abstract

Medial Clavicle Physeal Fracture: A Case Report from diagnosis to treatment

Michael Krantzow, DO (Resident)
Department of Orthopedic Surgery, North Shore / Long Island Jewish: PlainviewHospital, Plainview, NY  11803, USA

Correspondence: Michael Krantzow, DO, Department of Orthopedic Surgery, Department of Medical Education, NS/LIJ Plainview Hospital, 888 Old Country Road,
25 Building, Plainview, NY 11803
Ph: (516) 719-2546, Fax: (516) 719-2766
Email: MKrantzow@gmail.com

Abstract
Medial clavicle fractures are the least common fracture of the clavicle. The diagnosis, evaluation and treatment of these injuries is often complicated by the delayed physeal closure of the medial clavicle. Treatment options vary depending on location of the fracture, the fracture pattern and displacement, from nonoperative management to surgical fixation.

A rare scenario is described in a patient where the diagnosis of medial clavicle physeal fracture or “pseudodislocation” was incorrectly initially diagnosed as a sternoclavicular dislocation. A discussion of the diagnosis and treatment of this injury pattern and the pearls and pitfalls associated with it are presented.

Case Report
This is a case report of a 17 year old, Caucasian male who had a fall onto the postero-lateral aspect of his right shoulder while skiing approximately 4 weeks prior to presentation. The patient was diagnosed with a clavicle fracture and placed in a sling. When no improvement was noted the patient was referred to an upper extremity trauma specialist. The patient noted no improvement in pain and function since the accident.
Upon physical examination all vital signs were stable and the patient was in no acute distress. There was an obvious deformity to the medial aspect of the clavicle, with ecchymosis over the superior chest wall. The patient was able to elevate the upper extremity with significant difficulty and pain. There was significant tenderness to palpation about the medial edge of the clavicle.

Radiographs at the time of presentation showed possible displacement of the medial edge of the clavicle and a possible sterno-clavicular joint dislocation. Further imaging studies were performed, including a computed tomography scan of the sterno-clavicular joint. The radiologist interpreted the CT scan as a posterior sterno-clavicular dislocation with resulting hematoma. No damage to the mediastinum or the great vessels was noted. Upon presentation the CT scan was reviewed and the previous diagnosis of SC dislocation was revised to a medial phyesal fracture with posterior displacement of the clavicle.

Figure 1

After discussion with the patient and the patient’s legal guardians regarding surgical and non-surgical options, the decision was made to take the patient for surgical fixation of the sterno-clavicular fracture and dislocation. During the surgical procedure a thoracic surgeon was present and available.  A horizontal incision was made that was centered over the SC joint measuring six centimeters in length and extending over the midline of the chest wall. Dissection through the clavicular fascia and through the periosteum was performed until the physeal fracture was visualized. At this time the sterno-clavicular joint was visualized and confirmed to be intact, with the fracture of the medial clavicle extending through the physis with the clavicle displaced posteriorly and leaving the epiphysis in continuity with the sternum.  After clearing the fracture site of callus formation and all soft tissue a towel clamp was placed around the clavicle and a gentle reduction maneuver was performed.  Using a clamp to hold the fracture reduced, three drill holes were made on the medial end of the clavicle as well as through the epiphyhseal fragment. After confirming with fluoroscopy that an appropriate reduction was achieved, three stands of thick braided biocomposite suture (#5 FiberWire) were passed through the drill sites in a crossed fashion and tied firmly in place.  Closure of the periostium and fascia over the clavicle was performed, and the skin was closed with a running subcuticular closure.  Radiographs confirmed the reduction was stable after closure and dressing. A shoulder immobilizer was used postoperatively to limit motion of the upper extremity in the initial postoperative phase.

The patient remained non-weight bearing to the right upper extremity and was instructed to leave the sling in place at all times.  Daily dressing changes were performed and the patient was seen at one and two weeks postoperatively where radiographs were performed that confirmed continued reduction of the fracture. At four weeks postoperatively a CT scan was performed that showed proper alignment of the fracture of the medial clavicle as well as the sterno-clavicular joint.  At this time the shoulder immobilizer was discontinued and gentle range of motion exercises were initiated.

Discussion
An exact definition of the injury that occurred in the patient presented is required prior to complete understanding of the case. While this injury was described on physical exam as well as radiologic studies as a sterno-clavicular dislocation, this is not the case. This injury should be described as a Salter Harris Type I or II fracture of the medial clavicle1 or a pseudodislocation of the sterno-clavicular joint.  For reasons that will be discussed the SC joint was unaffected by the trauma, while the clavicle suffered fracture through the physis as well as posterior displacement. The case that is presented is noted to be a Salter Harris type I fracture.

