of this blow is inferior and medial movement of the acromion while the clavicle remains stable because of the sternoclavicular joint ligaments.121 Propagation of the force to the coracoclavicular ligaments and deltotrapezial fascia can occur following complete disruption of the AC ligaments.126 Indirect force can also result in injury to the AC joint, as occurs during a fall onto an outstretched hand or elbow.128 

Assocaited Injuries with Acromioclavicular Dislocations

As with any injury to the shoulder region, the entire shoulder girdle must be examined for a concomitant injury. Anterior sternoclavicular dislocations or additional scapula, humerus, or clavicle fractures can occur simultaneously if enough force was present at the time of impact. In addition, brachial plexus or cervical spine injuries may be present, especially if the injury occurred during a collision sport, such as football. 

Signs and Symptoms of Acromioclavicular Dislocations

Patients with AC dislocations usually complain of pain in the shoulder region localized to the AC joint area. Numbness and tingling may be present because of swelling or concomitant cervical spine/brachial plexus injury. Sometimes, they only complain of a “bump” in the region. 
The physical examination should begin by observation of the shoulder region with the patient in an upright position, which permits the weight of the arm to make any deformity more apparent. Swelling, ecchymosis, abrasions, and skin tenting should be noted. Palpation overlying the AC joint will cause significant discomfort and should be reserved until the end of the examination. Additional areas that should be palpated first include the proximal humerus, the midshaft and medial clavicle, the sternoclavicular joint, and the cervical spine. A thorough neurologic examination should be performed to assess for concomitant brachial plexus or cervical spine injury. Most displaced distal clavicle fractures are malpositioned superiorly and have both visual and palpable deformities. However, some displace posteriorly, get entrapped in the trapezius muscle, and have a palpable prominence and tenderness medial and posterior to the acromion. These type IV injuries may be hard to diagnose unless examined specifically. 
Once an AC injury is suspected, the joint should be assessed for stability if possible. Typically this needs to be done after the acute pain has subsided, approximately 5 to 7 days following the injury. Horizontal and vertical stabilities can be assessed and potentially the joint can be reduced by closed means. This is performed by stabilizing the clavicle with one hand and using the other hand to place an upward force under the ipsilateral elbow. Once the joint is reduced in the coronal plane, the midshaft of the clavicle can be grasped and translated in an anterior and posterior direction to assess horizontal stability.128 

Imaging and Other Diagnostic Studies for Acromioclavicular Dislocations

Plain radiographs are the initial imaging modality of choice and should include a true AP view of the shoulder, an axillary lateral view of the shoulder, and a Zanca view to better visualize the AC joint. The Zanca view is performed with the patient in an upright position, allowing the injured arm to hang by the weight of gravity, and aiming the x-ray beam 10 to 15 degrees cephalad.149 In addition, stress views can be performed, to differentiate between types II and III injuries, by having the patient hold a weight in their hand. The posterior fracture dislocation (type IV) is often difficult to recognize by plain radiographs and may require a CT scan for accurate diagnosis. 

Classification of Acromioclavicular Dislocations

The classic description of acromioclavicular injuries for adults is that of Tossy et al.136 and Allman3 which was subsequently modified by Rockwood (Fig. 22-13).144 Type I injuries have normal radiographs with the only finding being tenderness to palpation over the AC joint due to a sprain of the AC ligaments. Type II injuries have disruption of the AC ligaments and a sprain of the coracoclavicular (CC) ligaments. The radiographs show a widened AC joint with slight vertical displacement demonstrated by a mild increase in the coracoclavicular space. Type III injuries have disruption of the AC and CC ligaments with the radiographs showing the clavicle displaced superiorly relative to the acromion by 25% to 100% the width of the clavicle. Type IV injuries have disruption of the AC and CC ligaments as well as the deltopectoral fascia which allows for the clavicle to be posteriorly displaced into or through the trapezius muscle. Type V injuries have disruption of the AC and CC ligaments as well as the deltopectoral fascia with concomitant injury to the deltoid and trapezius muscle attachments to the clavicle. These injuries present with the clavicle displaced greater than 100% and lying in the subcutaneous tissue. Type VI injuries have disruption of the AC ligaments and deltopectoral fascia, but the CC ligaments remain intact. This occurs due to a high-energy mechanism of injury that causes the shoulder to be hyperabducted and externally rotated. The end result is that the clavicle lies subacromial or subcoracoid, with a resultant decrease in the coracoclavicular distance seen on radiographs. 
Figure 22-13
Schematic depicting the Rockwood classification of acromioclavicular joint injuries.
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The classification mentioned above has been modified for the pediatric and adolescent populations as true AC injuries are rare during skeletal immaturity compared to fractures of the distal clavicle.35 Typically, the clavicle itself displaces out of the periosteal sleeve, leaving the periosteum attached to the coracoclavicular and AC ligaments. The resultant clavicle injuries are then analogous to the six types described for the adult classification. 

Outcome Measures for Acromioclavicular Dislocations

No outcome scores exist that specifically assess the results of pediatric and adolescent AC injuries or any injury about the shoulder. However, numerous adult shoulder and upper extremity outcome scores are available to assess these injuries in older adolescents. Typically, results of AC injuries have been reported based on subjective outcomes, the development of AC osteoarthritis, and range of motion. 

Pathoanatomy and Applied Anatomy Relating to Acromioclavicular Dislocations

The AC joint is formed by the distal end of the clavicle and medial aspect of the acromion with a fibrocartilaginous disk between them. It is an important contribution to the superior shoulder suspensory complex, a bone–soft tissue ring composed of the glenoid, coracoid, coracoclavicular ligaments, distal clavicle, AC joint, and acromion (Fig. 22-14). This complex maintains a normal relationship between the scapula, upper extremity, and axial skeleton to permit fluid scapulothoracic motion. While the clavicle does rotate some relative to the acromion through the AC joint, the majority of motion occurs synchronously.41 
Figure 22-14
A: Frontal view. B: Lateral view.
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Figure 22-14
Schematic of the superior shoulder suspensory complex.
A: Frontal view. B: Lateral view.
A: Frontal view. B: Lateral view.
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The ligamentous structures about the AC joint provide the vast majority of stability with a smaller component provided by the muscular attachments of the anterior deltoid onto the clavicle and trapezius onto the acromion. Horizontal stability is provided by the AC ligaments that reinforce the joint capsule, mainly the posterior and superior ligaments.75 Vertical stability is provided by the coracoclavicular ligaments, including the conoid ligament medially and trapezoid ligament laterally.44 The normal distance between the coracoid and the clavicle, the coracoclavicular space, should be 1.1 to 1.3 cm.16 

Treatment Options for Acromioclavicular Dislocations

Nonoperative Treatment of Acromioclavicular Dislocations

Indications/Contraindications

Nonoperative treatment of types I and II AC injuries is uniformly accepted. However, treatment of type III injuries remains somewhat controversial. The vast majority of types IV, V, and VI injuries should be treated surgically to reduce the AC joint and restore stability to the superior shoulder suspensory complex. Absolute contraindications to nonoperative treatment include open injuries and injuries with associated neurovascular injury requiring operative intervention (Table 22-13). 
 
Table 22-13
Acromioclavicular Dislocations
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Table 22-13
Acromioclavicular Dislocations
Nonoperative Treatment
Indications Relative Contraindications
Type I injuries Open injuries
Type II injuries Injuries with associated neurovascular injuries requiring operative treatment
X

Techniques

Nonoperative treatment is performed utilizing immobilization in a sling or shoulder immobilizer for 2 to 4 weeks. Following the period of immobilization and resolution of the pain, patients are gradually progressed from pendulum exercises to active range of motion. Strengthening is begun once range of motion is equal to the uninjured side. Contact sports are avoided for 3 months following injury to allow for complete ligamentous healing and for prevention of converting an incomplete injury (type II) to a complete injury (type III).128 

Outcomes

Little published data exists regarding the nonoperative treatment of types I and II injuries in the pediatric and adolescent populations. The adult literature has demonstrated a 9% to 30% rate of pain and limitation of activities with closed treatment of type I injuries and a 23% to 42% rate for closed treatment of type II injuries, some of which required surgical intervention.17,100 Children and adolescents seem to do better in terms of pain and restoration of function but it has not been studied extensively. 
Treatment of type III injuries remains controversial because of the outcomes demonstrated in the adult literature. Bannister et al.12 found that injuries with 2 cm or more of displacement treated nonsurgically had 20% good or excellent results compared to 70% in the surgically treated group. However, a study involving athletes and laborers with type III injuries treated nonoperatively showed that they were able to recover adequate strength and endurance to return to their preinjury activities.146 A meta-analysis by Phillips et al.115 supported nonoperative treatment of type III injuries as patients treated surgically had a higher complication rate, with patients treated nonoperatively able to return to work and preinjury activities faster. 

