Working Diagnosis:
Right posteriorly displaced medial clavicle Salter-Harris 1 fracture
Subacute right first rib fracture, healing

Treatment:
Patient was admitted to orthopedic service and underwent an open reduction and internal fixation of the right medial clavicle the following day (~1 week after injury)

Outcome:
He was discharged to home the same day of the procedure in a sling. Four weeks after surgery he was referred to Physical Therapy to begin rehabilitation. In addition, he was instructed he could discontinue use of the sling when at home, however he was to continue wearing the sling when at school. Three months after the surgery he was allowed to begin a gradual return to activities as tolerated

Author's Comments:
Sternoclavicular (SC) joint dislocations are uncommon injuries, especially in the pediatric population. The medial clavicle physis closes later than other physes and given the relative weakness of the physis in comparison to the surrounding soft tissue structures, a medial clavicle fracture is more likely to occur in the pediatric population relative to a true sternoclavicular dislocation. Although uncommon, posteriorly displaced physeal fractures of the medial clavicle, similar to posteriorly displaced SC joint dislocations, can have devastating consequences which include brachial plexus or vascular injuries, tracheal compression, or esophageal rupture. Clinically, patients may present with vague pain and swelling located along the medial clavicle and may also exhibit decreased range of motion of the affected shoulder. Complaints of difficulty breathing and/or swallowing or vascular abnormalities should be managed emergently. As with many diagnostic tests in medicine, radiographs can demonstrate abnormalities that may not directly fit the clinical picture. In this case, the radiographs demonstrated a right first rib fracture with abundant callus formation. However, the radiographic injury did not directly correlate with his history and clinical exam, raising heightened concern for injury to the medial clavicle, specifically the physis and sternoclavicular joint. Most medial clavicle physeal injuries, similar to SC joint dislocations in adults, are difficult to visualize on radiographs alone, so a high index of suspicion and further cross sectional imaging is often necessary to confirm diagnosis.
Computed tomography or MRI can be helpful to confirm the diagnosis, while allowing for the assessment of displacement. Both open reduction and closed reduction have been described. Closed reduction is thought to be more successful if attempted <48 hours from injury. Given the potential for the above associated complications, both closed and open reductions are often performed in the presence of an orthopedic surgeon and cardiothoracic surgeon. In some extreme cases medial clavicle excision can be performed for persistent SC joint pain or recurrent/chronic anterior or posterior SC joint dislocations.

References:
Chaudry S. Pediatric Posterior Sternoclavicular Joint Injuries. J Am Acad Orthop Surg 2015 Aug 23(8):468-475
Tepolt, F., Carry, PM, Heyn, MS, Miller, NH. Posterior Sternoclavicular Joint Dislocation in the Pediatric Population. Am J Sports Med October 2014 vol. 42 no. 10 2517-2524
Sidhu VS, Hermans D, Duckworth DG. The operative outcomes of displaced medial-end clavicle fractures. J Shoulder Elbow Surg 2015.24: 1728-1734

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