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a direct blow to the clavicle. Indications for operative management of clavicle
fractures are evolving. While skeletally immature patients have a high rate of
fracture healing and good remodeling, recent evidence in the adult literature
suggests there may be superior outcomes in patients treated operatively for
completely displaced midshaft fractures. Skeletally mature adolescents, with their
higher activity level and functional expectations, may potentially benefit from
this interventional approach, but large, high-level studies about displaced clavicle
fractures in this age group are lacking. Routine operative treatment is not
currently recommended for pediatric closed, displaced clavicle fractures without
threat to skin integrity.
Clinical Considerations
Clinical recognition. Children may present with shoulder pain and cradling of the
injured arm; however not uncommonly, these fractures can go unnoticed until a
large callus forms. Then, the fracture gradually remodels over the next 6 to 12
months. The most common fracture type in younger patients is a greenstick
fracture of the midshaft, attributable to the thick periosteum of this part of the
bone. Older children and adolescents are at higher risk for complete
displacement, which is suggested on physical examination by a lowering of the
affected shoulder, local swelling, and point tenderness. Medial injuries to the
sternoclavicular joint, suggested by localized pain and swelling or a palpable
anterior or posterior displacement, are typically physeal injuries secondary to the
strong ligaments that anchor the clavicle to the sternum and the relative weakness
of the physis. The lateral aspect of the clavicle is anchored by the
coracoclavicular and AC ligaments, and thus, fracture through the physis is more
common than dislocation ( Fig. 111.9 ). Lateral physeal separation presents
clinically as pain with all movements of the shoulder. Typically, the proximal
fracture fragment is displaced superiorly, and the radiographic appearance
suggests AC separation. However, the periosteum remains whole inferiorly with
its ligamentous connections intact. With severe displacement, the skin may be
tented over the AC joint. Special note should be made of the “floating shoulder,”
an unstable fracture resulting from a glenoid neck fracture combined with an

ipsilateral clavicle fracture, such that there is no stable bony connection between
the upper extremity and the trunk.