Anatomy

Incidence

Numerous studies have reported on the incidence of fractures in children. However, these studies are affected by multiple factors, which include cultural differences, climate, and environmental factors; patient factors such as age and gender likewise exert an influence on the occurrence of the different fracture types.

Fractures of the proximal humerus have been reported to be about 5% of all children’s fractures.^32–36 The incidence of fractures of the proximal humerus show a linear increase with age, with Salter–Harris type I fractures predominating in younger children, metaphyseal fractures more common in children 5 to 11 years, and Salter–Harris type II fractures in children older than 11 years. Fractures of the proximal humeral epiphysis represent 2% to 7% of all growth plate injuries in children.^37–39

Mechanism of Injury

Shoulder dystocia is an infrequent cause of birth injuries in children. Shoulder dystocia is usually associated with conditions such as maternal diabetes, macrosomia, post-term pregnancy, and a previous history of shoulder dystocia. Gherman and colleagues reported on the incidence of birth injuries and found the incidence of birth injuries associated with shoulder dystocia to be 24.9%, with a 4.2% incidence of proximal humeral fractures.⁴⁰ The mechanism of injury is also related to arm position during delivery. Abnormal positions implicated in birth fractures, such as separation of the proximal humeral physis, include hyperextension and external rotation of the humerus.^41–44

In the older child, both direct and indirect trauma to the proximal humerus has been implicated. Injuries from sports, vehicular or traffic accidents, and falls are the most common cause of proximal humerus fractures in children.⁴⁵ Six mechanisms of injury have been reported by Williams: forced extension, forced flexion, flexion with lateral rotation or with medial rotation, and forced extension with lateral rotation or with medial rotation.⁴⁶

Repetitive injury can also cause damage to the proximal humeral physis (Fig. 15-1). Slipping of the proximal humeral growth plate has been reported to occur in gymnasts.⁴⁷ Stress-related injuries have likewise been reported secondary to gymnastics, baseball pitching, and various sporting activities, causing stress secondary to upper extremity loading.^48–55

FIGURE 15-1 Epiphysiolysis in a 12-year-old right hand–dominant male baseball pitcher who came in for evaluation of right shoulder pain. A and B, On initial evaluation, radiographs showed widening of the proximal humeral growth plate. C, The patient was managed conservatively with activity modification for 3 months and went on to heal uneventfully.

Pathologic fractures occurring through benign lesions have been reported infrequently (Fig. 15-2), particularly common benign lesions causing pathologic fractures through the proximal humerus, including aneurysmal and unicameral bone cysts.^56–59 Malignant lesions have been reported to cause pathologic fractures through the proximal humerus.^59–62

FIGURE 15-2 A, A 7-year-old boy who sustained a pathologic fracture through a simple bone cyst. This fracture was treated conservatively with a shoulder immobilizer. B, Follow-up radiographs show healing of the pathologic fracture with the presence of residual cystic lesion. C, The residual cystic lesion was treated with percutaneous biopsy, curettage, and bone grafting with Osteoset calcium sulfate pellets. D, Latest follow-up films showing progressive healing and remodeling through the lesion.

Metabolic conditions such as pituitary gigantism can cause weakening of the growth plate, leading to development of deformity.⁶³ Underlying neuromuscular conditions such as Arnold–Chiari malformation, syringomyelia, myelomeningocele, and cerebral palsy have been identified as risk factors or etiologic agents in the development of growth plate injuries and fractures about the proximal humerus.^64–67

Nonaccidental injury should also be considered when children present with the proximal humerus fracture, particularly if the underlying cause is unclear and multiple injuries are noted.^68–72

Classification

Fractures of the proximal humerus in children may be classified according to the location of the injury. Growth plate injuries in children are classified according to the Salter–Harris classification.¹⁸ In younger children (<5 years), Salter–Harris type I injuries predominate (Fig. 15-3). In children older than 11 years, Salter–Harris type II fracture patterns predominate (Fig. 15-4).³⁹ The other three types Salter–Harris—types III, IV, and V—are very rare, particularly in the proximal humerus. However, cases of Salter–Harris type III injuries have been reported in the literature.⁷³

FIGURE 15-3 AP radiograph of a 2 year old who sustained a displaced Salter–Harris type I fracture through the proximal humeral growth plate.

