Clavicle fractures in children

Clavicle injuries and dislocations

The mechanism of injury to the sternoclavicular joint is usually associated with severe lateral compression of the shoulder girdle. In pediatric traumatology, there is a strict pattern: dislocations of the sternal end are exclusively anterior.

To make an accurate diagnosis, the doctor relies on a number of prominent clinical signs:

• Visually and by palpation, a characteristic step-like deformity is determined in the sternoclavicular joint area.
• Subcutaneous hematoma rapidly develops.
• Sharp tenderness occurs upon palpation.
• A positive "piano key" sign is revealed — the protruding end of the bone springs under finger pressure.

In fresh cases, elimination of the dislocation or subluxation is often achieved by simple finger pressure on the protruding segment. Full reduction of the sternal end is performed under local anesthesia: the patient's shoulders are maximally spread to the sides and elevated. Then the physician palpatorily displaces the sternal end of the bone downward and backward. Mandatory conditions for successful reduction also include complete abduction of the shoulder, its flexion, and general elevation of the shoulder girdle.

After reduction, fixation is necessary. Most commonly, a Desault bandage is used, which is reinforced with plaster for rigidity, and a pressure pad is applied to the area of the reduced sternal end. Alternative options include an abduction splint with a pad on the acromial end or a "spica" plaster cast. The standard immobilization period for the clavicle is 3 weeks.

Fractures of proximal humerus

Clavicle injuries are often accompanied by or differentiated from humeral injuries. In children, fractures of the upper epimetaphysis, diaphysis, and distal region are distinguished.

In the proximal zone, tubercular osteoepiphysiolyses of the humeral head predominate. At the same time, supratubercular injuries and impacted fractures are practically absent in childhood.

Depending on the direction of displacement in surgical neck injuries, the following are distinguished:

1. Adduction fractures.
2. Abduction fractures.

Most of these fractures are accompanied by complete displacement of fragments both in length and width, often complemented by their mutual rotation. For primary diagnosis, the referred pain test is used: with gentle tapping on the elbow joint, the patient feels pronounced pain in the upper third of the humerus. The final diagnosis is established exclusively based on X-ray results.

Conservative management is indicated for greenstick fractures, osteoepiphysiolyses without displacement, or in cases where the angular displacement of fragments does not exceed 10–15°. A wide plaster splint is applied (from the healthy scapula to the base of the fingers), and a tight roller is placed in the axillary fossa.

Specifics of reduction in children

Reduction of displaced bone fragments should be performed in the first few hours. The main biomechanical difficulty is the presence of a strong periosteum. On the concave side of the deformity, it remains intact, which makes standard "adult" reduction techniques ineffective.

For abduction fractures of the surgical neck, the N. F. Sys method is used:

• The first assistant provides counter-traction by the upper part of the shoulder.
• The second assistant pulls the arm along the axis and smoothly abducts it, intentionally increasing the angular deformity (this is necessary to relax the taut periosteum).
• The surgeon grasps the proximal section with both hands: with the thumbs, they adduct the central fragment, and with the remaining fingers, they fix the peripheral fragment from the inner side, displacing it outward.
• In the finale, the second assistant adducts the arm to the torso, eliminating the angular deformity.

For adduction fractures, the tactics change. The second assistant exerts traction and adducts the shoulder to the torso, also increasing the deformity. The surgeon, with thumbs from the axillary fossa, "pushes" the central fragment outward, and with the remaining fingers moves the peripheral part inward. After that, the second assistant, maintaining traction, abducts the shoulder from the torso.

For particularly complex cases (a combination of abduction fractures with severe displacement), the Gromov technique is used: the straightened limb is abducted above the horizontal line and intensive axial traction along the torso is performed with counter-traction.

Principles of immobilization

After successful reduction, the forearm is always flexed at a right angle (90°), necessarily using a small cotton-gauze roll.

The duration of wearing a plaster cast for humeral fractures strictly depends on age:

• Children under 7 years old: 10–12 days.
• Older children: 15–16 days.

For clavicle dislocations, the duration of fixation increases to 3 weeks regardless of age.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Humeral shaft fractures in children
• Distal humeral injuries
• Radiological signs of transtubercular osteoepiphysiolysis
• Technique for applying the "figure-of-eight" plaster cast
• Biomechanics of the intact periosteum in greenstick fractures

Other topics in the section "Specifics of bone and joint injuries in children"

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