Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Clavicle Fractures

1. Pediatric Orthopedic Imaging Case Studies
Kelsey Lena, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Department of Emergency Medicine1 & OrthoCarolina2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Pediatric Orthopedic Imaging Mastery Project
January 2022

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. It’s All About The Anatomy!

4. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that is to be
penetrated
• If there is no tissue, the color of the x-ray will be black
• The greater the density, the lighter the color

5. Reading Systematically
• Identify you are reviewing the correct patients imaging
(name, date of birth, date of imaging)
• Review both AP and lateral views, as this can help you
describe the fracture/deformity in both planes
• X-rays of two adjacent joints must be taken or a joint
injury could potentially be missed
• Identify which bone and what fractured part of the bone is
injured
Diaphysis
Metaphysis
Epiphysis

6. CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
CASE #1:
A 9-month-old female
presents to the Emergency
Department for respiratory
distress. The physician
obtains a chest x-ray due to
concern for possible
pneumonia and notices an
irregularity of the patient’s
clavicle.
Diagnosis?

7. CASE #1:
A 9-month-old female
presents to the Emergency
Department for respiratory
distress. The physician
obtains a chest x-ray due to
concern for possible
pneumonia and notices an
irregularity of the patient’s
clavicle.
Diagnosis?
Healing Clavicle Fracture
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
Secondary To
Birth Trauma

8. Here Is Another Example
Of A Clavicle Fracture
Secondary to Birth Trauma
A 7-Week-Old Patient
With An Oblique
Hairline Shaft
Fracture That Appears
To Be Healing

9. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 6-year-old male presents
to the Emergency
Department with right
shoulder pain after falling
onto his right side while
learning to ride a bike.
Physical examination is
limited, as the patient will
not allow you to abduct or
adduct the right arm.
Diagnosis?

10. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 6-year-old male presents
to the Emergency
Department with right
shoulder pain after falling
onto his right side while
learning to ride a bike.
Physical examination is
limited, as the patient will
not allow you to abduct or
adduct the right arm.
Diagnosis?
Mid-Shaft Right Clavicle
Fracture
Mildly Displaced Fracture

11. Another Example Of A
Minimally Displaced Left
Clavicle Fracture In An 18-
Month-Old Male

12. Here Is Another Minimally Displaced Mid-Shaft
Clavicle Fracture In A 14-Year-Old

13. Example Of Subtle
Acromion Fracture
Note The Minimally Displaced
Fracture At The Tip Of The
Acromion Extending Into The Joint

14. CASE #3:
A 14-year-old female
presents to the Emergency
Department with left-sided
chest pain after sliding into
home base at a softball
tournament. Physical
examination reveals that the
patient is neurovascular
intact, but that there is
edema and pain to palpation
at the left clavicular region.
Diagnosis?

15. CASE #3:
A 14-year-old female
presents to the Emergency
Department with left-sided
chest pain after sliding into
home base at a softball
tournament. Physical
examination reveals that the
patient is neurovascular
intact, but that there is
edema and pain to palpation
at the left clavicular region.
Diagnosis?
Fracture of the middle
third of the clavicle
Apex Superior Angulation

16. In This Example, A 10-Year-Old Male
Was Diagnosed With A Left Midshaft
Clavicle Fracture With Apex Superior
Angulation

17. CASE #4:
A 2-year-old boy
presents to the
Emergency Department
crying and pointing to
the left portion of his
chest. Mother states he
was running on the
playscape at the park
when he suddenly
tripped and fell. On
physical examination
the patient is unwilling
to lift-up his upper
extremities.
Diagnosis?