FIGURE 15-4 Radiographs of an 8 year old who sustained a Salter–Harris type II growth plate injury secondary to a fall.

The location of the fracture may also be used to define the fracture. This is a broad categorization, dividing the fractures according to area of involvement, such as the proximal humeral metaphysis (Fig. 15-5), growth plate, and lesser and greater tuberosities. Fractures can also be classified based on the degree of deformity as well as the degree of displacement. Neer and Horwitz classified proximal humeral fractures according to degree of displacement.⁷⁴ They divided the fractures into four types based on degree of displacement:

FIGURE 15-5 A and B, Radiographs taken of an 8-year-old boy who sustained a metaphyseal fracture through the proximal humerus. This fracture was treated conservatively. C and D, Radiographs taken at 7 weeks after injury show complete healing of the fracture.

Open fractures of the proximal humerus, although uncommon, also occur and can be classified using the Gustilo–Anderson classification for open fractures.^75,76

Signs and Symptoms

In neonates and infants, evaluation of the shoulder for injuries may be very difficult. An infant who presents with the inability to move the shoulder should raise suspicion of a fracture or injury about the shoulder girdle or proximal humerus. A detailed history should be obtained, including any abnormalities throughout the prenatal period such as maternal diabetes or other maternal conditions that can predispose to macrosomia. Inability to move the shoulder and upper extremity should always raise the suspicion of an injury or pathologic condition in and about the shoulder girdle. Useful differential diagnosis includes fractures, dislocations, fracture-dislocations, infection, and brachial plexus injury. The neonate should have a thorough physical evaluation. Palpation of the upper extremity should likewise be performed for any warmth, direct tenderness, or deformity. Gentle range of motion (ROM) should be done to examine for any possible limitation of motion; abnormal motion likely points to a fracture or dislocation.

In the older child, a history consistent with a traumatic event can usually be elicited. The most common presentation is limited ROM of the shoulder, with abnormal fullness or deformity of the affected shoulder as compared to the contralateral extremity. Depending on the degree of trauma, other signs of injury are likewise present, including soft tissue injuries, ecchymosis, and swelling. The affected extremity is usually carried in an internally rotated posture. In posterior fracture-dislocations there is painful limited external rotation of the shoulder. In lesser tuberosity fractures there is limited abduction and external rotation of the shoulder.^77–79 Greater tuberosity fractures manifest with luxatio erecta.^80–82 The shoulder is in abduction with the elbow flexed and the hand above the head.

Radiographic Evaluation

Imaging of the proximal humerus can be challenging in neonates and infants because the proximal humerus is primarily cartilaginous. Generally, in neonates and infants with a suspected fracture of the proximal humerus or proximal humeral growth plate, a single anteroposterior (AP) view of the chest and upper extremities may be used to screen for injuries. On plain radiographs, the relationship of the proximal humeral metaphysis, scapula, and acromion are evaluated. These structures are compared with the contralateral side (Fig. 15-6). The abnormal relationship of the scapula and humerus has been described to denote a proximal humeral physeal injury with a posteriorly displaced proximal humeral fragment. This has been termed the vanishing epiphysis sign.^44,83 Ultrasound examination may be a valuable imaging tool.^84–88 Ultrasonography is quick and noninvasive, and the injury may be directly visualized, with the contralateral side serving as a comparison. Arthrography can also be valuable.^89,90 Computed tomography (CT) may also be useful in evaluating the shoulder injuries missed at birth, particularly those with posterior dislocation.⁹¹

FIGURE 15-6 In a newborn, injury to the proximal part of the humerus is usually a completely displaced physeal injury, a pseudodislocation. A, Radiographs in the newborn are sometimes misleading because of lack of ossification in the proximal epiphysis. B, Closed manipulation can be performed by applying longitudinal traction and gentle posterior pressure over the proximal end of the humerus. C, At 2.5 weeks, abundant callus is present and the patient is clinically asymptomatic. D, A 6-month follow-up radiograph shows no asymmetry when compared with the opposite side.