Fractures of the clavicle account for 2.6% of all fractures2. Recently, the mechanism of injury has been described most commonly as a direct trauma to the shoulder3,4 rather than a fall onto an outstretched hand5, which was the originally postulated cause. Sporting activities including biking and skiing are the most common causes of clavicle fractures6.

Clavicle fractures were originally divided and classified by Allman5 into medial, middle and distal fractures. The rate of occurrence of each fracture location has been described by Robinson7, with midshaft fractures occurring in 80% of cases, lateral fractures occurring in 20% and medial fractures occurring in less than 3%. The cause of the frequency of clavicle fractures is twofold. Firstly the clavicle is a subcutaneous structure throughout most of its length lending an inherent susceptibility8. Secondly, the clavicle acts as a strut from the upper extremity to the trunk, transmitting significant forces through it9.

Medial clavicle fractures are rare, but when they occur, they are most commonly nondisplaced10. The pathoanatomy of fractures of the medial clavicle are distinct in regard to the status of the medial physis. The medial clavicle physis is the last physis in the body to close, and this usually occurs between ages 23-2511.  Medial clavicle physeal fractures are classified using the Salter Harris classification of physeal injuries with most injuries being type I or type II fractures.  In addition to a decrease in structural integrity of the medial clavicle because of an open physis, the strong sternoclavicular ligaments primarily attach to the epiphyseal portion of the medial clavicle, leaving the physis unprotected12.

The evaluation of medial clavicle fractures begins with the physical exam. In the case of posteriorly displaced medial physeal fractures, injuries to the great vessels, trachea and esophagus are especially worrisome. Specific assessment regarding difficulty speaking, swallowing or breathing should be undertaken, as well as assessment of diminished upper extremity pulses and distension of the neck veins13. The association of posterior displaced medial clavicle fractures with vascular and thoracic trauma was the reason a thoracic surgeon was present during the surgical fixation in the case presented.

Radiographic evaluation of medial clavicle injuries includes plain radiographs, including the “serendipity” view. This view visualizes both clavicles and is taken with 40 degrees of cephalic tilt and assesses displacement of the medial end of the injured clavicle in relation to the uninjured side14.  Currently, a CT scan provides the most useful information in the setting of a medial clavicle injury. It provides detailed information regarding physeal injury, degree of displacement, as well as evaluation of underlying intrathoracic injury15. Treatment guidelines for clavicle fractures had previously been based on work by Neer16 and Rowe17 that described the nonunion rate of clavicle fractures treated nonoperatively at only 1%. More recent literature shows that displaced clavicle fractures treated nonoperatively have a nonunion rate of up to 15%, but when treated operatively the rate of nonunion decreases to 2.5%18.

A recent multicenter, randomized clinical trial performed by the Canadian Orthopaedic Trauma Society confirmed the improved results with surgical fixation of clavicle fractures with an improved time to union, rate of nonunion and rate of malunion19. While many of these reports regarding mechanism of injury and treatment guidelines are related to midshaft clavicle fractures due to the large numbers of cases, specific data related to medial clavicle fractures is not available due to the limited population with this injury.

Treatment of medial clavicle physeal separation injuries can vary from nonoperative management to surgical management. If the injury is nondisplaced or minimally displaced, nonoperative management is recommended due to the potential risks of open treatment of injuries adjacent to the mediastinum20,21.  Nonsurgical management consists of sling immobilization, pain control and appropriate physical therapy. Surgical options range from closed reduction under anesthesia to a formal open reduction.  Closed reduction is performed using a sterile towel clip to grasp the clavicle through the skin and using gentle traction to manipulate the displaced clavicle into proper alignment22. Stable reduction is often difficult to maintain and an open reduction may be required23.  Multiple techniques for the open reduction of posteriorly displaced medial physeal clavicle fractures are described, all requiring a gentle reduction followed by fixation of the clavicle to the epiphysis. Kirschner wires24, 22-gauge wire25 and suture23,26  have all been documented as possible options for fixation. Significant risk exists in the use of Kirschner wires as fatal migration of the wires has been documented.27,28
A final note should be made regarding the timing of presentation of the patient for treatment. If the posteriorly displaced fracture is discovered acutely (within 48 hours) closed reduction was successfully performed over 55% of cases. However, if the presentation is delayed (more than 48 hours), closed reduction is successful in only 30% of cases29. In the case presented above, significant delay in presentation led to the decision to skip a closed reduction and perform an immediate open reduction.