Operative Treatment of Acromioclavicular Dislocations

Indications/Contraindications

Indications for operative treatment of AC injuries include complete disruptions of the joint, leading to true dislocations in adolescents or fracture dislocations in the pediatric population, mainly types IV, V, and VI injuries. The most common operative indication in the young is a type IV injury with displacement and entrapment in the trapezius muscle posteriorly. In addition, an injury that is open or has a concomitant neurovascular injury requiring operative intervention should be treated operatively. As noted above, the treatment of type III injuries is somewhat controversial. 

Surgical Procedure for Acromioclavicular Dislocations

Preoperative Planning

Treatment of AC injuries surgically requires planning to ensure that the appropriate equipment is available. If implants are being utilized, these may include a hook plate, cannulated screws, Kirschner wires, or heavy nonabsorbable suture. Reconstruction of the ligaments, however, requires either planning to obtain hamstring autograft or having allograft available (Table 22-14). 
 
Table 22-14
ORIF of Acromioclavicular Dislocations
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Table 22-14
ORIF of Acromioclavicular Dislocations
Preoperative Planning Checklist
OR Table: Standard table able to go into beach chair position
Position/positioning aids: Beach chair position with adequate sterile space above the shoulder adjacent to the head
Fluoroscopy location: Contralateral side
Equipment: Implants may include hook plate, cannulated screws, Kirschner wires, heavy nonabsorbable suture, hamstring autograft, allograft
Tourniquet (sterile/nonsterile): None
X

Positioning

Whether open reduction or ligament reconstruction is being performed, the beach chair position is utilized. A bump is placed behind the scapula to bring the acromion into a more anterior position. 

Surgical Approach(es)

A direct approach to the AC joint is utilized by making an incision along the lateral clavicle and anterior aspect of the joint in Langer skin lines. Sharp dissection is carried out through the skin only. Subsequently, electrocautery is utilized the remainder of the way down to bone so that hemostasis and dissection can occur simultaneously. It is easiest to incise the periosteum of the distal clavicle and acromion before entering the joint. It is imperative to avoid disruption of the coracoclavicular ligaments in type VI injuries as they are intact. The AC and coracoclavicular ligaments as well as the deltopectoral fascia are disrupted in types II, IV, and V injuries in the skeletally mature; they are attached to the periosteum in younger patients. 

Technique

Once the dissection has exposed the AC joint, an open reduction of the joint is performed. Type IV injuries necessitate carefully extracting the distal clavicle from the trapezius muscle, type V injuries require reducing the distal clavicle from the subcutaneous tissue, and type VI injuries require removing the distal clavicle from beneath the coracoid process. Once the distal clavicle is reduced to the level of the acromion, temporary pin fixation may be necessary to hold the reduction. As the periosteum is torn but still attached to the acromion, once the clavicle is reduced simple repair of the periosteum and ligamentous structures may be all that is required in the pediatric population. 
If the patient is older and a hook plate is being utilized, the lateral end of the plate is placed deep to the acromion and the medial side is placed on the clavicle, which will facilitate joint reduction and maintenance of the reduction. Bicortical screws are now placed into the clavicle to hold the plate in place. 
Ligament reconstruction and/or augmentation have been performed, via various methods as the primary method of treatment for the injury in adults. Fortunately these operations are rare in the acute setting for adolescents. More often these reconstructions are in chronic, painful AC separations in adults. Both semitendinosus autograft and allograft can be used as a loop around the coracoid and clavicle66 or placed through bone tunnels in the coracoid and clavicle and secured with interference screws.90 The interference screws are placed at the locations of the coracoclavicular ligaments in an attempt to restore normal anatomy. 
Coracoclavicular screw placement or loops of heavy nonabsorbable suture/Dacron tape around the coracoid and clavicle has also been described to treat AC injuries, either by itself or in conjunction with ligament reconstruction.19 Screw placement requires removal whereas the loop technique can lead to suture cutout or aseptic foreign body reactions.18,132 The modified Weaver Dunn procedure has been performed in arthritic situations by resecting the distal end of the clavicle, detaching the coracoacromial ligament from the deep surface of the acromion, and transferring it to the distal end of the clavicle. Again, this is very rarely performed in children and adolescents (Table 22-15). 
 
Table 22-15
ORIF of Acromioclavicular Dislocations
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Table 22-15
ORIF of Acromioclavicular Dislocations
Surgical Steps
  1.  
    Skin incision in Langer line directly anterior to acromioclavicular joint
  2.  
    Electrocautery down to distal clavicle and acromion
  3.  
    Reduce acromioclavicular joint
  4.  
    Repair periosteum and ligamentous structures and assess stability
  5.  
    Utilize hook plate if joint remains unstable, for segmental fractures, or intra-articular fractures
  6.  
    Place lateral end of hook plate under acromion and facilitate AC joint reduction by placing medial part of plate on clavicle
  7.  
    Place bicortical screws in medial part of hook plate
  8.  
    Irrigate wound and close
  9.  
    Plate removal 2–3 months postoperatively
X

Author's Preferred Treatment of Acromioclavicular Dislocations

We treat all types I and II AC injuries as well as the vast majority of type III injuries, nonoperatively with immobilization in a sling or shoulder immobilizer for 2 to 4 weeks followed by early restoration of range of motion. Contact sports are avoided for at least 3 months. The vast majority of types IV, V, and VI injuries are treated operatively. Once the distal clavicle is exposed, we determine whether repair of the periosteum and ligamentous structures surrounding the clavicle is sufficient or if a plate is required. The vast majority can be treated with periosteal repair over the reduced clavicle. Most often operative repair is for type IV fracture-dislocations with entrapment in the trapezius. Hook plates are most commonly utilized in older patients with fractures that are either segmental or intra-articular. Following plate placement, the periosteum and ligamentous structures are repaired. 

Postoperative Care for Acromioclavicular Dislocations

Postoperatively patients are placed in either a sling or shoulder immobilizer for 4 to 6 weeks. Pendulum exercises are then begun followed by gentle active range of motion below shoulder level for 6 to 8 weeks. At 8 weeks full active range of motion is permitted. If a hook plate or coracoclavicular screw was placed, it is removed with sufficient healing, usually at approximately12 weeks. Contact sports are avoided for a minimum of 3 months following operative intervention. 

Potential Pitfalls and Preventive Measures for Acromioclavicular Dislocations

One of the biggest pitfalls when treating AC injuries is failure to recognize a type IV injury. Although types V and VI injuries are fairly obvious on AP plain radiographs, type IV injuries because of their posterior displacement may not be readily apparent. Furthermore, lateral views may be inadequate or difficult to obtain, thus making it easy to miss a type IV injury. A high index of clinical suspicion, careful examination, and often a CT scan are necessary for accurate diagnosis and appropriate surgical treatment (Table 22-16). 
 
Table 22-16
Acromioclavicular Dislocations
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Table 22-16
Acromioclavicular Dislocations
Potential Pitfalls and Preventions
Pitfall Prevention
Missing a type IV injury Careful assessment of the radiographs
Adequate lateral radiograph
Utilize physical examination to aid in the diagnosis
CT scan
X

Treatment-Specific Outcomes for Acromioclavicular Dislocations

No studies have specifically evaluated the treatment of AC injuries in the pediatric and adolescent populations. In our experience, operative treatment of types IV, V, and VI injuries has yielded excellent outcomes in the majority of patients. Restoration of joint congruity and stability permits rapid return to function. However, we do not have long-term data to determine how many patients develop degenerative arthritis. 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Acromioclavicular Dislocations

Development of degenerative arthritis can be treated by distal clavicle resection. However, the results of this are not favorable if the coracoclavicular ligaments are disrupted as instability will ensue.31 Persistent instability following closed treatment of an AC joint injury can be treated with ligament reconstruction or augmentation. 
Complications related to open reduction include migration of pins, symptomatic hardware, and persistent pain. As noted earlier, usage of synthetic material can lead to suture cutout or aseptic foreign material reaction. Any technique that passes material around the coracoid may lead to coracoid fracture or injury to the musculocutaneous nerve (Table 22-17). 
 