Plain radiographs are still the mainstay in the initial evaluation of shoulder injuries in older children. Well-performed radiographs obtained in orthogonal views should be adequate in providing information on the pathology. A true AP and lateral view of the shoulder are usually sufficient for assessing the injury. A true AP image of the shoulder is taken in the scapular plane with the beam parallel to the glenohumeral joint. The axillary lateral view is preferred, although it may be difficult to obtain in the setting of an acutely injured child. In lieu of the axillary lateral view, alternative views such as the transthoracic axillary view or the scapular Y view may be obtained. The apical oblique view is also valuable in some cases.

Treatment

The treatment of fractures of the proximal humerus generally depends on the age of the patient and on the fracture type and location. In general, the prognosis for most proximal humerus fractures in children is good, with the vast majority amenable to nonoperative management. Because the proximal humeral physis contributes the most growth of the upper extremity and closes late, there is tremendous remodeling potential for the proximal humerus (Fig. 15-7). The location of the fracture likewise exerts a great influence on the management, whether the fracture involves the growth plate or extends through the metaphysis.

FIGURE 15-7 A, Radiographs of a 9-year-old boy who had sustained a Salter–Harris II fracture of the proximal humerus, showing angulation of the proximal fragment in the AP plane. B, The child was treated conservatively, and follow-up radiographs taken 6 weeks after injury show excellent callus formation and healing of the fracture. C and D, Radiographs taken 9 months after injury show full healing of the previous fracture with remodeling of the proximal humerus.

In neonates with birth injuries, the prognosis is generally good; only the most severely displaced fractures require any attempt at reduction. If reduction is performed, gentle maneuvers without anesthesia generally work well. These maneuvers may be monitored using ultrasonography. In the vast majority of cases, the shoulder can be immobilized efficiently by pinning the shirt sleeve or soft dressing to the shirt. These fractures heal very quickly, usually within 2 to 3 weeks.^19,43

Children with a slipped proximal humeral epiphysis usually do not need any form of reduction. These injuries generally respond well to nonoperative management.

In general, fracture treatment is determined by the degree of displacement and the amount of remodeling potential. Beaty recommended treatment guidelines based on the patient’s age (Table 15-1).⁹² In young children, excellent outcomes have been reported with nonoperative management.^19,74,93 In older children, nonoperative management has been reported to have good results, particularly in Neer type 1 and type 2 cases. Reduction, however, was required more often in Neer type 3 and 4 fractures.^19,74,93,94

TABLE 15-1 Guidelines for Reduction

Reduction

In general, reduction is reserved for severely displaced or angulated fractures in older children. Potential barriers to reduction include periosteum, capsule, and biceps tendon.^92,95–97 Numerous reduction maneuvers have been recommended. Most fractures can be treated with gentle traction coupled with abduction, external rotation, and flexion of the shoulder. Neer and Horwitz recommended reduction with 90 degrees of forward flexion, abduction, and external rotation.⁷⁴ Others recommend reduction with 135 degrees of abduction and 30 degrees of flexion and external rotation; the fracture is manipulated directly to obtain reduction.^98,99

Once acceptable or adequate reduction is obtained, any of several immobilization techniques may be used. Immobilization methods described in the literature include sling and swathe (Fig. 15-8), two-prong splint, thoracobrachial bandage, shoulder spica cast, Statue of Liberty cast, and hanging arm cast.^{19,74,93,100,101} It is important for the surgeon and family to understand that very displaced proximal humerus fractures in older children are generally quite unstable. Some loss of reduction is common if internal fixation is not used.

