Craig P. Eberson
DEFINITION
Commonly seen fractures include proximal humerus fractures (physeal and metaphyseal) and clavicle fractures and dislocations, as well as less commonly seen fractures of the scapula.
Most of these injuries can be treated nonoperatively because of the significant remodeling potential.
Certain fractures will require operative treatment, however, due to decreased remodeling capacity in the older child (proximal humerus), risk to surrounding structures (sternoclavicular dislocations), and open or threatened skin (clavicle fractures).
Acromioclavicular joint injuries are often physeal fractures in the growing child and are almost exclusively so in children younger than 16 years old. The ligaments usually remain attached to the thick clavicular periosteum, and are thus usually intact.
Opinion varies on the need for surgical repair, although most do well treated nonoperatively.2,6
Aggressive surgical treatment for some of these injuries (clavicle fractures, scapular fractures) is rarely indicated for most children. Operative treatment in these cases is the same as for the adult patient and will be covered in other chapters in this book.
ANATOMY
The proximal humeral physis is responsible for 80% of humeral growth. It remains open usually until age 14 to 17 in girls, age 18 in boys.
A major portion of the physis is extracapsular and vulnerable to injury.
The anterior periosteum is usually thinner than the posterior, often leading to hinging of the fragments posteriorly and possible entrapment of the periosteum anteriorly.
FIG 1 • Relationship of the brachial plexus and axillary artery to the proximal humerus. The axillary nerve wraps around the humerus to insert into the deltoid, roughly 5 cm distal to the acromion.
The proximal humerus lies in close proximity to the brachial plexus and axillary vessels. Care should be taken to document function of the innervated musculature before initiating treatment (FIG 1).
The medial clavicular epiphysis is the last in the body to appear (age 18 to 20 years) and the physis is the last to close (age 23 to 25 years).
This is why most of these injuries are physeal fractures rather than true dislocations.2
Immediately posterior to the sternoclavicular joint lie the trachea, esophagus, and great vessels.
PATHOGENESIS
Injuries to the proximal humerus occur from either a direct blow to the region or indirect trauma, such as a fall onto the outstretched hand.
In cases of pathologic fractures through bone cysts, throwing a ball or reaching overhead can precipitate an injury.
Sternoclavicular injuries are usually caused by a direct blow to the clavicle, or by a blow to the lateral shoulder girdle that dislocates the clavicle anteriorly or posteriorly.
Scapular fractures are high-energy injuries, requiring comprehensive evaluation as per Advanced Trauma Life Support protocols.
NATURAL HISTORY
Because of the significant remodeling potential in young children, most patients will heal without sequelae from fractures of the proximal humerus or clavicle.
Intra-articular fractures of the glenoid should be treated as in the adult.
Morbidity from associated injuries, however, may be significant, and thus a thorough evaluation is of paramount importance. Posterior sternoclavicular dislocations in particular threaten the great vessels, trachea, and esophagus.
Debate exists as to the natural history of distal clavicle fractures with significant displacement, but most agree that conservative treatment is effective.2
General guidelines are available to define acceptable healing alignment for proximal humeral fractures (Table 1).
Examples of complete or near-complete remodeling are readily found in the literature for even completely displaced fractures in children less than 15 years old, however, so a clear understanding of the goals of the procedure and its associated risks is crucial.1,5
PATIENT HISTORY AND PHYSICAL FINDINGS
History should include mechanism of injury, antecedent pain, and neurologic symptoms in the hand and arm.
A high-energy injury should also prompt a full trauma workup using standard Advanced Trauma Life Support protocols.
Physical examination begins with a thorough assessment of the skin for areas of compromise, particularly in clavicle fractures.
Swelling from a sternoclavicular dislocation may mask initial displacement, so this area should be palpated for pain or crepitance. Stridor in the setting of a sternoclavicular injury is particularly worrisome.
A neurologic examination to include the brachial plexus distribution, as well as a vascular examination of the arm, is necessary.
Neurologic injury in conjunction with fracture may signify ongoing compression (ie, sternoclavicular dislocation) and may affect prognosis.
A high suspicion for vascular injury is important in preventing late sequelae.
The clinician should palpate the medial and lateral clavicles and the proximal humerus to differentiate fracture from soft tissue injury.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Standard initial views of the shoulder should include a true anteroposterior (AP) view, a “shoot-through” lateral, and an axillary lateral view (FIG 2A,B).
The “serendipity view” is helpful in cases of medial clavicle fracture or dislocation. This is taken by obtaining an AP radiograph of both clavicles with the beam angled 40 degrees cephalad (FIG 2C).