Table 22-17
Acromioclavicular Dislocations
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Table 22-17
Acromioclavicular Dislocations
Common Adverse Outcomes and Complications
Posttraumatic arthritis
Persistent instability
Symptomatic hardware
Pin migration
Persistent pain
Suture cutout
Aseptic foreign body reaction
X

Summary, Controversies, and Future Directions Related to Acromioclavicular Dislocations

AC injuries are relatively rare in the pediatric and adolescent populations. The injury patterns are classified similar to the adult population. However, in the young, the periosteum tears permitting the clavicle to displace while the periosteal attachment to the acromion and coracoid remain intact. Treatment can be immobilization alone for injuries that are not widely displaced, but operative intervention should be performed for significantly displaced injuries. Restoration of normal anatomy by reduction of the AC joint, suture repair of the periosteum, and ligamentous repair as needed can yield excellent outcomes in the pediatric population while avoiding utilization of metal implants. Future studies are necessary to assess outcomes of these injuries in the pediatric and adolescent populations. 

Introduction to Sternoclavicular Fracture-Dislocations

Injuries to the sternoclavicular joint are rare, representing less than 5% of shoulder girdle injuries.27,63 These injuries occur secondary to high-energy mechanisms and therefore can be associated with life-threatening complications. Historically, treatment by observation has occurred in the pediatric and adolescent populations. More recent trends are to operatively reduce and stabilize acute posterior fracture-dislocations to restore anatomy and improve functional outcomes. 

Assessment of Sternoclavicular Fracture-Dislocations

Mechanisms of Injury for Sternoclavicular Fracture-Dislocations

A significant amount of force is required to disrupt the sternoclavicular joint because of the numerous surrounding ligaments as well as the stability provided by the rib cage. Therefore, high-energy mechanisms, such as motor vehicle accidents and sports participation, result in greater than 80% of injuries.21,105,141 Motor vehicle collisions, the most common mechanism of injury, may result in either an anterior or posterior force across the joint with a resultant anterior or posterior dislocation or fracture/dislocation.56,96 A direct lateral blow to the shoulder with the shoulder extended will result in the more common anterior dislocation. Posterior dislocations can result from indirect force transferred to the shoulder girdle when the shoulder is adducted and flexed. Alternatively, a posteriorly directed blow, such as would occur when someone is jumped on while lying supine or kicked while on the ground, is another mechanism for development of a posterior dislocation during sports participation.53 Of note, most cases of anterior sternoclavicular instability are atraumatic and associated with ligamentous laxity. 

Associated Injuries with Sternoclavicular Fracture-Dislocations

Due to the high-energy mechanisms that cause posterior sternoclavicular injuries, associated chest wall injuries due occur such as rib fractures. In addition, the trachea, esophagus, lungs, or great vessels may be compressed. Patients may also experience a brachial plexopathy. Very rarely, the entire clavicle may dislocate from both the sternoclavicular joint and AC joint, thus constituting a floating shoulder. It is imperative to carefully evaluate the entire shoulder girdle for concomitant fractures or dislocations. 

Signs and Symptoms of Sternoclavicular Fracture-Dislocations

Patients who sustain sternoclavicular joint injuries present with complaints of pain localized to the sternoclavicular joint. Additional subjective complaints may include shortness of breath, dyspnea, dysphagia, odynophagia, or hoarseness.142 If an associated brachial plexopathy is present, patients may report the presence of paresthesias and/or weakness in the ipsilateral arm. 
Objective evaluation will demonstrate a significant amount of swelling and ecchymosis present, so much so, that it may be difficult to determine the direction of the dislocation.53 Anterior dislocations may exhibit prominence of the medial clavicle, which is more easily appreciated with the patient supine (Fig. 22-15).53 In contrast, the corner of the sternum may be palpable in cases of posterior dislocation, as the medial clavicle is displaced posteriorly.105 However, at times, the posterior fracture dislocation can be more subtle than expected as the swelling can mimic normal sternoclavicular alignment on cursory examination. 
Figure 22-15
Clinical photograph demonstrating an anterior sternoclavicular dislocation.
 
This was more easily identified once the patient was lying supine.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
This was more easily identified once the patient was lying supine.
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Figure 22-15
Clinical photograph demonstrating an anterior sternoclavicular dislocation.
This was more easily identified once the patient was lying supine.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
This was more easily identified once the patient was lying supine.
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Passive range of motion of the ipsilateral shoulder will cause pain and may elicit the sensation of instability. It is imperative that a formal trauma team or emergency room physician evaluation occurs to rule out associated life-threatening injuries. Signs of venous congestion and arterial insufficiency to the involved extremity or neck region may be present due to compression of vessels. 

Imaging and Other Diagnostic Studies for Sternoclavicular Fracture-Dislocations

As with any injury, plain radiographs are the initial imaging modality performed. The routine AP chest radiograph may demonstrate asymmetry of the sternoclavicular articulations or clavicle lengths. However, these studies can be quite difficult to interpret because of the overlap of the medial clavicle, lungs, ribs, sternum, and spine (Fig. 22-16). 
Figure 22-16
 
A: Apparent normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating asymmetry of the sternoclavicular joint with a posterior dislocation on the right. C: CT scan clearly showing the right posterior sternoclavicular dislocation.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Apparent normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating asymmetry of the sternoclavicular joint with a posterior dislocation on the right. C: CT scan clearly showing the right posterior sternoclavicular dislocation.
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Figure 22-16
A: Apparent normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating asymmetry of the sternoclavicular joint with a posterior dislocation on the right. C: CT scan clearly showing the right posterior sternoclavicular dislocation.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Apparent normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating asymmetry of the sternoclavicular joint with a posterior dislocation on the right. C: CT scan clearly showing the right posterior sternoclavicular dislocation.
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Specific radiographic views to evaluate the sternoclavicular joint have been described to overcome these obstacles. Heinig described a tangential view of the sternoclavicular joint which is obtained by laying the patient supine and placing the cassette behind the opposite shoulder. The beam is then angled coronally, parallel to the longitudinal axis of the opposite clavicle (Fig. 22-17A).55 Hobbs59 proposed taking a 90-degree cephalocaudal lateral view, by having the patient seated and flexed over a table while the beam is directed through the cervical spine (Fig. 22-17B). Lastly, the serendipity view described by Rockwood is performed by placing the cassette behind the chest and angling the x-ray beam 40 degrees cephalad while it is centered on the sternum, thus providing a view of both sternoclavicular joints (Fig. 22-17C).145 In cases of anterior dislocation, the affected side will appear superiorly displaced, whereas in cases of posterior dislocation, the affected side will appear inferiorly displaced (Fig. 22-18). 
Figure 22-17
 
A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
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A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
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Figure 22-17
A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
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A: Schematic demonstrating tangential view of Heinig. B: Schematic demonstrating the 90-degree cephalocaudal lateral of Hobbs. C: Schematic demonstrating a serendipity view of Rockwood.
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Figure 22-18
 
A: Serendipity radiograph showing a left posteriorly dislocated sternoclavicular joint. Note that the affected side appears inferiorly displaced. B: CT scan of the same patient clearly showing the left posterior dislocation.
A: Serendipity radiograph showing a left posteriorly dislocated sternoclavicular joint. Note that the affected side appears inferiorly displaced. B: CT scan of the same patient clearly showing the left posterior dislocation.
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Figure 22-18
A: Serendipity radiograph showing a left posteriorly dislocated sternoclavicular joint. Note that the affected side appears inferiorly displaced. B: CT scan of the same patient clearly showing the left posterior dislocation.
A: Serendipity radiograph showing a left posteriorly dislocated sternoclavicular joint. Note that the affected side appears inferiorly displaced. B: CT scan of the same patient clearly showing the left posterior dislocation.
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Despite these described plain radiographic views, the easiest way to evaluate the sternoclavicular joint is with computed tomography which provides a three-dimensional view of the joint (Fig. 22-19). In addition to assessment of the sternoclavicular joint, one can evaluate the adjacent soft tissue structures including the esophagus, trachea, lungs, and brachiocephalic vessels. Distinction between a physeal fracture and a true dislocation may also be possible if the secondary center has ossified. 
Figure 22-19
 
A: CT scan showing a posterior dislocation of the right sternoclavicular joint. B: Three-dimensional reconstruction makes the injury more apparent.
A: CT scan showing a posterior dislocation of the right sternoclavicular joint. B: Three-dimensional reconstruction makes the injury more apparent.
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Figure 22-19
A: CT scan showing a posterior dislocation of the right sternoclavicular joint. B: Three-dimensional reconstruction makes the injury more apparent.
A: CT scan showing a posterior dislocation of the right sternoclavicular joint. B: Three-dimensional reconstruction makes the injury more apparent.
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Magnetic resonance imaging can also be utilized to evaluate the sternoclavicular joint as well as the surrounding soft tissues. The integrity of the costoclavicular ligaments and intra-articular disk may be possible.53 Despite the potential to gain additional information, CT scan is recommended over MRI scan to evaluate acute injuries because of its speed and availability. 

