Case In Point: Clavicle Fractures in Children

Case 1

Clavicle fractures in the pediatric population are very common. Clinical manifestations include decreased movement of the arm on the affected side, crepitus, and/or bony irregularity at the fracture site. In neonates, the Moro reflex may be absent on the affected side.

NEWBORNS

Perinatal fractures have been reported to occur in 0.2% to 5% of newborns.^1-5 A high birth weight and difficult vaginal delivery--especially with the shoulder in the vertex presentation and extended arms in a breech delivery--may put a neonate at increased risk for fracture of the clavicle. However, such fractures can also occur when a baby is of average weight and the delivery is not complicated.

The presence of a clavicle fracture in a neonate does not signal an underlying pathologic process. If other fractured bones of the arms, legs, skull, and ribs are present, osteogenesis imperfecta is a likely diagnosis: other characteristics of this disorder include the presence of wide sutures, wormian bones, blue sclerae, and a family history of frequent bone breakage. In a child with multiple fractures, child abuse is also suggested.

The vast majority of perinatal clavicle fractures heal completely without intervention. The radiograph displays callus formation that had developed by the time the child was a few weeks old (Case 1). In the rare child with an associated brachial plexus injury, close monitoring is required along with management by a physical therapist and, possibly, by a pediatric neurologist and/or neurosurgeon.

Case 2

OLDER CHILDREN

The clavicle is the most commonly fractured bone: it can break when the child falls on the shoulder or on an outstretched hand or it can result from a direct blow to the bone itself (Case 2).

Treatment of clavicle fractures has to be individualized based on the patient's age and location of the injury. The primary care physician can manage the uncomplicated midshaft fracture, which is the most common location for a fracture. Treatment consists of supportive care only. Immobilization of the shoulder and limb for pain control and subsequent physical therapy are beneficial. In a cooperative child, the most commonly applied treatment for pain relief is an arm sling that braces the upper extremity against the torso. The use of a figure-eight brace offers no advantage over the sling and may cause discomfort.

Follow-up at 2 to 3 weeks and again at 6 to 8 weeks is appropriate in most instances to ensure that the patient is pain-free and has normal range of motion. Repeated radiographs are not necessary unless you suspect non-union in a patient with continued pain at 6 to 8 weeks postinjury. The patient can return to his or her usual sports activities when the pain is gone and results of the physical examination are normal. If the patient returns to aggressive activity too early, refracture of the clavicle is a possibility--especially in the first 6 weeks after injury.⁵

Referral to a pediatric orthopedic surgeon is indicated if the distal or medial third of the clavicle has been fractured or if there is a rare complication, such as neurovascular compromise, pneumothorax, overlying skin damage, or symptomatic non-union, mal-union, or callus.