Computed tomography can be helpful to assess cases of suspected sternoclavicular dislocation, as a contrast study will provide information about potential vascular injury (FIG 2D), as well as detail the relationship of the clavicle to the trachea and esophagus (FIG 2E).
CT is the standard, although some have recommended MRI.4
DIFFERENTIAL DIAGNOSIS
Proximal humerus metaphyseal fracture
Proximal humerus physeal injury
Shoulder dislocation
Acromioclavicular fracture-dislocation
Sternoclavicular fracture-dislocation
Child abuse
FIG 2 • A,B. Preoperative AP and lateral radiographs of a Salter-Harris type II fracture of the proximal humerus in a 15-year-old girl show mild valgus angulation and complete displacement with 90 degrees of angulation on the lateral view. C. In a different patient, apical oblique radiograph taken with fluoroscopy before reduction of a posterior sternoclavicular dislocation. Note the asymmetric heights of the inferior clavicles (*). D. In another patient, three-dimensional contrast-enhanced computed tomography image of left posterior sternoclavicular dislocation. Note the relationship to the great vessels. E. Axial view of the same patient as in D, demonstrating the injury to be a physeal fracture. The epiphysis (arrow) remains in place, while the metaphysis (*) is posteriorly displaced, immediately anterior to the vasculature.
NONOPERATIVE MANAGEMENT
Most of these injuries can be treated nonoperatively.
For proximal humeral fractures with acceptable alignment, treatment consists of sling management for comfort for several weeks, followed by a home range-of-motion program and return to activities in 6 to 8 weeks.
Treatment of clavicle fractures consists of a sling for initial comfort, followed by a figure 8 bandage or sling, depending on the patient's preference.
Immobilization can usually be discontinued after 3 weeks, with return to sports by 6 to 8 weeks.
While surgical management of distal clavicular physeal injuries has been advocated by some, the majority of patients do well with treatment similar to clavicular shaft fractures.
Older children can be treated as adults, and the surgical treatment of these injuries is discussed elsewhere.
SURGICAL MANAGEMENT
The operative management of clavicle fractures and dislocations is well covered elsewhere in this text. Operative treatment of proximal humeral fractures will subsequently be discussed, as well as reduction of posteriorly displaced fracture-dislocations of the sternoclavicular joint.
For physeal or metaphyseal fractures of the proximal humerus, operative treatment should be considered for fractures with unacceptable residual displacement.
Closed reduction is often unstable and fixation is desirable.
Because of open growth plates, standard plate-fixation techniques are rarely indicated.
Threaded-wire fixation provides sufficient temporary fixation to allow healing.
Failure to obtain a satisfactory closed reduction may require an open reduction, and surgeons should be familiar with this technique as well.
Interposition of the biceps tendon has been noted to be the most common cause of a failed closed reduction,3 but other authors disagree.5
Preoperative Planning
Good-quality radiographs of the shoulder should be available.
It is important to rule out concomitant glenoid fracture or dislocation before surgery.
Positioning
Proximal Humerus Fractures
For proximal humeral fractures, the patient is positioned in a modified beach-chair position, with the back elevated roughly 30 degrees.
The imaging machine is then brought in from the head of the table. It can be tilted “over the top” to get an AP view and rotated to get an axillary lateral view (FIG 3).
If the table if too upright, the AP view may be difficult to obtain because of limited excursion of the C-arm past neutral.
A vacuum positioning device (beanbag) is positioned under the patient's head, neck, and upper torso. This allows the patient to be slid slightly over the edge of the table to allow full access to the shoulder girdle.
A chest pad attached to the table prevents the patient from being pulled off the table inadvertently when traction is applied to the arm.
Alternately, a sheet can be wrapped around the torso and secured by an assistant on the opposite side of the table.
Sternoclavicular Dislocation
Patients with posterior sternoclavicular dislocations should be positioned supine with a roll between their shoulders to allow hyperextension of the shoulder girdle. It is helpful to position the patient with the operative side near the edge of the table.
FIG 3 • Intraoperative positioning for reduction. A. The patient is over the edge of the table with the entire arm exposed. The imaging machine is brought in from the head of the table. It is tilted into the “over-the-top” position to obtain a true AP view of the shoulder. Note the surgeon's hands; traction is applied with the left hand, while the right helps to correct the adduction of the distal shaft fragment. B.Without moving the arm, the image can be rotated to obtain an axillary lateral view. In this simulated figure, the fluoroscopy unit is not draped for clarity; in practice, it is brought up beneath the drapes to maintain the sterile field. The surgeon is applying pressure to reduce the apex anterior angulation, while maintaining traction with the left hand. Under the drapes, a chest pad prevents the patient from being pulled off the table with traction; a sheet wrapped around the torso and held by an assistant would accomplish the same purpose.
