Paediatric Clavicle Fracture
The clavicle is one of the most commonly fractured bones in children.
50% of all the paediatric clavicle fractures occur under the age of seven years.
Based on the location of the fracture, clavicle fractures are classified into three types –
Middle third – 80%
Lateral third – 15%
Medial third – 5%
Clavicle fractures are the most common perinatal fracture associated with birth trauma.
The other causes are fall on an outstretched hand, fall onto the point of the shoulder, and motor vehicle accidents.
Infants and toddlers may present having been observed not using the arm, without a witnessed trauma.
Older children present with a history of falls, pain, swelling, and deformity along the line of the clavicle.
Fractures of the medial third are usually the result of direct trauma to the anterior chest such as in a motor vehicle accident and can be associated with neurovascular, pulmonary, and cardiac (rare) injuries.
All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.
Standard anteroposterior and anteroposterior with 15 degrees cephalic tilt x-ray of the clavicle will show the fracture in two planes and define displacement.
Computed tomography may be needed for medial third injuries with sternoclavicular dislocation to assess tracheal impingement and thoracic anatomy.
Middle third clavicle fractures do not require reduction and are treated with broad arm sling to support the limb for 2 weeks or until comfortable and regular analgesia as required.
Both medial and lateral third clavicle non displaced fractures are treated with a broad arm sling and displaced fractures need further evaluation.
Operative interventions are indicated in the following situations –
Severely comminuted or shortened middle third (>2 cm in 12 years and above age)
Neurovascular injury with fracture
The skin at risk over the fracture
Pathological fracture ( Congenital pseudoarthrosis of the clavicle)
The majority of uncomplicated middle third fractures will have excellent functional and cosmetic outcomes.
Pain and restriction of the movement are usual for 2-3 weeks.
The child should re-attend if the pain is increasing or when there is abrupt sensation change.
Neurovascular complications are rare. Early neurovascular injury is due to trauma and late compromise is due to excessive callus development.
Non-union is uncommon.
Malunion with palpable or visual lump is common. It diminishes with remodelling.
Degenerative arthritis if acromioclavicular joint intra-articular incongruence is present.