FIGURE 15-8 Clinical photograph of a 9-year-old girl wearing a homemade sling and swathe used in the treatment of proximal humerus fractures. A stockinette is padded at pressure points with cast padding and held in position with safety pins.

Operative Treatment

Operative management is rarely indicated for children with fractures of the proximal humerus. However, occasionally, some fractures are not amenable to reduction due to soft tissue interposition. More often, these fractures require an open reduction and possible internal fixation. The operative consent for internal fixation of proximal humerus fractures should include the possibility of open reduction, should interposed tissue cause an obstacle to reduction. Other indications for operative management include segmental fractures to obtain adequate stabilization, the rare displaced, intra-articular fracture, open fractures requiring débridement, fracture-dislocations, and fracture of the proximal humerus with concomitant neurovascular injury. Open reduction of proximal humeral fractures is generally carried through a deltopectoral approach. A limited skin incision may be used to gain direct access into the joint space. The significant advantage of performing a reduction is that it lessens the amount of time needed for remodeling.

There are numerous options for internal fixation of proximal humerus fractures. Displaced fractures may be treated with closed reduction and percutaneous techniques or open reduction and internal fixation.^102–104

Percutaneous pin fixation may be performed once adequate reduction has been obtained (Fig. 15-9).^105,106 Percutaneous pinning can be done under image intensification. The patient is placed supine on the operating table. A closed reduction is performed under image intensification. Once adequate reduction has been obtained, the pins are inserted laterally through the metaphysis, in an inferior-to-superior fashion. The surgeon should be careful to avoid the axillary nerve laterally and anteriorly, as well as the other neurovascular structures more medially. The pinning technique can be challenging because the optimal trajectory is quite steep and the cortex of the proximal humerus can be very hard. Smooth pins can be used, or the small external fix-it or pins with threaded tips can be used instead, if there are concerns about pin migration.

FIGURE 15-9 Technique of percutaneous pinning of a proximal humeral metaphyseal fracture from a distal approach to avoid the axillary nerve. A, AP radiograph demonstrating a displaced proximal humerus metaphyseal fracture. B and C, Once satisfactory reduction is obtained, pins are inserted distally through the deltoid and advanced in an inferior-to-superior direction. D, AP radiograph after pin removal showing a healed fracture, which has started to remodel.

(From Rockwood CA, Wilkins KE, Beaty J [eds]: Fractures in Children. Philadelphia: JB Lippincott, 1996.)

Depending on the stability of the fracture after reduction, two or more pins may be used. In younger children, when smooth pins are used, they can be left in the percutaneous position and removed in the office. In older children with threaded pins, the pins should be buried in the subcutaneous tissue and removed in the operating room once the fracture has healed.

Flexible intramedullary nails have also been used to manage proximal humerus fractures in children (Fig. 15-10).¹⁰⁷

FIGURE 15-10 A, Radiograph of an 11-year-old boy with multiple trauma, including bilateral femoral fractures and a contralateral proximal humeral fracture. The left side was treated in closed fashion. B, The proximal end of the right humerus was treated by closed reduction with flexible nails (Synthes titanium elastic intramedullary nails) to facilitate mobilization. C, The fracture was well maintained with this internal splint.

(Courtesy of Richard L. Munk, MD.)

Authors’ Preferred Treatment

Operative

Fractures that exceed the Beaty guidelines are treated with closed reduction and possibly internal fixation. The patient is placed supine on a radiolucent table. A bump may be placed under the scapula to allow greater ROM of the shoulder. The fracture is reduced using fluoroscopic guidance, using the maneuvers described earlier. If closed reduction is unsuccessful, the deltopectoral interval can be opened to facilitate reduction.