Classification of Sternoclavicular Fracture-Dislocations

Sternoclavicular dislocations are classified based on the direction of displacement, anterior or posterior, as well as the chronicity of the injury, acute or chronic. The injury needs to be defined as a dislocation (displacement between the epiphysis and the sternum) or a fracture (displacement through the physis with the epiphysis still articulating with sternum). In addition, a sprain, rather than a true dislocation, may occur leading to subluxation. 

Outcome Measures for Sternoclavicular Fracture-Dislocations

No specific outcome scores exist that specifically evaluate sternoclavicular joint injuries. Results reported have assessed subjective complaints of pain, recurrence of instability, return to function, and utilization of adult shoulder outcome measures, such as the ASES score, the simple shoulder test, and Rockwood scores. 

Pathoanatomy and Applied Anatomy Relating to Sternoclavicular Fracture-Dislocations

The sternoclavicular joint is a true diarthrodial joint comprising the medial clavicle and clavicular notch of the sternum. Thus, this joint is the only connection between the axial skeleton and the upper extremity. However, less than 50% of the clavicular head articulates with the clavicular notch of the sternum, resulting in little bony congruity. Stability is therefore provided by the multiple ligamentous and muscular attachments, including the sternocleidomastoid, pectoralis major, and sternohyoid muscles. The ligamentous structures include anterior and posterior sternoclavicular ligaments which reinforce the joint capsule as well as the interclavicular (connects both medial ends of the clavicle) and costoclavicular ligaments (between the inferior aspect of the clavicle and the superior costal cartilage of the adjacent rib). In addition, there is an intra-articular disk that is attached to the superior-posterior part of the clavicular articular surface and inferiorly to the costocartilaginous junction of the first rib (Fig. 22-20). The greatest amount of stability with regard to anterior translation is provided by the posterior capsule and sternoclavicular ligaments. The greatest stability with regard to posterior translation is provided by the posterior capsule.129,130 
Figure 22-20
Schematic drawing of the sternoclavicular joint.
 
Note the numerous ligamentous structures that provide stability.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
Note the numerous ligamentous structures that provide stability.
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Figure 22-20
Schematic drawing of the sternoclavicular joint.
Note the numerous ligamentous structures that provide stability.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
Note the numerous ligamentous structures that provide stability.
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The medial epiphysis of the clavicle does not ossify until approximately 18 to 20 years of age, and closes between 22 and 25 years of age. Therefore, sternoclavicular injuries occurring in pediatric and adolescent patients are difficult to discern radiographically between fractures and dislocations. Operative treatment of posterior sternoclavicular injuries has taught us that dislocations and physeal fractures have near equivalent incidence rather than the previous teaching that most posterior sternoclavicular injuries were physeal fractures. Although the medial physis contributes approximately 80% of longitudinal growth of the clavicle, the degree of remodeling possible from a physeal fracture is uncertain. Clearly remodeling cannot occur with a dislocation. 

Treatment Options for Sternoclavicular Fracture-Dislocations

Nonoperative Treatment of Sternoclavicular Dislocations

Indications/Contraindications

An atraumatic anterior dislocation should be treated nonoperatively. Some have advocated closed reduction maneuvers be performed for acute posterior fracture-dislocations due to potential stability of reduction and/or remodeling of the medial clavicle.80,145 Acute posterior dislocations with associated neurovascular injury, dyspnea, dysphagia, odynophagia, or hoarseness should clearly be treated with open reduction. We advocate that all posterior fracture-dislocations should be treated operatively (Table 22-18). 
 
Table 22-18
Sternoclavicular Dislocations
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Table 22-18
Sternoclavicular Dislocations
Nonoperative Treatment
Indications Relative Contraindications
Atraumatic anterior dislocations Acute posterior dislocations with associated neurovascular injury, dyspnea, dysphagia, odynophagia, or hoarseness
X

Techniques

Closed treatment of a nondisplaced injury consists of sling immobilization for approximately 3 weeks followed by gradual return to activities. Attempted closed reduction of anterior dislocations can be performed by placing a posteriorly directed force over the medial clavicle as the scapula is retracted by utilization of a bump placed between the shoulders. Subsequently, the patient is placed in a figure-of-eight strap or Velpeau-type sling for 6 weeks.53 Successful reduction can often be obtained; however, recurrent instability is common. 
Closed reduction of a posterior dislocation is performed by placing the patient supine on an operating room table with a thick bump placed between the scapulae to extend the shoulders and the involved arm off the edge of the table. The ipsilateral arm is then abducted in line with the clavicle, with traction applied, while an assistant applies countertraction and stabilizes the patient. Traction is continued and increased and the arm is brought into extension as the joint reduces.53 Alternatively, the arm can be placed in adduction while posterior pressure is applied to the shoulder which levers the clavicle over the first rib to permit reduction of the joint.20 If these maneuvers fail, a sterile towel clip can be used to percutaneously grasp the medial clavicle and draw it anteriorly while traction is applied to the ipsilateral limb. An audible snap is typically noted as the joint reduces.53 
Closed reductions of posterior sternoclavicular injuries are at risk for mediastinal hemorrhage and hemodynamic compromise. Therefore, closed reductions are performed in the controlled setting of the operating suite with vascular surgery standby. In addition, the orthopedic concern with closed reduction is recurrent instability.48,54,142 

Outcomes

The majority of patients treated with immobilization alone for anterior dislocations yield good outcomes, despite the high rates of recurrent instability.36 Those patients that develop symptoms following closed treatment of anterior dislocations may achieve relief of symptoms with physical therapy to promote scapular retraction and avoid provocative positions. If therapy is unsuccessful, ligament reconstruction can be performed with reasonable outcomes anticipated.7,23,129 
Posterior fracture-dislocations that are reduced by closed means have been reported by some to be stable following reduction54 whereas others have shown recurrent instability does occur.48,54,142 If the reduction is maintained over time, return to full activities can be expected in the majority of patients. 

Operative Treatment of Sternoclavicular Fracture-Dislocations

Indications/Contraindications

Although many surgeons have attempted closed treatment of posterior fracture-dislocations with either immobilization alone or closed reduction followed by immobilization, recurrent instability can occur leading to symptomatic patients who require operative intervention.13 Therefore, the majority of patients with acute traumatic posterior sternoclavicular fracture-dislocations are currently treated operatively. Operative intervention provides symptomatic relief, restores anatomy, and decreases the chance of late complications including recurrent instability and degenerative arthritis.142 
Additional indications for operative treatment include patients with symptomatic acute or chronic anterior dislocations who have failed conservative measures and symptomatic patients with chronic posterior dislocations. Contraindications to operative intervention include those patients with asymptomatic anterior dislocations or patients with atraumatic recurrent anterior instability. 

Surgical Procedure for Sternoclavicular Fracture-Dislocations

Preoperative Planning

It is imperative to be familiar with the anatomy surrounding the sternoclavicular joint as well as the bony articulation of the medial clavicle and clavicular notch of the sternum. Having a general surgeon or thoracic surgeon available to assist the orthopedic surgeon in case of hemodynamic compromise is essential during the reduction maneuver or open reduction (Table 22-19). 
 
