Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation

Abstract

We retrospectively reviewed six pediatric cases of medial clavicular injury, i.e., epiphyseal separation (Salter/Harris type I or II injury), diagnosed between 1993 and 1997. The clavicular metaphysis was displaced posteriorly in three cases and anteriorly in three. On conventional radiographic views the diagnosis was initially missed in two of three retrosternal dislocations. A special X-ray projection (described by Heinig) or computed tomography (CT) permitted correct diagnosis. Anterior dislocations were immediately and correctly diagnosed. Closed reduction successfully treated retrosternal displacement in two of the three patients. The third patient needed open reduction and internal fixation. Open reduction and internal fixation had to be performed in all three patients with anterior displacement. Follow-up assessment showed perfect functional results in all cases. Direct visualization during open reduction, which was necessary in four of six cases, yielded clear evidence that the so-called sternoclavicular dislocation in children and young adults is, in fact, a fracture of the medial growth plate with posterior or anterior displacement of the metaphysis.

The value of ultrasound in assessing displacement of a medial clavicular physeal separation in an adolescent

“…Where the medial clavicular epiphysis is not ossified, CT will not distinguish between sternoclavicular dislocation and medial physeal separation, nor will it reliably identify periosteal or ligamentous injury [7]. In hindsight, in our case, bony fragments anterior to the posteriorly dislocated clavicle may have represented small ossific fragments attached to the undisplaced periosteum (Fig 2a).…”

“…As in our case, the radiographic changes can be subtle or absent. Specialised radiographic views have been described including the Rockwood (serendipity) view, which is an AP view with 40°cranial angulation, and the Heinig view, which is a view taken with the patient supine, the beam directed in a coronal plane tangential to the joint and parallel to the opposite clavicle and the cassette placed across the opposite shoulder and perpendicular to the central ray [2,3,7]. However such specialised views can be difficult to perform reliably and are not be widely practised.…”

“…Posterior dislocations and physeal separations are less common than anterior injuries, but they are of greater clinical significance because of their association with potentially life-threatening mediastinal injury. For these reasons authors have emphasised the value of CT in diagnosing sternoclavicular dislocations and physeal injuries and excluding mediastinal complications [7,8,10]. Failure of closed reduction of sternoclavicular dislocations and physeal separations is well recognised in the literature, and this has been ascribed to the inherent instability of the bony structures, and failure to repair associated ligamentous or periosteal injury.…”

“…Since the medial clavicular epiphysis ossifies and fuses late, the medial clavicular physis may undergo separation in children and young adults instead of dislocation of the sternoclavicular joint itself [1][2][3]. Medial clavicular injuries are often associated with a delay in diagnosis due to subtle or absent signs on conventional radiographs [4][5][6][7][8][9]. Posterior dislocations and physeal separations are less common than anterior injuries, but they are of greater clinical significance because of their association with potentially life-threatening mediastinal injury.…”

Asymptomatic fibrous non-union of displaced sternoclavicular epiphyseal fractures: Case report and literature review

“…On occasions, diagnosis is not straightforward from a plain X-ray of the shoulder, especially in proximal clavicle fractures. 4 Fractures of the proximal end of the clavicle involving the medial epiphysis (Allman type III subtype IV) have been reported, but the cases published have had symptomatic complications. We describe a case with an asymptomatic complication of this type of fracture; fibrous non-union of the medial clavicle.…”