Once adequate reduction is achieved, percutaneous pins are inserted through the lateral cortex. We prefer the small external fixator or pins with a threaded tip to minimize the risk of migration. These pins are directed across the fracture site and into the head of the humerus, stopping short of the subchondral bone. Two or three pins are inserted until the fracture has been satisfactorily stabilized (Fig. 15-11). In older children (perhaps 13 years old and older), it is best to cut the pins and bury them beneath the skin, because fracture healing can take 4 to 6 weeks. The pins are cut to appropriate length. The extremity is placed in a shoulder immobilizer for 2 to 3 weeks.

FIGURE 15-11 A 14-year-old male quarterback who sustained an injury to his right shoulder when tackled. AP (A) and lateral (B) radiographs show a displaced and angulated fracture of the proximal humerus. Attempt at treatment in a hanging cast failed. A closed reduction was performed under anesthesia. C, The fracture was deemed unstable even after reduction and percutaneous pinning was performed. Postoperative course was uneventful. D, Radiograph taken 6 weeks into his postoperative period show excellent healing of the fracture.

Postfracture Care and Rehabilitation

Birth injuries and fractures in very young children tend to heal rapidly. Usually the healing is observed within 2 to 3 weeks. No rehabilitation is required in this age group.

In older children, injuries take longer to heal. In growth plate injuries, the fracture is usually stable in 3 weeks, after which gentle ROM and pendulum exercises can be instituted. After 6 weeks, active range-of-motion exercises, which include flexion and extension, abduction, and internal and external rotation, can be started. This is followed by strengthening of the deltoids and rotator cuff muscles.

Metaphyseal fractures may take 4 to 6 weeks to heal. Rehabilitation should start with gentle ROM exercises, followed by strengthening exercises once motion is restored.

Complications

Proximal humerus fracture complications may be divided into early and late. Early complications result directly from the fracture. These complications can be serious and develop into potentially limb-threatening injuries. Neurologic injuries have been reported to occur with proximal humerus fractures.^115–118 Typically, these are injuries to the brachial plexus from fracture dislocation. They can often be diagnosed early after injury, with loss of strength and sensation in the nerve distribution. Most of these injuries are neurapraxias that recover within 4 to 6 months. If no sign of recovery is noted, an EMG study is warranted to document whether there is actual improvement in the status of the nerve palsy. No improvement at this time is an indication for surgical exploration and possible repair or nerve grafting of the involved structure.¹¹⁵

Vascular injuries are uncommon but have been reported.^119–121 Implant-related complications such as hardware migration have also been reported after internal fixation of proximal humerus fractures.^{107,122–124} Loss of motion is also another complication that is seen, particularly in patients who were treated surgically.

Late complications are often sequelae of the original injury. Humerus varus usually occurs in children and neonates after a history of trauma, infection, or metabolic or hematologic conditions (Fig. 15-12).^125–130 This usually results in a decrease in the humeral neck-shaft angle accompanied by shortening of the humerus. The deformity results in slight limitation of ROM and often does not require surgical intervention. However, in some cases surgical management is needed to properly realign the humerus.^{121,127,130–132}

FIGURE 15-12 Proximal humeral varus resulting from an infection at 11.5 years of age. A, Marked shortening (arrow). B, Varus.

(From Rockwood CA, Wilkins KE, Beaty J [eds]: Fractures in Children. Philadelphia: JB Lippincott, 1996.)

Growth arrest has been reported in children who have growth plate fractures and in some pathologic conditions that cross the physis, such as chondroblastomas and bone cysts.^45,133–139 Complete physeal arrest has been reported but is relatively rare. More often these cases do not produce any functional deficit, and most children do not need any form of surgical intervention.

Hypertrophic scar formation is a complication seen after surgical management.^19,140,141 To avoid this, some authors have reported a more cosmetic axillary approach for treatment of these injuries.¹⁴² Osteonecrosis of the humeral head is a rare complication; however, even with osteonecrosis, good outcomes have been reported.¹⁴³ Glenohumeral subluxation has also been reported in children with proximal humerus fractures.^73,114 These often respond well to a period of nonoperative management, which includes supporting the extremity in a sling and instituting early rehabilitation.