Table 22-19
ORIF of Sternoclavicular Fracture-Dislocations
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Table 22-19
ORIF of Sternoclavicular Fracture-Dislocations
Preoperative Planning Checklist
OR Table: Standard table capable of going into beach chair position
Position/positioning aids: Beach chair position with a bump behind the scapula
Fluoroscopy location: Contralateral side if at all
Equipment: Heavy nonabsorbable suture, drill
General surgery or thoracic surgery backup
Tourniquet (sterile/nonsterile): None
X

Positioning

Patients undergoing any procedure involving the sternoclavicular joint are placed in the modified beach chair position with a large bump or rolled towel placed between the scapulae to provide scapular retraction. The entire limb and hemithorax including the contralateral sternoclavicular joint, medial clavicle and chest is prepped and draped into the operative field. The sternum to upper abdomen is prepped and draped in case an emergency median sternotomy is required (Fig. 22-21). 
Figure 22-21
Intraoperative photograph showing the area that should be prepped and draped into the sterile field.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
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Figure 22-21
Intraoperative photograph showing the area that should be prepped and draped into the sterile field.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
(From 


Waters PM,

Bae D, eds.
Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
View Original | Slide (.ppt)
X

Surgical Approach(es)

A transverse incision is made through the skin from the medial aspect of the clavicle over the ipsilateral sternoclavicular joint in Langer lines. The subcutaneous tissue and platysma are divided, utilizing electrocautery. The supraclavicular nerves are protected if in the operative field. The periosteum of the mid portion of the clavicle is elevated and a bone clamp is applied to the clavicle for control. The anterior periosteum is delicately divided over the posteriorly displaced clavicle until either the epiphysis or sternum is reached depending on whether it is a dislocation or a physeal fracture (Fig. 22-22). Typically, the posterior periosteum of the clavicle and the posterior joint capsule are intact, providing a protective layer between the bony injury and mediastinal structures. 
Figure 22-22
 
A: Marking of the anatomy prior to incision. The dashed lines represent the posterior dislocation of the right sternoclavicular joint. B: Identification and preservation of the supraclavicular nerves. C: Exposure of the medial clavicle and sternoclavicular joint following periosteal elevation.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Marking of the anatomy prior to incision. The dashed lines represent the posterior dislocation of the right sternoclavicular joint. B: Identification and preservation of the supraclavicular nerves. C: Exposure of the medial clavicle and sternoclavicular joint following periosteal elevation.
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Figure 22-22
A: Marking of the anatomy prior to incision. The dashed lines represent the posterior dislocation of the right sternoclavicular joint. B: Identification and preservation of the supraclavicular nerves. C: Exposure of the medial clavicle and sternoclavicular joint following periosteal elevation.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Marking of the anatomy prior to incision. The dashed lines represent the posterior dislocation of the right sternoclavicular joint. B: Identification and preservation of the supraclavicular nerves. C: Exposure of the medial clavicle and sternoclavicular joint following periosteal elevation.
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Technique

Following exposure of the physeal fracture or sternoclavicular dislocation, a gentle reduction is performed utilizing the aid of a fracture reduction clamp. Once the clavicle is brought anteriorly, it is important to converse with the anesthesiologist to ensure that the patient remained hemodynamically stable. An anatomic reduction is now performed ensuring that the clavicular head is anatomically seated in the clavicular notch of the sternum. 
Following anatomic reduction of either the fracture or dislocation, drill holes are made in the anterior metaphysis and epiphysis of the clavicle in cases of a fracture or the anterior epiphysis and sternum in cases of a dislocation. Placement of malleable retractors between the bone and posterior periosteum is helpful in preventing the drill from entering the mediastinum. Heavy nonabsorbable suture is then passed in a figure-of-eight fashion to provide the necessary stability (Fig. 22-23). The periosteum is then reapproximated with heavy suture to provide added stability, especially with a true dislocation as it provides indirect repair of the costoclavicular and sternoclavicular ligaments. Stability is now assessed by ranging the ipsilateral shoulder and limb. Once stability is satisfactory, the wound is irrigated and closed in sequential layers (Table 22-20). 
Figure 22-23
 
A: Drill holes created in the anterior medial clavicle and sternum in cases of true dislocations or anterior medial clavicular metaphysis and clavicular epiphysis in cases of physeal fracture. B: Heavy nonabsorbable suture placed through the drill holes in a figure-of-eight fashion. C: Anatomic joint reduction following tying of the sutures
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Drill holes created in the anterior medial clavicle and sternum in cases of true dislocations or anterior medial clavicular metaphysis and clavicular epiphysis in cases of physeal fracture. B: Heavy nonabsorbable suture placed through the drill holes in a figure-of-eight fashion. C: Anatomic joint reduction following tying of the sutures
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Figure 22-23
A: Drill holes created in the anterior medial clavicle and sternum in cases of true dislocations or anterior medial clavicular metaphysis and clavicular epiphysis in cases of physeal fracture. B: Heavy nonabsorbable suture placed through the drill holes in a figure-of-eight fashion. C: Anatomic joint reduction following tying of the sutures
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Drill holes created in the anterior medial clavicle and sternum in cases of true dislocations or anterior medial clavicular metaphysis and clavicular epiphysis in cases of physeal fracture. B: Heavy nonabsorbable suture placed through the drill holes in a figure-of-eight fashion. C: Anatomic joint reduction following tying of the sutures
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Table 22-20
ORIF of Sternoclavicular Fracture-Dislocations
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Table 22-20
ORIF of Sternoclavicular Fracture-Dislocations
Surgical Steps
  1.  
    Prep and drape entire limb and hemithorax including contralateral sternoclavicular joint, chest, and upper abdomen
  2.  
    Transverse skin incision in Langer lines from the diaphysis of the clavicle to the sternoclavicular joint
  3.  
    Divide subcutaneous tissue and platysma in line with skin incision. Protect the supraclavicular nerves.
  4.  
    Expose clavicle and sternum and incise periosteum working from lateral to medial on clavicle and from midline to lateral on sternum
  5.  
    Evaluate the sternoclavicular joint to determine whether a true dislocation or physeal fracture occurred
  6.  
    Reduce dislocation/fracture with aid of a fracture reduction clamp
  7.  
    Converse with anesthesia to ensure hemodynamic stability of patient
  8.  
    Place drill holes in anterior epiphysis and metaphysis for physeal fractures or anterior epiphysis and sternum for dislocations
  9.  
    Pass heavy nonabsorbable suture in a figure-of-eight fashion and tie
  10.  
    Reapproximate periosteum with heavy suture
  11.  
    Irrigate and close wound in sequential layers
  12.  
    Immobilize patient in sling and swathe or shoulder immobilizer
X

Author's Preferred Treatment for Sternoclavicular Fracture-Dislocations

We treat acute atraumatic anterior dislocations with immobilization alone for 1 to 4 weeks followed by gradual return to function. If patients experience recurrent instability, therapy is initiated. Operative intervention is reserved for patients with persistent symptoms and typically involves reconstruction of the ligaments. 
Acute posterior dislocations are treated operatively with open reduction and internal fixation. Chronic posterior dislocations that are symptomatic are treated with ligament reconstruction utilizing allograft. At times, medial clavicle resection is required in painful chronic dislocations that have deformity of the bone and early arthritis of the joint. 

Postoperative Care for Sternoclavicular Fracture-Dislocations

Postoperatively patients are placed in either a sling and swathe or shoulder immobilizer for 4 to 6 weeks. Subsequently, range-of-motion exercises are begun. Strengthening is permitted at 3 months postoperatively. Return to sports is dependent on full motion and strength, usually 3 to 6 months postoperatively. 

Potential Pitfalls and Preventive Measures for Sternoclavicular Fracture-Dislocations

It is imperative to be familiar with the sternoclavicular bony alignment as overreduction of the clavicle into the clavicular notch of the sternum can occur. In addition, utilization of Dacron tape may cause osteolysis. Pins may migrate and therefore should be avoided.85,119,139 (Table 22-21). 
 
Table 22-21
Sternoclavicular Dislocations
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Table 22-21
Sternoclavicular Dislocations
Potential Pitfalls and Preventions
Pitfall Prevention
Overreduction of clavicle into clavicular notch of sternum Be knowledgeable about the bony anatomy of the sternoclavicular joint
Osteolysis from Dacron Utilize heavy nonabsorbable suture
Kirschner wire migration Avoid Kirschner wires
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Treatment-Specific Outcomes for Sternoclavicular Fracture-DIslocations

The outcomes following open reduction and internal fixation of posterior sternoclavicular dislocations or medial clavicle physeal fractures in pediatric and adolescent patients have been quite favorable in the vast majority of reported cases.13,48,76,135,142 In a retrospective review by Waters et al.,142 all patients treated with open reduction and suture fixation of their posterior sternoclavicular joint fracture dislocation had restoration of joint stability and shoulder motion with full return to activities. Similar findings were reported by Goldfarb et al.48 with all patients returning to their preinjury function including sports participation. 

