Rockwood Children CH19

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SECTION TWO • Upper Extremity

A

B

Figure 19-2.  Photographs depicting skin tenting from a displaced, segmental left diaphyseal clavicle frac- ture. (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.)

view, ranging from 15-degree cephalad to 45-degree cephalad, are obtained (Fig. 19-3). These images provide visualization of the shoulder girdle region as well as the upper lung fields, both of which should be assessed for additional injuries. However, if clinical suspicion is present for additional injuries, dedicated series of the suspected part(s) should be obtained. Clavicle fractures are often detected on chest x-rays obtained for trauma patients, and rarely require additional imaging, if the general fracture pattern and approximate shortening can be assessed for completely displaced fractures. Advanced imaging is rarely needed to evaluate clavicle fractures, as the fracture pattern, displacement, and presence of comminution can almost always be assessed on plain films. As described in greater detail below, frac- tures or suspected dislocations about the sternoclavicular joint are frequently assessed with CT scans, but midshaft fractures, which are much more common, benefit from such imaging only in the case of a suspected or possible fracture nonunion or possible

refracture through a healing fracture. Distal fractures are assessed by CT scans at times to decide on degree and direction of displace- ment that might indicate need for operative intervention. CLASSIFICATION OF MIDSHAFT CLAVICLE FRACTURES Clavicle fractures are usually described based on the location of the fracture, the fracture pattern, and the presence or absence of dis- placement. Thus, clavicle fractures are either medial, midshaft, or lateral; nondisplaced or displaced; open or closed; comminuted or simple. Displaced fractures can be qualified as partially displaced, when the two fracture fragments of a two-part fracture are still in contact, with or without angulation, whereas completely displaced fractures have fracture fragments that are not in contact with each other, or are three-part or four-part fractures with comminution. The description of partially displaced fractures with angulation benefit from a measurement of the degree of angulation, as increas- ing angulation has been associated with a greater risk of refracture in some studies. 46,95 For completely displaced fractures, a measure- ment of the degree of “shortening,” as measured in millimeters (mm), has been used more commonly in adult clavicle fracture studies. For example, some authors have contended that shorten- ing greater than 14 or 20 mm may be associated with poorer out- comes with nonoperative treatment, when compared with lesser degrees of shortening. As a result, many have considered 20 mm as a potential threshold or an indication for surgery. However, import- ant studies by Schulz et al. 134a and Bae et al. 8 have suggested that even fractures with greater than 15 to 20 mm of shortening are not associated with functional limitations in adolescents treated nonoperatively. Moreover, new research suggests that traditional measurement techniques may grossly overestimate the ‘true’ short- ening of the clavicle, by not accounting for the oblique nature of clavicle fractures. 87a Thus, we believe that additional research is warranted before adult-based metrics are applied to the young who have greater healing and remodeling capacity. Classifications that go beyond this descriptive scheme, such as the AO classifica- tion, 44 have been proposed to evaluate clavicle fractures, but none are widely utilized, as they are either purely descriptive of fracture location 3 or cumbersome with multiple types and subtypes. 44,129

Figure 19-3.  Depiction of a 45-degree cephalic tilt to obtain an addi- tional view of the clavicle.