Anatomy

Relevant Anatomy

The clavicle is an S-shaped bone that articulates medially with the sternum and laterally with the scapula at the acromion process. Through the sternoclavicular and acromioclavicular joints, the clavicle functionally links the axial skeleton and upper extremity. The medial two thirds of the bone is round and tubular; the lateral third is flat. The anterosuperior aspect of the clavicle is subcutaneous. The subclavian vessels and brachial plexus lie posterior to the clavicle near the junction of the medial two thirds and lateral one third (Fig. 15-13).

FIGURE 15-13 Relationship of the clavicle and scapula to the brachial plexus and subclavian artery.

(From Sarwark JF, King EC, Luhmann SJ: Proximal humerus, scapula, and clavicle. In Beaty JH, Kasser JR [eds]: Fractures in Children, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, pp 703-771.)

Numerous muscles and ligaments attach to the clavicle. Anteriorly, the pectoralis major originates on the medial two thirds of the clavicle and the deltoid on the lateral third. Posteriorly, the trapezius muscle inserts on to the lateral third of the clavicle. The clavicular head of the sternocleidomastoid muscle originates on the superior surface. The subclavius muscle and enveloping clavipectoral fascia attach to the inferior surface.

By providing these muscular and ligamentous attachment sites, in particular to the principal mobilizers of the upper arm, the pectoralis major and deltoid muscles, the clavicle plays a significant part in overall motion and function of the upper extremity. In addition, through the sternoclavicular joint, the clavicle itself is responsible for limited motion.^146–148 Upward elevation of the clavicle approximately 30 to 35 degrees contributes to shoulder abduction. The clavicle can also protract and retract approximately 35 degrees in the anterior-to-posterior plane. Lastly, the clavicle can rotate 45 to 50 degrees about the long axis of the clavicle.

Laterally, the clavicle articulates with the acromion of the scapula through the acromioclavicular joint. The acromioclavicular joint is a diarthrodial joint, surrounded by a relatively weak capsule and supported superiorly and inferiorly by the acromioclavicular ligaments. In a child, the lateral third of the clavicle is surrounded circumferentially by thick periosteum that acts as a protective tube. The capsule and acromioclavicular ligaments blend with the periosteum of the lateral part of the clavicle. The primary stabilizing ligaments, the conoid and trapezoid portions of the coracoclavicular ligaments, arise from the coracoid and attach to the lateral end of the clavicle and its periosteum.

Medially, the clavicle articulates with the manubrium of the sternum and the first rib through the sternoclavicular joint. The sternoclavicular joint is also diarthrodial, and similar to the acromioclavicular joint, it lacks inherent structural stability. The joint is stabilized by a group of ligaments, including the intra-articular disk ligament, the anterior and posterior capsular ligaments, the interclavicular ligament, and the costoclavicular ligament (Fig. 15-14). The anterior portion of the capsular ligament is heavier and stronger than the posterior portion.¹⁴⁹ The capsular ligaments attach mainly to the epiphysis of the medial clavicle; therefore, the physis is extra-articular and susceptible during injuries to the medial clavicle. The sternoclavicular joint lies anterior to many important mediastinal structures such as the great vessels, the vagus and phrenic nerves, and the trachea and esophagus.

FIGURE 15-14 Anatomy of the sternoclavicular joint.

Incidence

Fractures of the clavicle occur in 1% to 13% of all births.¹⁵⁰ The clavicle is also commonly injured during childhood, and clavicle fractures represent between 8% and 15.5% of all pediatric fractures.¹⁵¹ Most fractures of the clavicle involve the middle third (76%-85%). The lateral third is second most commonly involved (10%-21%); the incidence of lateral fractures increases with age. Fractures in the medial third are less common and account for only 1% to 5% of clavicle injuries in children.