Management of Expected Adverse Outcomes and Unexpected Complications in Sternoclavicular Fracture-Dislocations

Recurrent instability following acute repair is relatively rare but can occur, especially if the sternoclavicular joint is overreduced. Patients will present with persistent pain and a sense of instability. Treatment with ligament reconstruction can be performed utilizing semitendinosus autograft or allograft passed in a figure-of-eight fashion similar to the suture utilized during the acute repair. Ideally the tendon is passed on the “instability side” to minimize the risk of recurrent instability occurring again. 
Alternatively, as a salvage procedure, medial clavicle resection arthroplasty can be performed with supplemental ligament reconstruction or soft tissue interposition. Approximately 1 cm of medial clavicle is excised in an oblique fashion to preserve the inferior ligamentous attachments. The intra-articular disk can be passed into the medullary canal of the clavicle by detaching its superior end while preserving the inferior attachments. Sutures are passed through drill holes in the superior clavicle and tied over a bony bridge (Fig. 22-24). Additional stability can be provided by sutures passed between the costoclavicular ligament and the clavicle. 
Figure 22-24
 
A: Schematic demonstrating the technique of medial clavicular resection arthroplasty. B: Intraoperative photograph of a patient with recurrent anterior sternoclavicular instability with resultant pain due to a deformed and irreducible clavicular head. C: Intraoperative photograph following medial clavicular head resection and intramedullary passage of the intra-articular disk ligament.
 
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Schematic demonstrating the technique of medial clavicular resection arthroplasty. B: Intraoperative photograph of a patient with recurrent anterior sternoclavicular instability with resultant pain due to a deformed and irreducible clavicular head. C: Intraoperative photograph following medial clavicular head resection and intramedullary passage of the intra-articular disk ligament.
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Figure 22-24
A: Schematic demonstrating the technique of medial clavicular resection arthroplasty. B: Intraoperative photograph of a patient with recurrent anterior sternoclavicular instability with resultant pain due to a deformed and irreducible clavicular head. C: Intraoperative photograph following medial clavicular head resection and intramedullary passage of the intra-articular disk ligament.
(From Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. Philadelphia, PA: Lippincott Williams & Wilkins; 2012, with permission.)
A: Schematic demonstrating the technique of medial clavicular resection arthroplasty. B: Intraoperative photograph of a patient with recurrent anterior sternoclavicular instability with resultant pain due to a deformed and irreducible clavicular head. C: Intraoperative photograph following medial clavicular head resection and intramedullary passage of the intra-articular disk ligament.
View Original | Slide (.ppt)
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The results of treatment for recurrent anterior instability have been reported by Bae et al. in a retrospective review. Sixty percent of patients had stable, pain-free joints following the procedure. No patients developed instability following their treatment.7 Many still had some minor limitations of function or persistent pain (Table 22-22). 
 
Table 22-22
Sternoclavicular Dislocations
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Table 22-22
Sternoclavicular Dislocations
Common Adverse Outcomes and Complications
Persistent pain
Recurrent instability
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Summary, Controversies, and Future Directions Related to Sternoclavicular Fracture-Dislocations

Although sternoclavicular joint injuries are relatively rare, they do occur, even in the pediatric and adolescent populations. As high-energy mechanisms cause sternoclavicular injuries, associated damage to critical mediastinal structures can occur and therefore a thorough evaluation is necessary to avoid missing an associated life-threatening injury. The majority of anterior dislocations can be treated with immobilization alone whereas acute posterior injuries are typically treated with operative intervention yielding good results. However, future investigation into the natural history of posterior dislocations treated nonoperatively is necessary to determine who should undergo immediate operative intervention and who should undergo either observation alone or have a closed reduction performed. 