FIG 4 • Approach for open reduction. A. One of two possible incisions is made: the standard incision made in the deltopectoral interval, which is helpful for wide displacement, or a more cosmetic incision in the axilla. In the latter incision, the skin is then undermined to perform the same deep dissection. B. The cephalic vein is identified as the marker for the interval. It is dissected free and the interval entered. C.The obstacles to reduction can now be cleared. Interposed biceps tendon, interposed periosteum, and buttonholing of the shaft through the deltoid are possible causes of inability to obtain a reduction.
Approach
Proximal Humeral Fractures
Reduction of proximal humeral fractures is, generally speaking, a closed procedure.
Interposed tissue may require an open approach, which is through the deltopectoral interval (FIG 4).
Sternoclavicular Joint
Reduction of sternoclavicular dislocations can also be performed in a closed fashion and treated without surgical repair of the ligaments.
While I have treated these injuries with closed reduction followed by a figure 8 splint, close follow-up and postreduction CT are required to detect loss of reduction.
Because of this, others have recommended primary repair of all of these injuries.8
Open reduction of these injuries is performed using a transverse incision overlying the sternoclavicular joint. A pediatric thoracic–vascular surgeon should be on standby, preferably in the room, because of the proximity of several vital structures in this region.
The incision is carried through the platysma muscle down to the clavicular periosteum, which is elevated to expose the clavicle.
Dissection is limited to within the periosteum to avoid injury to surrounding structures.
TECHNIQUES
PROXIMAL HUMERUS FRACTURE
Closed Reduction
To reduce the fracture, the forces acting on the humerus need to be understood. The proximal fragment tends to be abducted and externally rotated due to the pull of the rotator cuff musculature, while the shaft is adducted from the pull of the pectoralis major muscle. To correct this, the first step is usually abduction and external rotation of the arm.
Traction is then applied to disengage the fragments. It is helpful to have an assistant stabilize the torso.
Usually, the shaft can be manipulated in line with the head at this point.
The typical angulation to be corrected is varus and apex anterior angulation.
It is often helpful to think about pushing down on the proximal end of the shaft to correct the angulation while maintaining abduction to correct the varus.
In smaller, thin patients it is possible to grasp the head through the axilla to assist with the reduction.
Once reduced, stabilization ensues (see below).
Open Reduction
In rare cases, a closed reduction cannot be successfully achieved. A common cause is entrapment of periosteum or biceps tendon.
In these cases, a small deltopectoral incision can be made.
This is a limited approach, not the wide extensile exposure needed for open reduction and internal fixation.
A finger can usually be inserted through a small opening to allow clearance of obstructing soft tissue.
Fixation then ensues (see below).
Percutaneous Pin Fixation
Once reduced, the fracture is then stabilized.
Threaded-tip pins, such as the 2.5-mm guide pins found in most cannulated hip screw systems, are ideal for pediatric use and are my first choice, although they are potentially unsuitable for use in osteoporotic adult bone. Fully threaded pins can also be used.
It is important to understand the relationship of the important neurologic structures to the proximal humerus.
The axillary nerve lies in the deltoid muscle 5 cm (in an adult, less in a child) from the tip of the acromion laterally.
More anteriorly, the musculocutaneous nerve is at risk.
Pins are placed through small stab incisions using a tissue protection sleeve after a hemostat has been used to spread the tissue down to the bone.
Often the reduction is stable enough to allow the arm to be placed down at the patient's side and internally rotated, which is the position of postoperative immobilization.
If not, the pin can be inserted in the abducted position, but on moving the arm down, the skin will then be tented by the pin.
A relaxing incision can be made, or the first pin put in provisionally, the arm moved to the patient's side, and the first pin removed after additional fixation has been obtained.
The easiest pin to place first is usually from distal lateral to proximal medial (TECH FIG 1A).
The pin is started perpendicular to the shaft, and the surgeon's hand is then dropped to the correct angle.
TECH FIG 1 • Pinning of a proximal humeral fracture in the patient in Figure 2A,B with a Salter-Harris type II humeral fracture. A. After reduction, the first pin is placed. B. A second pin is then placed, starting more anteriorly and proximally. C. The pins are placed in a divergent fashion. The stab incisions (not shown) should be well distal to the pin–bone interface to prevent soft tissue tension. D. An “advance–withdrawal” test is performed under live fluoroscopy to confirm stability as well as the extra-articular nature of the pins.
It is important to make the initial approach down to the bone along the final angle of pin insertion to avoid skin tension problems later.
