Rockwood Children CH19

720

SECTION TWO • Upper Extremity

Neonates can sustain a clavicle fracture during the birthing process, especially those babies who are large for gestational age or those involved in difficult deliveries. 15,63,82 Additional risk factors include a lower mean head-to-abdominal circum- ference ratio and a prior history of the mother having a previ- ous child with macrosomia. 63 Neonatal clavicular fractures have been cited as one of the most frequent complications of natural delivery. 30,70,75,86,118,128 However, there is no uniform screening method for determining whether or not a fracture occurred. Therefore, the exact incidence of neonatal clavicle fractures remains unknown. The incidence has been reported to be as high as 4.4%, but the true incidence may be even higher, as some are diagnosed postdischarge from nursery. 86 Clavicle frac- tures due to birth trauma need to be distinguished from the rarer congenital pseudarthrosis of the clavicle, which is gener- ally seen on the right side, except in dextrocardia (Fig. 19-1). Based on the child’s neonatal position in the uterus, the ante- rior shoulder, typically the right side, is the most likely loca- tion of the clavicle fracture, as the left occiput anterior (LOA) position is the most common. 63 In addition, this is the most common side of injury in neonatal brachial plexus palsy. There- fore, when an infant sustains a clavicle fracture during the birth- ing process and limited motion is present about the affected extremity, it is often unknown if the child has a concomitant brachial plexus injury or is not moving their arm secondary to the pain associated with the fracture, a so-called pseudopalsy. Once the fracture heals, typically in 1 to 3 weeks in a newborn, repeat assessment of the brachial plexus must be performed to distinguish pseudopalsy from a true nerve injury. The exact mechanism for sustaining the clavicle fracture during the birthing process remains unknown. It is likely related to lateral compression of the shoulder girdle against the pelvis. However, neonatal clavicle fractures have also been shown to occur during cesarean sections. 63 Toddlers who sustain clavicle fractures may sustain the injury due to a fall from a height or injuries sustained during child abuse. 22,75,119 In a series of children aged 4 years or

Midshaft Clavicle Fractures

INTRODUCTION

The clavicle is one of the most commonly fractured bones in children, representing 5% to 15% of all pediatric fractures. 114 The most common location for a clavicle fracture is the midshaft of the bone, accounting for up to 80% of fractures. 114,117,121,129 Despite this high incidence, literature is limited regarding man- agement and outcomes of pediatric clavicle fractures. Much of the literature cited throughout this chapter is therefore extrapo- lated from scientific studies performed in adult clavicle fracture populations. However, there is a clear increasing trend for oper- ative fixation in adults and older children. 143,162 Therefore, more scientific investigations regarding the management of clavicle fractures in children are being performed, the results of which are of utmost importance to elucidation of future treatment algo- rithms for this younger population. Until a more methodolog- ically rigorous and comprehensive body of evidence emerges regarding the optimal treatment approach in children and, in particular, adolescents, this remains one of the most controver- sial areas in pediatric orthopedics and sports medicine.

ASSESSMENT OF MIDSHAFT CLAVICLE FRACTURES

MECHANISMS OF INJURY FOR MIDSHAFT CLAVICLE FRACTURES

Clavicle fractures are common in children of all ages, from birth to skeletal maturity, with different mechanisms of injury result- ing in the fracture based on age.

Figure 19-1.  A: Radiograph of a left midshaft clavicular fracture in an infant sustained during the birthing process. B: Neonatal pseudarthrosis of the clavicle. ( B: reprinted with permission from Waters PM, Bae DS, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide. 1st ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2012.)

A

B