References

Abbot AE, Hannafin JA. Stress fracture of the clavicle in a female lightweight rower. A case report and review of literature. Am J Sports Med. 2001; 29:370–372.
Ada JR, Miller ME. Scapula fracture. Analysis of 113 cases. Clin Orthop Relat Res. 1991; 269:174–180.
Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967; 49:774–784.
An HS, Vonderbrink JP, Ebraheim NA, et al. Open scapulothoracic disassociation with intact neurovascular status in a child. J Orthop Trauma. 1988; 2:36–38.
Anderson K. Evaluation and treatment of distal clavicle fractures. Clin Sports Med. 2003; 22:319–326.
Badhe SP, Lawrence TM, Clark DI. Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures. Arch Orthop Trauma Surg. 2007; 127:25–28.
Bae DS, Kocher MS, Waters PM, et al. Chronic recurrent anterior sternoclavicular joint instability: Results of surgical management. J Pediatr Orthop. 2006; 26:71–74.
Bae DS, Shah AS, Kalish LA, et al. Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. J Pediatr Orthop. 2013; 33(5):544–550.
Bahk MS, Kuhn JE, Galatz LM, et al. Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures. J Bone Joint Surg Am. 2009; 91:2492–2510.
Ballmer Ft, Gerber C. Coracoclavicular screw fixation for unstable fractures of the distal clavicle: A report of five cases. J Bone Joint Surg Br. 1991; 73:291–294.
Banerjee R, Waterman B, Padalecki J, et al. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011; 19:392–401.
Bannister GC, Wallace WA, Stableforth PG, et al. The management of acute acromioclavicular dislocation: A randomized prospective controlled trial. J Bone Joint Surg Br. 1989; 71:848–850.
Baumann M, Vogel T, Weise K, et al. Bilateral posterior sternoclavicular dislocation. Orthopedics. 2010; 33:510.
Baumgarten KM. Arthroscopic fixation of a type II-variant, unstable distal clavicle fracture. Orthopedics. 2008; 31.
Beall MH, Ross MG. Clavicle fracture in labor: risk factors and associated morbidities. J Perinatol. 2001; 21:513–515.
Bearden JM, Hughston JC, Whatley GS. Acromioclavicular dislocation: Method of treatment. J Sports Med. 1973; 1:5–17.
Bergfield JA, Andrish JT, Clancy WG. Evaluation of the acromioclavicular joint following first- and second-degree sprains. Am J Sports Med. 1978; 6:153–159.
Boldin C, Frankhauser F, Ratschek M, et al. Foreign-body reaction after reconstruction of complete acromioclavicular dislocation using PDS augmentation. J Shoulder Elbow Surg. 2004; 12:99–100.
Bosworth BM. Acromioclavicular separation: New method of repair. Surg Gynecol Obstet. 1941; 73:866–871.
Buckerfield CT, Castle ME. Acute traumatic retrosternal dislocation of the clavicle. J Bone Joint Surg Am. 1984; 66:379–385.
Buckley BJ, Hayden SR. Posterior sternoclavicular dislocation. J Emerg Med. 2008; 34:331–332.
Bullock DP, Koval KJ, Moen KY, et al. Hospitalized cases of child abuse in America; Who, What, When, and Where. J Pediatr Orthop. 2009; 29:231–237.
Burrows HJ. Tenodesis of subclavius in the treatment of recurrent dislocation of the sterno-clavicualr joint. J Bone Joint Surg Br. 1951; 33B:240–243.
Butters KP. Fractures and dislocations of the scapula. In: Rockwood CA Jr, Green DP, Bucholz RW, eds. Fractures in Adults. New York, NY: J.B. Lippincott; 1991:990–1019.
Calder JD, Solan M, Gidwani S, et al. Management of paediatric clavicle fractures- is follow-up necessary? An audit of 346 cases. Ann R Coll Surg Engl. 2002; 84:331–333.
Candian Orthopedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced mishaft clavicular fractures: A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007:89A:1–10.
Cave EF. Fractures and other Injuries. Chicago, IL: Year book medical publishers; 1958.
Chang DC, Knight V, Ziegfeld S, et al. The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry. J Trauma. 2004; 57:1189–1198.
Checcia SL, Doneux PS, Miyazaki AN, et al. Treatment of distal clavicle fractures using an arthroscopic technique. J Shoulder Elbow Surg. 2008; 17:395–398.
Cohen AW, Otto SR. obstetric clavicular fractures: a three-year anaylsis. J Reprod Med. 1980; 25:119–122.
Corteen DP, Teitge RA. Stabilization of the clavicle after distal resection: A biomechanical study. Am J Sports Med. 2005; 33:61–67.
Coupe BD, Wimhurst JA, Indar R, et al. A new approach for plate fixation of midshaft clavicular fractures. Injury. 2005; 36:1166–1171.
Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, PA: Lippincott-Raven; 1996:1009–1193.
Curtis RJ, Rockwood CA. Fractures and dislocations of the shoulder in children. In: Rockwood CA Jr, Matsen FAI, eds. The Shoulder. Philadelphia, PA: W.B. Saunders; 1990:991–1032.
Dameron TB, Rockwood CA Jr. Fractures and dislocations of the shoulder. In: Rockwood CA Jr, ed. Fractures in Children. Philadelphia, PA: J.B. Lippincott; 1984: 577–682.
de Jong KP, Sukul DM. Anterior sternoclavicular dislocation: a long-term follow-up study. J Orthop Trauma. 1990; 4:420–423.
Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle: A case for fixation. Injury. 1992; 23:44–46.
Edwards SG, Whittle AP, Wood GW 2nd. Nonoperative treatment of ipsilateral fractures of the scapula and clavicle. J Bone Joint Surg Am. 2000; 82:774–780.
Fazal MA, Saksena J, Haddad FS. Temporary coracoclavicular screw fixation for displaced distal clavicle fractures. J Orthop Surg (Hong Kong). 2007; 15:9–11.
Ferraz IC, Papadimitriou NG, Sotereanos DG. Scapular body nonunion: a case report. J Shoulder Elbow Surg. 2002; 11:98–100.
Flatow EL. The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect. 1993; 42:237–245.
Flinkkila T, Ristiniemi J, Hyvonen P, et al. Surgical treatment of unstable fractures of the distal clavicle: A comparative study of Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand. 2002; 73:50–53.
Fracture and dislocation compendium: Orthopedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996; 10(suppl 1):1–154.
Fukada K, Craig EV, An KN, et al. Biomechanical study of the ligamentous system of the acromicolavicular joint. J Bone Joint Surg Am. 1986; 68:434–440.
Gardner E. The embryology of the clavicle. Clin Orthop. 1968; 58:9–16.
Gilbert A, Whitaker I. Obstetrical brachial plexus lesions. J Hand Surg Br. 1991; 16:489–491.
Goldberg JA, Bruce WJ, Sonnabend DH, et al. Type 2 fractures of the distal clavicle: A new surgical technique. J Shoulder Elbow Surg. 1997; 6:380–382.
Goldfarb CA, Bassett GS, Sullivan S, et al. Retrosternal displacement after physeal fracture of the medial clavicle in children treatment by open reduction and internal fixation. J Bone Joint Surg Br. 2001; 83:1168–1172.
Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am. 1992; 74:299–305.
Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg. 1994; 3:42–52.
Goss TP. Scapular fractures and dislocations: Diagnosis and treatment. J Am Acad Orthop Surg. 1995; 3:22–33.
Grassi FA, Tajana MS, D'Angelo F. Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma. 2001; 50:1096–1100.
Groh GI, Wirth MA. Management of traumatic sternoclavicular injuries. J Am Acad Orthop Surg. 2011; 19:1–7.
Groh GI, Wirth MA, Rockwood CA Jr. Treatment of traumatic posterior sternoclavicular joint dislocations. J Shoulder Elbow Surg. 2011; 20:107–113.
Hening CF. Retrosternal dislocation of the clavicle: early recognition, x-ray diagnosis, and management [abstract]. J Bone Joint Surg Am. 1967; 50:830.
Hening CF. Retrosternal dislocations of the clavicle: Early recognition, xray diagnosis and management. J Bone Joint Surg Am. 1968; 50:830.
Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radiol. 1982; 9:27–32.
Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997; 79-B:537–539.
Hobbs DW. Sternoclavicular joint: a new axial radiographic view. Radiology. 1968; 90:801.
Hsu TY, Hung FC, Lu YJ, et al. Neonatal clavicular fracture: clinical analysis of incidence, predisposing factors, diagnosis, and outcome. Am J Perinatol. 2002; 19:17–21.
Ideberg R, Grevsten S, Larsson S. Epidemiology of scapular fractures. Incidence and classification of 338 fractures. Acta Orthop Scand. 1995; 66:395–397.
Imatani RJ. Fractures of the scapula: A review of 53 fractures. J Trauma. 1975; 15:473–478.
Jaggard MK, Gupte CM, Gulati V, et al. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J Trauma. 2009; 66:576–584.
Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007; 15:239–248.
Jin CZ, Kim HK, Min BH. Surgical treatment for distal clavicle fracture associated with coracoclavicular ligament rupture using a cannulated screw fixation technique. J Trauma. 2006; 60:1358–1361.
Jones HP, Lemos MJ, Schepsis AA. Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee: Surgical technique and case report. Am J Sports Med. 2001; 29:234–237.
Joseph PR, Rosenfeld W. Clavicular fractures in neonates. Am J Dis Child. 1990; 144:165–167.
Kalamaras M, Cutbush K, Robinson M. A method for internal fixation of unstable distal clavicle fractures: Early observations using a new technique. J Shoulder Elbow Surg. 2008; 17:60–62.
Kao FC, Chao EK, Chen CH, et al. Treatment of distal clavicle fracture using Kirschner wires and tension=band wires. J Trauma. 2001; 51:522–525.
Kaplan B, Rabinerson D, Avrech OM, et al. Fracture of the clavicle in the newborn following normal labor and delivery. Int J Gynaecol Obstet. 1998; 63:15–20.
Kaplan LD, Flanigan DC, Norwig J, et al. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med. 2005; 33:1142–1146.
Kavanagh BF, Bradway JK, et al. Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am. 1993; 75:479–484.
Kellum E, Creek A, Dawkins R, et al. Age-related patterns of injury in children involved in all-terrain vehicle accidents. J Pediatr Orthop. 2008; 28(8):854–858.
Khan LA, Bradnock TJ, Scott C, et al. Fractures of the clavicle. J Bone Joint Surg Am. 2009; 91:447–460.
Klimkiewicz JJ, Williams GR, Sher JS, et al. The acromioclavicular capsule as a restraint to posterior translation of the clavicle: A biomechanical analysis. J Shoulder Elbow Surg. 1999; 8:119–124.