18. CASE #4:
A 2-year-old boy
presents to the
Emergency Department
crying and pointing to
the left portion of his
chest. Mother states he
was running on the
playscape at the park
when he suddenly
tripped and fell. On
physical examination
the patient is unwilling
to lift-up his upper
extremities.
Diagnosis?
Left Mid-Clavicle
Fracture
Mild To Moderate
Apex Anterior Angulation

19. Non-displaced Transverse Fracture Through The Middle Third
Of The Right Clavicle With Mild Angulation

20. 6-Month Old With
History of Osteogenesis
Imperfecta
Transverse Fracture of
Right Femur
In This Example, Note The
Markedly Displaced Right
Midshaft Clavicle Fracture
The Distal Aspect Of The
Medial Fracture Fragment
Extending Significantly
Superiorly And
Approximating The Skin
Surface

21. Another Example Of An Angulated
Clavicle Fracture
This Right Clavicle Fracture Is
Superiorly Angulated At The Mid-
Shaft

22. Pediatric Clavicle Fractures
• Overall incidence is approximately 15% of pediatric upper extremity injuries
• Most commonly occurs secondary to falling on an outstretched arm or
following direct trauma to the lateral aspect of the shoulder
• Clavicle fractures in a newborn are typically secondary to birth trauma
Incidence:
0.5% of normal deliveries
1.6% of breech deliveries
• A clavicle fracture in a < 2-year-old should raise possibility for non-accidental
trauma

23. Pediatric Clavicle Fractures: Allman Classification
Type I • Middle 1/3
• Most common
Type II • Lateral 1/3
Type III • Medial 1/3

24. Pediatric Clavicle Fractures: Clinical Presentation
Physical
Exam
• Newborn examination can range from being asymptomatic to
experiencing pseudo-paralysis secondary to pain or upper extremity
paralysis due to a brachial plexus injury
• Non-Newborn examination can reveal edema, tenderness overlying the
clavicle, apparent deformity, or patient notably supporting affected
arm with the contralateral arm
Neurologic
Assessment
• Assess for brachial plexus injury (Roots C5-T1)
Vascular
Assessment
• Assess for warm, pink skin with capillary refill <2 seconds
• Ensure carotid and radial pulses are present with palpation or doppler
signal

25. Pediatric Clavicle Fractures: Complications Based On Allman Classification
Type I • Subclavian artery injury
• Subclavian vein injury
• Brachial plexus injury
Type II • Acromioclavicular (AC) joint dislocation or subluxation
• Coracoclavicular ligament injury
Type III • Intrathoracic injury
• Rib fracture
• Sternal fracture

26. Orthobullets.com
AC Joint Stability:
• The acromioclavicular
ligament provides
anterior/posterior
stability
• The coracoacromial
ligament provides
superior/inferior
stability

27. Pediatric Clavicle Fractures: Management
Sling or Shoulder Immobilizer
• For patients < 12 years old, almost all fractures are treated non-operatively due to
high remodeling potential
• Union occurs at approximately 1 week post-injury
Prospective studies have shown no difference between sling vs. shoulder
immobilizer
• Approximately 2 - 4 weeks post-injury: gentle range of motion exercises
• Approximately 6 -10 weeks post-injury: strengthening exercises
Indications For Open Reduction Internal Fixation (ORIF):
• Displaced fracture with skin tenting
(impending soft tissue compromise)
• Open fracture
• Neurovascular compromise

28. Overview:
-Systemic review to assess factors
which may predispose children to
form clavicle fracture non-union
-Overall, non-union is extremely
rare in the pediatric population
-The majority of non-unions occur
after displaced clavicle fractures on
the right side or with re-fractures
-The mean time of non-union
presentation was approximately 1
year following the injury
-Management included surgical
fixation, which provides
radiographic healing improved
functional outcomes

29. Summary of This
Month’s Diagnosis
Clavicle Fractures:
Type I
Type II
Type III

30. Resources
• Hughes K, Kimpton J, Wei R, Williamson M, Yeo A, Arnander M, Gelfer Y. Clavicle
fracture nonunion in the paediatric population: a systematic review of the literature. J
Child Orthop 2018;12:2-8. DOI 10.1302/1863-2548.12.170155
• Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative
interventions for treating middle third clavicle fractures in adolescents and adults
Cochrane Database Syst Rev 2009; (2): CD007121.
• McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative
care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical
trials J Bone Joint Surg Am 2012; 94(8): 675-84.
• Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures
of the clavicle J Bone Joint Surg Am 2004; 86-A(4): 778-82.
• https://www.orthobullets.com/pediatrics/322128/clavicle-shaft-fracture--pediatric