A healthy thirteen-year-old male, who is a competitive basketball and baseball player, sustained a closed, completely displaced fracture involving the medial clavicle after falling off an all-terrain vehicle. He was initially seen in the emergency department, placed in a sling, and referred to the orthopedic service for definitive management. The patient is right-hand dominant and does not smoke. He has no prior history of injury to the right clavicle. At the time of his orthopedic consultation, his pain was described as moderate and sharp localized to the medial end of the right clavicle. The patient reported no numbness or tingling in his arm.
Physical examination revealed a healthy-appearing, pleasant male responding appropriately and in no apparent distress. The pertinent findings on examination included no signs of cervical radiculopathy, no pain or winging of the scapula, intact skin, but significant tenting and swelling over the medial right clavicle, and obvious asymmetry of the right clavicle compared to the left clavicle consistent with a displaced fracture. The end of the clavicle lateral to the fracture site was displaced anterior to the medial component. The remainder of the physical examination revealed no additional injury to the upper extremity. Motor function and sensation were intact throughout the right upper extremity. The brachial and radial pulses were normal and symmetric to the left upper extremity.
Initial radiographs of the right clavicle revealed a fracture involving its medial end without disruption of the sternoclavicular joint (Figures 1(a) and 1(b)). Subsequent CT scan revealed a completely displaced fracture of the right medial clavicle. The fracture site was lateral to the medial physis of the clavicle and without disruption of the sternoclavicular joint. The CT scan allowed for a more definitive characterization of the fracture pattern. Given the rarity with which medial clavicle fractures not involving the physis occur in the pediatric population, a CT scan was desired to provide this information and to help with surgical planning.
Nonoperative and operative treatment options were discussed with the patient and his parents. The factors relevant to pursuing operative treatment included complete displacement at the site of the fracture, desire to obtain anatomic alignment of the fracture to promote healing, potential impact of the displaced clavicle fracture on shoulder function relative to daily activities and overhead sports in basketball and baseball, and clinical outcome allowing the patient to return to activity without pain and restricted function. The operative treatment agreed upon was reduction of the fracture and placement of an elastic intramedullary clavicle nail. Informed consent was signed by the parents and the patient.
At the time of the surgery, a trial of closed reduction revealed an unstable fracture. Subsequently, an incision was made centered over the fracture site. Exposure of the fracture site confirmed complete displacement with the lateral end of the clavicle anterior to the medial end. A drill hole using a 2.7 mm drill was made approximately 1 cm lateral to the medial end of the clavicle. The fracture was reduced and then a 1.5 mm elastic intramedullary titanium nail was passed through the drill hole in the metaphyseal area of the clavicle. The nail was advanced into the intramedullary canal, across the fracture site, and into the lateral end of the clavicle. Placement of the intramedullary nail was confirmed under fluoroscopy (Figures 2(a) and 2(b)). The reduction and fixation were stable as the right upper extremity was brought through a full range of motion. An end cap was placed on the medial end of the clavicle nail to prevent migration. After wound closure and placement of a sterile dressing, the right upper extremity was placed in a shoulder immobilizer. The patient recovered from anesthesia without complications. Preoperative and postoperative examinations of motor function, sensation, and pulses were equivalent.
Postoperatively, the patient was immobilized for 6 weeks until healing was evident on radiographs. He then started active-assisted shoulder stretching exercises at home. Although earlier mobilization could have been considered for this patient, we thought it prudent given his age and nature of the fracture to protect him during the immediate postoperative period for 6 weeks. Given the desire to return the patient to his basketball season and knowing the stress he would put on it during other sports requiring overhead activity of his operative arm, we wanted to ensure complete healing and avoid potential mechanical complications relating to the nail during the early postoperative period. At 8 weeks after surgery, the patient started using his right upper extremity for simple activities of daily living and strengthening exercises. At 10 weeks after surgery, he returned to basketball without any pain or functional limitations. Radiographic images in orthogonal planes confirmed complete healing of the fracture (Figures 3(a) and 3(b)). Approximately 18 weeks after his initial surgery, the patient underwent an uncomplicated procedure to remove the intramedullary nail. Two weeks after intramedullary nail removal, the patient returned to activities without complications.