Scapular fractures
These injuries account for only 0.1% of all pediatric fractures. Subperiosteal injuries resulting from a direct blow to the back area are predominantly encountered. Fractures of the neck and glenoid fossa are extremely rare, as ligaments and cartilage act as shock absorbers during a fall.
The clinical presentation depends on the injury site:
- Scapular body: pain increases with scapular adduction and arm abduction. Komoli's sign is characteristic — swelling that strictly follows the bone contours.
- Acromial process: edema along the lateral surface of the joint.
- Scapular neck: with sharp pain during active movements, passive movements are completely preserved. This is the main sign distinguishing a fracture from a dislocation.
Treatment of subperiosteal fractures requires immobilization with a Desault bandage with a axillary pad for 10–14 days, followed by a sling for 7–9 days. For neck or acromial injuries, an abduction splint is used for 2–3 weeks (for the acromion, 10° of posterior arm abduction is required).
Clavicle fractures: from toddlers to adolescents
This is one of the most frequent injuries (13% of extremity fractures, 3rd in frequency). One-third of cases occur in children aged 2–4 years. The injury is more often indirect — falling onto an outstretched arm or compression of the shoulder girdle.
Greenstick and subperiosteal fractures predominate in preschoolers. They are difficult to diagnose: there is no deformity, only local edema and pain. A specific sign is increased pain with axial loading on the shoulder.
In children aged 8–14 years, fractures are often accompanied by typical displacement: the central fragment moves upward and posteriorly, and the peripheral fragment moves downward and anteriorly. Shortening of the shoulder girdle and a step-off deformity occur.
Principles of treatment:
- The majority of cases are treated conservatively.
- In children under 8–10 years, the Desault bandage yields excellent results.
- In older children with complete displaced fractures, reduction under local anesthesia is required. An figure-of-eight bandage or Chizh frame is used for immobilization.
- Surgery is indicated only for open fractures, threat of skin perforation, vascular and nerve compression, or risk of tissue interposition.
Immobilization periods depend on age: under 7 years — 10–14 days, 7–10 years — 16–18 days, over 10 years — up to 3 weeks.
Diagnostic challenges and birth injuries
In young children, a subperiosteal clavicle fracture can be confused with a fracture of the proximal humerus or radial head subluxation. In all three injuries, the child assumes a characteristic forced posture: the arm is pressed against the trunk, the forearm is semi-flexed and pronated. For precise differentiation, radiographs of both shoulder girdles are taken on a single film.
Special attention should be given to clavicle fractures in newborns. They occur during difficult labor, are localized in the middle third, and can be complicated by obstetric palsy. If there is no displacement, the injury is often detected only on days 5–7 due to formed callus. A reliable sign in case of displacement is fragment crepitus. Uncomplicated fractures are treated by bandaging the arm to the trunk for 7 days. Palsy requires the “traffic controller pose” (90° arm abduction and elbow flexion).
Clavicular dislocations and reduction technique
Dislocation of the acromial end of the clavicle is a rare injury in children. It is diagnosed by the presence of deformity, hematoma, and a positive “piano key” sign. In dubious cases, radiography with an additional weight in the hands is performed. Reduction is done under local anesthesia.
If simultaneous closed reduction is necessary (e.g., of displaced clavicular fragments along the length), the child is placed supine with a roller. Assistants pull the head with maximal extension of the thoracic spine, while the surgeon eliminates the displacement with their fingers. After the procedure, bed rest on a firm board with a roller between the shoulder blades for 10–12 days is mandatory.
Briefly: answers to topical questions
Which muscles cause the typical displacement of fragments in clavicle fractures in older children?
Typical fragment displacement in a clavicle fracture is caused by the traction of the sternocleidomastoid and pectoral muscles.
- Sternocleidomastoid muscle (m. sternocleidomastoideus) — displaces the central (medial) fragment upward and posteriorly.
- Pectoral muscles — together with the weight of the limb, displace the peripheral (lateral) fragment downward, anteriorly, and medially.
Which specific vessels and nerve trunks can be compressed during a displaced clavicle fracture?
In a displaced clavicle fracture, damage to the neurovascular bundle located near its inferior surface is possible. These structures include:
- Brachial plexus (plexus brachialis), specifically its subclavian part.
- Subclavian vessels (a. et v. subclavia) — subclavian artery and vein.
What special radiographic projections and tests are used to confirm dislocation of the acromial end of the clavicle?
To diagnose dislocation of the acromial end of the clavicle, the following are used:
- Comparative radiography of both acromioclavicular joints in the anteroposterior projection.
- Comparative functional radiography with load to assess vertical stability: the study is performed standing, with weights of 2–5 kg attached to both hands.
For differential diagnosis of forced posture in toddlers: if the forearm does not rotate, the problem is in the radius; if the humeral metaphysis hurts, it's the humerus; and if pain worsens with axial loading on the shoulder, the clavicle is fractured.
Class and exam questions
How to distinguish a scapular neck fracture from a shoulder dislocation?
In a scapular neck fracture, active movements are painful, but passive movements are completely preserved. In a dislocation, passive movements in the joint are impossible.
Why is a clavicle fracture often missed in young children?
At the age of 2–4 years, incomplete subperiosteal fractures predominate. There is no deformity, and the main clinical sign is pain upon loading along the axis of the humerus.
What is Komoli's sign?
This is a characteristic sign of a scapular body fracture — swelling that precisely follows the anatomical contour of the bone itself.
Should the clavicle be operated on in case of angular deformity in a child?
As a rule, no. Due to active child growth, angular deformities and clavicular shortening of up to 1.5 cm are completely corrected over time.
What else to study on this topic
- Technique of applying a Desault bandage, figure-of-eight bandage, and Chizh frame in pediatric practice.
- Radiographic signs of displacement in scapular neck fractures.
- Indications for surgical treatment of clavicle fractures in adolescents.
- Pathogenesis and clinical presentation of obstetric palsy in newborns.
- Features of performing comparative functional radiography in clavicular dislocations.
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