Koch MJ, Wells L. Proximal clavicle physeal fracture with posterior displacement: Diagnosis, treatment, and prevention. Orthopedics. 2012; 35:e108–e111.
Labler L, Platz A, Weishaupt D, et al. Clinical and functional results after floating shoulder injuries. J Trauma. 2004; 57:595–602.
Lam MH, Wong GY, Lao TT. Reappraisal of neonatal clavicular fracture. Relationship between infant size and risk factors. J Reprod Med. 2002; 47:903–908.
Lee YS, Lau MJ, Tseng YC, et al. Comparison of the efficacy of hook plate versus tension band wire in the treatment of unstable fractures of the distal clavicle. Int Orthop. 2009; 33:1401–1405.
Leighton RK, Buhr AJ, Sinclair AM. Posterior sternoclavicular dislocations. Can J Surg. 1986; 29:104–106.
Levin MG, Holroyde J, Wood JR Jr, et al. Birth trauma: incidence and predisposing factors. Obstet Gynecol. 1984; 63:792–295.
Levy O. Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg. 2003; 12:24–28.
Liberson F. Os acromiale: A contested anomaly. J Bone Joint Surg. 1937; 19:683–689.
Liechti R. Fractures of the clavicle and scapula. In: Weber BG, Brenner C, Freuler F, eds. Treatment of Fractures in Children and Adolescents. New York, NY: Springer-Verlag; 1980:87–95.
Lyons FA, Rockwood CA Jr. Migration of pins used in operations on the shoulder. J Bone Joint Surg Am. 1990; 72:1262–1267.
Macheras G, Kateros KT, Savvidou OD, et al. Coracoclavicular screw fixation for unstable distal clavicle fractures. Orthopedics. 2005; 28:693–696.
Mall JW, Jacobi CA, Philipp AW, et al. Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: An alternative osteosynthesis. J Orthop Sci. 2002; 7:535–537.
Martin SD, Weiland AJ. Missed scapular fracture after trauma. A case report and a 23-year follow-up report. Clin Orthop Relat Res. 1994; 299:259–262.
Mayo KA, Benirschke SK, Mast JW. Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation. Clin Orthop Relat Res.. 1998; 347:122–130.
Mazzocca AD, Santangelo SA, Johnson ST, et al. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med. 2006; 34:236–246.
McGahan JP, Rab GT, Dublin A. Fractures of the scapula. J Trauma. 1980; 20:880–883.
McGraw MA, Mehlman CT, Lindsdell CJ, et al. Postnatal growth of the clavicle: Birth to 18 years of age. J Pediatr Orthop. 2009; 29:937–943.
McKee MD, Wild LW, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003; 85-A:35–40.
McKee RC, Whelan DB, Schemitsch EH, et al. Operative versus nonoperative care of displaced midshaft clavicular fractures: A Meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012; 94:675–684.
Mehlman CT, Yihua G, Bochang C, et al. Operative treatment of completely displaced clavicle shaft fractures in children. J Pediatr Orthop. 2009; 29:851–855.
Mehta JC, Sachdev A, Collins JJ. Retrosternal dislocation of the clavicle. Injury. 1973; 5:79–83.
Michael D, Fazal MA, Cohen B. Nonunion of a fracture of the body of the scapula: case report and literature review. J Shoulder Elbow Surg. 2001; 10:385–386.
Mooney JF III, Webb LX. Fractures and dislocations about the shoulder. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. Philadelphia, PA: Saunders Elsevier; 2009:283–312.
Morrison DS, Lemos MJ. Acromioclavicular separation: Reconstruction using synthetic loop augmentation. Am J Sports Med. 1995; 23:105–110.
Mounshine E, Garofalo R, Crevoisier X, et al. Grade I and II acromioclavicular dislocations: Results of conservative treatment. J Shoulder Elbow Surg. 2003; 12:599–602.
Namdari S, Ganley TJ Jr, Baldwin K, et al. Fixation of displaced midshaft clavicle fractures in skeletally immature patients. J Pediatr Orthop. 2011; 31:507–511.
Neer CS II. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma. 1963; 3:99–110.
Neer CS II. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968; 58:43–50.
Neer C II. Fractures and dislocations of the shoulder. In: Rockwood CA Jr, Green DP, eds. Fractures in Adults. Philadelphia, PA: J.B. Lippincott; 1984:711–712.
Nettles JL, Linscheid RL. Sternoclavicular dislocations. J Trauma. 1968; 8:158–164.
Nettrour LF, Krufky EL, Mueller RE, et al. Locked scapula: Intrathoracic dislocation of the inferior angle. A case report. J Bone Joint Surg Am. 1972; 54:413–416.
Nogi J, Heckman JD, Hakala M, et al. Non-union of the clavicle in a child. A case report. Clin Orthop. 1975; 110:19–21.
Nordqvist A, Petersson C. Fracture of the body, neck, or spine of the scapula. A long-term follow-up study. Clin Orthop Relat Res. 1992; 283:139–144.
Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994; 300:127–132.
Norqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture: 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand. 1993; 64:87–91.
Nourissat G, Kakuda C, Dumontier C, et al. Arthroscopic stabilization of Neer type 2 fracture of the distal part of the clavicle. Arthroscopy. 2007; 23:674.e1–4.
Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures: A prospective study during a two-year period in Uppsala, Sweden. Injury. 2000; 31:353–358.
Oppenheim WL, Davis A, Growdon WA, et al. Clavicle fractures in the newborn. Clin Orthop Res. 1990; 250:176–180.
Pandya NK, Baldwin K, Wolfgruber H, et al. Child abuse and orthopaedic injury patterns: Analysis at a level I pediatric trauma center. J Pediatr Orthop. 2009; 29:618–625.
Phillips AM, Smart C, Groom AF. Acromioclavicular dislocation: Conservative or surgical therapy. Clin Orthop Relat Res. 1998; 353:10–17.
Postachhini F, Gumina S, De Santis P, et al. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002; 11:452–456.
Pujol N, Philippeau JM, Richou J, et al. Arthroscopic treatment of distal clavicle fractures: A technical note. Knee Surg Sports Traumatol Arthrosc. 2008; 16:884–886.
Regel JP, Pospiech J, Aalders TA, et al. Intraspinal migration of a Kirschner wire 3 months after clavicular fracture fixation. Neurosurg Rev. 2002; 25:110–112.
Reilly P, Bruguera JA, Copeland SA. Erosison and nonunion of the first rib after sternoclavicular reconstruction with Dacron. J Shoulder Elbow Surg. 1999; 8:76–78.
Renfree KJ, Riley MK, Wheeler D, et al. Ligamentous anatomy of the distal clavicle. J Shoulder Elbow Surg. 2003; 12:355–359.
Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports med. 2007; 35:811–817.
Roberts S, Hernandez C, Adams M, et al. Neonatal clavicular fracture: an unpredictable event. Am J Obset Gynecol. 1993; 168:433.
Robinson CM. Fractures of the clavicle in the adult: Epidemiology and classification. J Bone Joint Surg Br. 1998; 80:476–484.
Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004; 86:778–782.
Robinson CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004; 86:1359–1365.
Rockwood CA Jr, Williams GR Jr, et al. Disorders of the acromioclavicular joint. In: Rockwood CA, Matsen FA, eds. The Shoulder. Philadelphia, PA: WB Saunders; 1998:483–553.
Rokito AS, Zuckerman JD, Shaari JM, et al. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis. 2002–2003; 61:32–39.
Simovitch R, Sanders B, Ozbaydar M, et al. Acromioclavicular joint injuries: Diagnosis and management. J Am Acad Orthop Surg. 2009; 17:207–219.
Spencer EE, Kuhn JE, Huston LJ, et al. Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg. 2002; 11:43–47.
Spencer EE Jr, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am. 2004; 86:98–105.
Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture: A clinical and biomechanical analysis. J Bone Joint Surg Br. 1988; 70:461–464.
Stewart AM, Ahmad CS. Failure of acromioclavicular reconstruction using Gore-Tex graft due to aseptic foreign-body reaction and clavicle osteolysis: A case report. J Shoulder Elbow Surg. 2004; 13:558–561.
Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid fractures using suture anchors. Arthroscopy. 2005; 21:635.
Thompson DA, Flynn C, Miller PW, et al. The significance of scapular fractures. J Trauma. 1985; 25:974–977.
Tompkins M, Bliss J, Villarreal R, et al. Posterior-sternoclavicular disruption with ipsilateral clavicle fracture in a nine-year-old hockey player. J Orthop Trauma. 2010; 24:e36–e39.
Tossy JD, Mead MC, Sigmond HM. Acromioclavicular separations: Useful and practical classification for treatment. Clin Orthop Relat Res. 1963; 28:111–119.
Tsai CH, Hsu HC, Huan CY, et al. Late migration of threaded wire (schanz screw) from right distal clavicle to the cervical spine. J Chin Med Assoc. 2009; 72:48–51.
Vander Have KL, Perdue AM, Caird MS, et al. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop. 2010; 30:307–312.
Venissac N, Alifano M, Dahan M, et al. Intrathoracic migration of Kirschner pins. Ann Thorac Surg. 2000; 69:1953–1955.
Waninger KN. Stress fracture of the clavicle in a collegiate diver. Clin J Sport Med. 1997; 7:66–68.
Waskowitz WJ. Disruption of the sternoclavicular joint: An analysis and review. Am J Orthop. 1961; 3:176–179.
Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicula fracture-dislocations in children and adolescents. J Pediatr Orthop. 2003; 23:464–469.
Webber MC, Haines JF. The treatment of lateral clavicle fractures. Injury. 2000; 31:175–179.
Williams GR Jr, Nguyen VD, Rockwood CA Jr. Classification and radiographic analysis of acromioclavicular dislocations. Appl Radiol. 1989; 18:29–34.
Wirth MA, Rockwood CA Jr. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg. 1996; 4:268–278.
Wojtys EM, Nelson G. Conservative treatment of Grade III acromioclavicular dislocations. Clin Orthop Relat Res. 1991; 268:112–119.
Wu CD, Chen YL. Stress fracture of the clavicle in a professional baseball player. J Shoulder Elbow Surg. 1998; 7:164–167.
Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth method for unstable fractures of the distal clavicle. Int Orthop. 1998; 22:366–368.
Zanca P. Shoulder pain: Involvement of the acromioclavicular joint: Analysis of 1,000 cases. Am J Roentgenol Radium Ther Nucl Med. 1971; 112:493–506.
Zdravkovic D, Damholt VV. Comminuted and severely displaced fractures of the scapula. Acta Orthop Scand. 1974; 45:60–65.