Working Diagnosis:
Left medial clavicle physeal fracture

Treatment:
The patient underwent open reduction and internal fixation (ORIF) of the left medial clavicle physeal fracture, providing good stabilization of the physeal fracture. He was discharged home from the hospital in a sling. At follow up, he had full range of motion of the left shoulder without pain.

Outcome:
After definitive management via ORIF, the patient was placed in a sling with gentle range of motion exercises, followed subsequently by a formal physical therapy program. The patient had complete recovery with full range of motion of the shoulder without pain. He was able to begin sports specific movements 10 weeks post operatively.

Author's Comments:
A medial clavicle physeal fracture is a rare injury seen in adolescents, caused by direct trauma or a fall on an outstretched hand (FOOSH). It is considered a Salter I or II fracture. The medial clavicle physis is the last to close (age 20-25). Although anterior displacement is more common, posterior displacement can cause airway and neurovascular compromise. Symptoms include dyspnea, dysphonia, dysphagia, or paresthesias. It is difficult to clinically differentiate between anterior and posterior displacement. Therefore, x-rays are initially obtained, including a serendipity view. CT is the study of choice. Non-operative management can be considered. However, most injuries require ORIF, as closed reduction typically fails.

Editor's Comments:
Sternoclavicular joint injuries are rare and dislocations make up less than 1% of all dislocations. There are 3 types; Type I: Sprain with no instability, Type II: Subluxation with partial rupture of the associated ligaments, and Type III: Complete dislocation with gross disruption. Posterior dislocations are considered a high-risk injury given the vital structures located directly behind the sternoclavicular joint. There is a 12.5% mortality associated with this injury and a 30% incidence of a vital structure injury. A high clinical suspicion must be maintained along with a focused physical exam to identify venous or arterial injury, tracheal, esophageal, and brachial plexus injuries, and pneumothorax. Severe posterior dislocations that involve associated injury or airway compromise require emergency reduction in the operating room. This is typically done by the orthopedic surgeon with a thoracic or trauma surgeon available along with a sterile sternal saw easily accessible should a mediastinal injury arise.

In adolescent patients the diagnosis of physis injuries (pseudo-dislocation/Salter-Harris Type I or II) can be difficult to differentiate from a true dislocation and is most reliably diagnosed with MRI or with open visualization. A study by Tepolt et al in 2014 showed that 69% of adolescents undergoing open reduction had a physical injury and only 23% had true dislocations. 80% of longitudinal growth originates from the medial clavicular physis and reduction decreased the incidence of fibrous nonunion and long-term complications. Thus, stable adolescent cases may benefit from closed reduction if done within the first 10 days given that this avoids complications from adhesion to the surrounding structures.

References:
1.Madden, C. C., & Netter, F. H. (2010). Netter's sports medicine. Philadelphia: Saunders/Elsevier.
2.Chaudhry, Sonia MD Pediatric Posterior Sternoclavicular Joint Injuries, Journal of the American Academy of Orthopaedic Surgeons: August 2015 - Volume 23 Issue 8 - p 468-475 doi: 10.5435/JAAOS-D-14-00235
3.Tepolt F, Carry PM, Heyn PC, Miller NH: Posterior sternoclavicular joint injuries in the adolescent population: A meta-analysis. Am J Sports Med 2014;42(10):2517–2524.
4.Kiel J, Ponnarasu S, Kaiser K. Sternoclavicular Joint Injury. [Updated 2020 Sep 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507894/

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