Clavicle fractures in older children are commonly the result of injuries associated with trauma, play, or sports. In a retrospective study of 3666 pediatric patients involved in road traffic accidents, 17% of upper extremity fractures involved the clavicle [22]. The Robinson classification for clavicle fractures considers the anatomical location of the fracture, and classification subtypes denote the presence of fracture displacement and whether there is intra-articular involvement [23]. (Table 12.1.) Medial physeal fractures , often misdiagnosed as sternoclavicular (SC) dislocations in younger adult patients, occur because the physis fails before the stronger sternoclavicular ligaments. A Type 1 Salter–Harris fracture is the most common injury associated with substantial trauma [24]. Acromioclavicular (AC) dislocations in children are generally metaphyseal or physeal injuries with accompanying periosteal sleeve avulsions. Importantly, this distinction influences treatment principles and outcomes, as pediatric AC and SC fractures do not cause ligamentously unstable joints when the fractures heal.

Typically, closed pediatric clavicle fractures are diagnosed with radiographs (primarily anteroposterior and cephalic tilt) and treated conservatively through a strategy of protective immobilization in a sling and early controlled range of motion of the involved limb. For midshaft clavicular fractures in neonates, nonoperative management with arm immobilization using a stockinet or long sleeved shirt safety pinned to the torso portion of the shirt is indicated for 1–2 weeks. Reassurance and counseling of the parents to avoid motion of the extremity that causes pain is beneficial; controlled and protected motion of the involved limb will be tolerated generally when bridging callous is identified on plain radiographs. In older children, nonoperative management with a sling for 3–6 weeks is preferred. Indications for surgical management include open fracture, impending open fracture (due to soft tissue compromise), and neurologic or vascular compromise requiring exploration. Athletic children may benefit from fixation of displaced fractures similar to the indications in adults (kickstand fragment, fractures with >2 cm shortening). Surgical options include periosteal sleeve suturing in young children and plating or intramedullary fixation in older children. Lateral clavicular fractures without disruption of the acromioclavicular and coracoclavicular generally heal well with nonoperative management although surgical fixation and suture repair of the periosteal sleeve is an option for intra-articular and displaced fractures (Robinson type 3B). Surgical reduction and repair of medial clavicular fractures are indicated generally for posteriorly displaced fractures due to the risk of compression of the great vessels and/or other mediastinal structures. Preoperatively, a computed tomography (CT) study can be beneficial. A cardiothoracic surgeon should be consulted and on standby if operative fixation is performed based on the proximity of the fracture and relative risk to vital structures and to the pleura. Initial management of displaced fractures involves closed reduction under anesthesia in the OR. A posteriorly directed force is exerted on the shoulder with the arm adducted to the body; if stable reduction is obtained, a figure-of-eight harness or sling can be utilized for 3–6 weeks. If the fracture remains unstable or unacceptably displaced despite attempts at closed reduction, open reduction and stabilization using suture fixation through bone tunnels in the sternum and clavicle is recommended [25].

Outcomes of nonoperative management of pediatric clavicle fractures are generally good to excellent (Fig. 12.2) [26]. Complications of nonoperative treatment include nonunion, malunion, refracture, pain, loss of motion, weakness, and cosmetic deformity. Osteomyelitis in the setting of previously undiagnosed closed clavicle fracture has been described in the neonatal population [27]. Confounding injuries involving the brachial plexus of vascular structures associated with the index trauma likely correlate with the increasing energy imparted to the region during injury (Fig. 12.3). Previous authors have proposed that failure of the clavicle is protective of the plexus in the setting of ipsilateral clavicle fracture and brachial plexus palsy , as these palsies tend to be less severe and resolve without intervention compared to those injuries to the brachial plexus that are not associated with a clavicle fracture [28]. Wu et al. reported on an arteriovenous fistula discovered at time of surgical fixation of posttraumatic nonunion in an adolescent initially treated nonoperatively for 6 months [29].

Open treatment of fractures can be complicated by adverse events associated with wound healing, neurovascular injury, and infection, as well as those issues associated with closed treatment. To our knowledge, the rare injuries that indicate operative fixation (Robinson 1B and 3B fractures) have limited outcomes reporting based on a review of the literature. A comparison of adolescents treated surgically to adolescents treated nonsurgically revealed a complication rate of 21.7% for surgical patients: refracture, need for plate removal secondary to hardware prominence, and nonunion. In comparison, no refractures nor malunions necessitating surgery occurred in the nonoperative group. Selection bias was unavoidable; however, adolescents treated surgically were more likely to have fractures with greater displacement and comminution compared to the nonsurgical group [30]. Li et al. reported complications in 86% of patients with midshaft clavicle fractures treated with surgical plate and screw fixation [31]. Complications included hardware prominence, chest wall numbness, wound healing complications, secondary fracture around the plate or following plate removal. Danisman et al. described a brachial plexus palsy and concomitant ipsilateral clavicle fracture [14, 15]. Patient satisfaction has been reported high at 1 year for 10–15-year-olds treated with intramedullary nailing of clavicle fractures [32]. When time to return to full activity is compared for operatively versus nonoperatively treated clavicle fractures in the pediatric population, no statistical difference has been reported between these two groups. Time to full shoulder range of motion was 7.85 weeks in the nonoperative group versus 8.74 weeks in the operative cohort. Time to radiographic healing, and DASH scores were not statistically different between operatively and nonoperatively treated fractures [33].