The pin is advanced into the head, stopping several millimeters below the subchondral bone.
A second pin is then added (TECH FIG 1B).
I usually prefer to place this pin starting more proximally and anteriorly to the first pin.
If the first pin is aimed at the inferior portion of the head, the second can be aimed more superiorly for greater pin divergence across the fracture (TECH FIG C).
If needed, a third pin can be added from the greater tuberosity downward into the shaft.
This is helpful in small patients for better purchase in the head, but I usually avoid this pin because of a higher rate of soft tissue complications.
After fixation is complete, an “advance–withdrawal” test is performed (TECH FIG 1D), similar to that done for a slipped capital femoral epiphysis.
The shoulder is rotated and the tips of the pins should appear to approach the joint surface and then withdraw with continued rotation.
Pins that appear too long should be pulled back.
In larger patients near or at skeletal maturity with sufficient bone stock, cannulated screws can be inserted over a wire in the same fashion as described for threaded pins.
I have found this technique rarely necessary, but it does avoid the issue of pin management (see below).
POSTERIOR STERNOCLAVICULAR FRACTURE-DISLOCATIONS
Closed Reduction
My preferred initial technique is to attempt a closed reduction of these injuries. This is usually successful only if performed within 48 hours of injury.
With a sandbag or towel roll placed between the shoulder blades, the patient is placed supine with the involved side close to the edge of the operating table.
Intravenous anesthesia or conscious sedation may be used, but I prefer to perform the reduction under general anesthesia, both for patient comfort and so I can proceed to open reduction if required.
Longitudinal traction on the ipsilateral arm is applied by an assistant.
The shoulder is then gradually extended.
This often will reduce the dislocation.
If unsuccessful, the clavicle can be grasped and pulled upward, especially in thin patients.
Finally, the region can be prepared and draped and a towel clip used percutaneously to grasp the clavicle and reduce it.
The reduction is usually marked by a satisfying clunk and is often stable. This is not always the case, however, and the stability should be carefully confirmed.
Gentle posterior pressure on the clavicle confirms the stability of the reduction.
The shoulder is taken through a range of motion and the reduction checked as well.
Finally, intraoperative fluoroscopy is used to confirm symmetry of the sternoclavicular joints.
If confidence in a stable reduction exists, the patient is awakened and a postoperative CT scan obtained to assess the reduction (TECH FIG 2).
Reductions of questionable stability require an open reduction.
Open Reduction
The first step in this procedure is ensuring the presence of a pediatric vascular-thoracic surgeon in proximity to the operating room, preferably in the room.
The medial clavicle is approached through a transverse incision centered on the sternoclavicular joint (TECH FIG 3A).
The platysma muscle is divided and the clavicle periosteum exposed.
It is helpful to come down on the clavicle laterally away from the injury. The periosteum can then be elevated medially, toward the injury.
This allows careful exposure of the medial fracture (in the case of a true dislocation) or the physeal fracture site (in the case of a fracture-dislocation).
The epiphysis lies laterally to the intra-articular disc ligament. Care should be taken when exposing this area so that dissection does not inadvertently excise the epiphysis.2
The medial clavicle is grasped with a pointed tenaculum and reduced (TECH FIG 3B).
Although descriptions exist of temporary plating or pinning, the risks of these fixation techniques (migration of Kirschner wires, need for plate removal) do not justify their use. Suture fixation can be performed simply with good results.4,8
TECH FIG 2 • Same patient as in Figure 2D and E, a 15-year-old boy with a posterior sternoclavicular fracture-dislocation. CT scan obtained after closed reduction shows acceptable reduction of the physeal injury (arrow).
For true dislocations, 1- to 2-mm holes are made in the medial clavicle and the sternum (TECH FIG 3C).
I use a burr for better control.
There should be a generous bone bridge between the holes.
An absorbable, braided no. 1 suture (as opposed to wire often used in adults) is passed through the drill holes in a figure 8 fashion and tied securely.
For fracture-dislocations, the same technique is applied, but the medial holes are placed in the metaphyseal fragment (TECH FIG 3D).
It is occasionally easier to pass two separate sutures in these cases.
The needle is passed through one drill hole, out across the fracture site, and up through the hole in the corresponding fragment.
This is repeated, and both sutures are subsequently tied.
The periosteum is then repaired.
After fixation, the reduction is tested for stability, and after confirmation of such, the wound is closed using standard technique.
