clinicians must be attentive to injuries to the medial and lateral aspects of the clavicle which may include dislocations and physeal injuries FIGURE 111.7 Radiograph of the pelvis and femur of an 18-month-old girl with osteogenesis imperfecta There is a healing fracture of the right femur (large arrow ), as well as an acute fracture of the left femur (small arrow ) CLINICAL PEARLS AND PITFALLS Clavicle fractures in children less than years old (excluding the newborn period), particularly of the lateral end of the clavicle are uncommon, and should raise concern for possible nonaccidental trauma The newborn or preverbal child who cries upon being picked up under the arms should be evaluated for possible clavicular fracture Patients with sternoclavicular fractures and dislocations following bluntforce trauma to the chest, may present with referred pain to the shoulder and neck Posteriorly displaced sternoclavicular fractures may cause damage to the underlying neurovascular and airway structures Current Evidence The clavicle is the most frequently fractured bone in children, and management considerations vary by the location of fracture (medial, shaft, or lateral), age of patient, and degree of displacement Clavicle fractures may occur in newborns as a result of birth trauma, and in ambulatory children and adolescents secondary to a fall onto the shoulder or an outstretched hand, or from a direct blow to the clavicle Indications for operative management of clavicle fractures are evolving While skeletally immature patients have a high rate of fracture healing and good remodeling, recent evidence in the adult literature suggests there may be superior outcomes in patients treated operatively for completely displaced midshaft fractures Skeletally mature adolescents, with their higher activity level and functional expectations, may potentially benefit from this interventional approach, but large, high-level studies about displaced clavicle fractures in this age group are lacking Routine operative treatment is not currently recommended for pediatric closed, displaced clavicle fractures without threat to skin integrity Clinical Considerations Clinical recognition Children may present with shoulder pain and cradling of the injured arm; however not uncommonly, these fractures can go unnoticed until a large callus forms Then, the fracture gradually remodels over the next to 12 months The most common fracture type in younger patients is a greenstick fracture of the midshaft, attributable to the thick periosteum of this part of the bone Older children and adolescents are at higher risk for complete displacement, which is suggested on physical examination by a lowering of the affected shoulder, local swelling, and point tenderness Medial injuries to the sternoclavicular joint, suggested by localized pain and swelling or a palpable anterior or posterior displacement, are typically physeal injuries secondary to the strong ligaments that anchor the clavicle to the sternum and the relative weakness of the physis The lateral aspect of the clavicle is anchored by the coracoclavicular and AC ligaments, and thus, fracture through the physis is more common than dislocation ( Fig 111.9 ) Lateral physeal separation presents clinically as pain with all movements of the shoulder Typically, the proximal fracture fragment is displaced superiorly, and the radiographic appearance suggests AC separation However, the periosteum remains whole inferiorly with its ligamentous connections intact With severe displacement, the skin may be tented over the AC joint Special note should be made of the “floating shoulder,” an unstable fracture resulting from a glenoid neck fracture combined with an ipsilateral clavicle fracture, such that there is no stable bony connection between the upper extremity and the trunk FIGURE 111.8 Radiograph of a 5-year-old girl with an osteosarcoma of the left femur showing an acute pathologic fracture (arrows ) Amputation was ultimately necessary TABLE 111.3 DIFFERENTIAL DIAGNOSIS OF PATHOLOGIC FRACTURES ... fractures in this age group are lacking Routine operative treatment is not currently recommended for pediatric closed, displaced clavicle fractures without threat to skin integrity Clinical Considerations