In conclusion, an unusual fracture pattern was identified that had the potential for serious concomitant injuries. Proper diagnosis and classification as a physeal fracture is unlikely using plain radiographs, and a CT scan should be performed. Due to the potential for mediastinal injuries a thorough physical exam should be performed, and signs of intrathoracic injury should be evaluated urgently. While nonoperative management is the most common treatment for medial clavicle injuries, posteriorly displaced medial physeal fractures are likely to be treated with a closed reduction or open reduction.  If surgical reduction is performed a thoracic surgeon able to perform an immediate sternotomy should be present due to the risk of damage to the mediastinal structures.

References

  1. Salter RB, Harris WR. Injuries involving the epiphyseal plate. JBJS 1963; 45: 587-622
  2. Nowak J, Mallmin H, Larson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury 2000;35(5):353–358
  3. Fowler AW. Treatment of fractured clavicle. Lancet 1968;1:46–47
  4. Sankarankutty M, Turner BW. Fractures of the clavicle. Injury 1975;7:101–106
  5. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg
    Am
    1967;49:774–784
  6. Matsumoto K, Miyamoto K, Sumi H, et al. Upper extremity injuries in snowboarding and skiing: a comparative study. Clin J Sport Med 2002;12(6):354–359
  7. Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg
    Br
    1998;80:476–484
  8. Beaty J and Kasser J, Rockwood and Wilkin’s fractures in children. 7th Ed Pg 620
  9. Moseley HF. Shoulder lesions. Edinburgh: Churchill Livingstone, 1972
  10. Nordqvist A, Petersson, C. The incidence of fractures of the clavicle. Clin Orthop 1994;127–132
  11. Jit I, Kulkarni M. Times of appearance and fusion of epiphysis at the medial end of the clavicle. Ind J Med Res 1976;64:773–782.
  12. Kogutt MS, Swischuk LE, Fagan CJ. Patterns of injury and significance of uncommon fractures in the battered child syndrome. Am J Roentgenol Radium Ther Nucl Med 1974;121:143–149
  13. Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma 1967;7:416–423
  14. Wirth MA, Rockwood CA Jr. Disorders of the sternoclavicular joint: pathophysiology, diagnosis, and management. In: Iannotti JP, Williams GR Jr, eds. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams & Wilkins, 1999:783–785
  15. Beaty J and Kasser J, Rockwood and Wilkin’s fractures in children. 7th Ed Pg 622
  16. Neer CS. Nonunion of the clavicle. JAMA 1960;172:1006–1011
  17. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop 1968;58:29–42.
  18. Zlowodzki M, Zelle BA, Cole PA, et al: Treatment of acute midshaft clavicle fractures: J Orthop
    Trauma
    19:504, 2005
  19. Canadian Orthopaedic Trauma Society, Nonoperative treatment compared to plate fixation of displaced midshaft clavicle fractures. J Bone and Joint Surg AM 2007 1:89, 1-10
  20. Lewonowski K, Bassett GS. Complete posterior sternoclavicular epiphyseal separation. A case report and review of the literature. Clin Orthop 1992;84–88
  21. Zaslav KR, Ray S, Neer CS 2nd. Conservative management of a displaced medial clavicular physeal
    injury in an adolescent athlete. A case report and literature review. Am J Sports Med1989;17:833–836
  22. Buckerfield C, Castle M. Acute traumatic retrosternal dislocation of the clavicle. J Bone Joint Surg 1984;
    66A: 379-385
  23. Waters PM, Bae DS, Kadiyala RK. Short-Term outcomes after surgical treatment of traumatic posterior sternoclavicular fracturedislocationsin children and adolescents. J Pediatr Orthop 2003;23
  24. Denham RH, Dingley AF. Epiphyseal separation of the medial end of the clavicle. J Bone Joint Surg
    1967;49:1179
  25. Goldfarb CA, Bassett GS, Gordon JE. Retrosternal displacement after physeal fracture of the medial clavicle in children. J Bone Joint Surg Br 2001;83:1168-72
  26. Tennet TD et al, A new technique for stabilizing adolescent posteriorly displaced physeal medial clavicular fractures. J Shoulder Elbow Surg (2012) 21, 1734-1739
  27. Clark RL, Fatal aortic perforation and cardiac tamponade due to a Kirschner wire migrating from the
    Right SC Joint. South Med J 1974: 67: 316-318
  28. Venissac N, Alifano M, Dahan M, Mouroux J. Intrathoracic migration of Kirschner pins. Ann Thorac
    Surg
    2000;69:1953-5
  29. Tepolt F, et al. Posterior SC Joint injuries in the adolescent population AJSM 2/2014

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