Mechanism of Injury

The clavicle is the most commonly fractured bone during childbirth. The risk of birth-related clavicle fractures is increased for infants of larger birth weight (>4500 g), increased height (>52 cm), and shoulder dystocia.¹⁵² However, the majority of birth-related clavicle fractures occur in uneventful deliveries of average-birth-weight infants.

In children, falls, especially onto the shoulder, are the most common cause of fractures of the clavicle.¹⁵¹ Fractures of the clavicle can also occur in motor vehicle accidents and secondary to direct trauma sustained in sports such as football. Nonaccidental trauma can also be a cause. Stress fractures are rare but do occur.

Signs and Symptoms

Fractures of the clavicle in newborns may be difficult to diagnose. One of the more reliable signs is difficulty with palpation of the margins of the injured clavicle due to generalized edema. Pain is usually present with forced movement about the shoulder or direct palpation of the clavicle. Presumably to lessen pain, newborns with clavicle fractures sometimes voluntarily splint or immobilize the ipsilateral arm. This pseudoparalysis can at times be misdiagnosed as a brachial plexus injury. To minimize pain related to the pull of the sternocleidomastoid muscle across the fracture site, affected infants might turn their head toward the side of the fracture. Infants with acute clavicle fractures generally have an asymmetric Moro reflex.

In older children, the diagnosis of a clavicle injury is typically straightforward. Pain is present around the area of the fracture. Ecchymosis, swelling, and tenderness can also be present around the fracture site. Children with fractures of the clavicle resist and stop movement of the affected arm. A bony prominence or deformity may be noted with severely displaced fractures.

Associated Injuries

Fractures involving the clavicle are at risk for serious vascular injuries, including subclavian and axillary artery disruption; subclavian vessel compression, thrombosis, and pseudoaneurysm; and arteriovenous fistulas.^153–155 Brachial plexus neuropathy has also been reported in association with injuries to the clavicle.^156–158 Thorough neurovascular examination of the upper extremity is warranted. Onset of neurologic deficits related to brachial plexus neuropathy can be early or late. Open reduction and stabilization of the fractured clavicle may be required.

Fractures of the clavicle can be secondary to high-energy injuries and so can be associated with injuries to the ipsilateral lung and chest wall such as pneumothorax, hemothorax, pulmonary contusion, and rib fractures. Additional injuries to the ipsilateral upper extremity and shoulder girdle are also common.

Posterior displaced fractures of the medial clavicle and posterior dislocations of the sternoclavicular joint are at particular risk for concomitant injury to the retrosternal structures in the mediastinum, including the great vessels, the esophagus, and the trachea.^159–165 The index of suspicion should be raised in children who are choking or having difficulty with speaking, breathing, or swallowing. Signs of venous congestion and diminished distal pulses can also suggest associated injury. These associated injuries can be life threatening. Associated injury to the brachial plexus can also occur.

Fractures of the clavicle are rarely associated with atlantoaxial (C1-C2) rotatory subluxation (Fig. 15-15).^166,167 Clinically, the head is tilted laterally toward and rotated away from the fractured clavicle. The diagnosis of C1-C2 rotatory subluxation is difficult because of the masking of the torticollis by the acute symptoms of the fractured clavicle, but it should be suspected by asymmetrical ROM. The diagnosis is best confirmed by dynamic CT.

FIGURE 15-15 A, Lateral radiograph of the cervical spine with increased atlantodental interval and anterolisthesis of the atlas. B, Axial CT showing significant atlantoaxial rotatory subluxation. C, Coronal CT reconstruction showing the eccentric axis of the dens in relation to lateral masses of the atlas.

(From Nannapaneni R, Nath FP, Papastefanou SL: Fracture of the clavicle associated with a rotatory atlantoaxial subluxation. Injury 32:71-73, 2001.)

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