TECH FIG 3 • Approach for open reduction of a posterior sternoclavicular injury. A. The incision is centered on the joint, in line with the clavicle. Under the subcutaneous tissue lies the platysma muscle, which is also split in line with the incision. B. The clavicle is exposed subperiosteally, beginning laterally and working medially toward the joint. It can then be grasped with a towel clip and reduced. It is crucial to remain subperiosteal with the clip to avoid inadvertent injury to the vessels lying immediately posteriorly. After reduction, fixation is achieved with sutures. C. For a pure dislocation, a figure 8 pattern through burr holes will secure the joint. D. For a fracture-dislocation, it is often easier to use two separate sutures perpendicular to the fracture line.
FIG 5 • Radiograph taken 4 weeks after surgery of the patient in Techniques Figure 1, before pin removal. Medial sclerosis indicates healing.
POSTOPERATIVE CARE
Proximal Humeral Fractures
Aftercare of the pins is controversial. I prefer to leave the pins out of the skin for removal in the office.
This is usually easily accomplished at 3 to 4 weeks, when the fracture has gained sufficient stability from healing (FIG 5).
A battery-powered hand drill is helpful for securely grasping the pins and backing them out, as the tips are threaded.
The pins are wrapped in iodine-soaked gauze and covered.
They can be checked and redressed if concern exists, and pin care with half-strength peroxide is helpful.
In obese patients, or in young patients who may have difficulty with activity restriction in the sling, soft tissue movement around the pins may lead to infection.
In these patients, the pins should be cut beneath the skin.
Removal then requires an additional trip to the operating room, usually at 4 to 6 weeks after surgery.
After pin removal, the patients are instructed to begin gentle active-assisted shoulder range of motion.
Once healing is complete radiographically, formal physical therapy can be initiated to gain any additional mobility and strength.
Most children do well, however, by gradually resuming activities at their own pace.
Sternoclavicular Joint Injuries
After postreduction CT confirms reduction, the patient is followed at weekly intervals for the first 3 weeks with apical oblique radiographs.
Immobilization in a figure 8 harness is continued for 6 weeks.
Return to sports is allowed at 3 months.
Open reductions are protected for 4 to 6 weeks in sling and swathe.
Gentle range of motion is begun at 4 weeks.
Again, sports participation is restricted for 3 months.
OUTCOMES
Proximal Humerus
Most patients with proximal humeral fractures will do well regardless of the treatment method chosen.
Younger patients, particularly less than 15 years of age, will do well with closed treatment in the absence of neurovascular injury or open fracture.
Operative treatment usually results in satisfactory healing, although several reports note a high rate of complications from operative treatment, including late fracture through a pin hole and late osteomyelitis.1
Sternoclavicular Joint
Patients who undergo closed reduction of posterior sternoclavicular joint fracture-dislocations can be expected to do well.
Some authors recommend accepting residual displacement unless the patient has symptoms of mediastinal compression, as remodeling of the fracture can be expected; however, that view is not universal.10
Some authors believe that closed reduction is not sufficiently stable and report excellent functional outcomes from open reduction.8
Anterior sternoclavicular joint injuries, after reduction, are usually unstable.
The outcome in these injuries is usually quite good, as remodeling will occur and there is no risk to mediastinal structures.2
COMPLICATIONS
Proximal humerus fractures
Nerve injury
Pin tract infection or osteomyelitis
Persistent stiffness
Growth disturbance
Fracture through pin hole in cortex
Sternoclavicular injur.
Infection
Neurovascular injury
Persistent subluxation
REFERENCES
1. Beringer D, Weiner DS, Noble JS, et al. Severely displaced proximal humerus epiphyseal fractures: a follow-up study. J Pediatr Orthop 1998;18:31–37.
2. Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop 2005;432:41–48.
3. Dobbs MB, Luhmann SL, Gordon JE, et al. Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208–215.
4. Lehnert M, Maier H, Heike J, et al. Fracture and retrosternal dislocation of the medial clavicle in a 12-year-old child: case report, options for diagnosis, and treatment in children. J Pediatr Surgery 2005;40:e1–e3.
5. Lucas JC, Mehlman CT, Laor T. The location of the biceps tendon in completely displaced proximal humerus fractures in children. J Pediatr Orthop 2004;24:249–253.
6. Kubiak R, Slongo T. Operative treatment of clavicle fractures in children: a review of 21 years. J Pediatr Orthop 2002;22:736–739.
7. Kwon Y, Sarwark JF. Proximal humerus, clavicle, and scapula. In Beatty JH, Kasser JR, eds. Rockwood and Wilkins' fractures in children, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2001: 741–806.
8. Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop 2003;23:464–469.
9. Wilkins KE. Principles of fracture remodelling in children. Injury 2005;36:S-A 1–S-A11.
10. Wirth MA, Rockwood CA. Acute and chronic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268–278.