1 Introduction

Medial third clavicle fractures are rare injuries in children and adolescents, accounting for 0–3.9 % of all paediatric clavicle fractures.^1,2 The majority of paediatric clavicle fractures occurred during sports injury, with other commonly reported mechanisms being motor vehicle collisions, falls, and biking accidents.^2–4 Although 39.9–54 % of paediatric clavicle fractures present completely displaced,^2,5 only 1.3–1.6 % required surgical treatment due to excellent remodelling potential of children.^2,4 Even rarer are complications arising from clavicle fractures, which have been reported at 2.5 %, and comprises mainly delayed/nonunions and skin irritation from bony protrusions.^2,5 Severe complications exist only in case reports.^6–11 In a series of 57 medial third of clavicle fractures in an adult population, no pulmonary or neurovascular injury was reported with the exception of a subclavian vein perforation from a gunshot wound.¹² In a smaller series of eight extra-physeal medial clavicle fractures in children, all were uncomplicated and healed with excellent outcomes.¹³

We present a rare case of a low energy medial third clavicle fracture in an adolescent, complicated by pulmonary perforation and persistent intrapulmonary displacement of the lateral fragment.

2 Case report

A healthy 15 year old boy presented to our paediatrics emergency department with a completely displaced right medial clavicle fracture and an ipsilateral undisplaced scapular body fracture after colliding with a teammate during a basketball game. The impact of the collision had caused him to fall to the ground, but he was able to stand up again with the help of teammates. He had remained alert with stable vital signs and full oxygen saturations on room air. At the time of orthopaedic consultation, he had complained of tolerable shoulder pain. There were never any complaints of shortness of breath or chest pain. He had no known medical conditions and had a normal birth and developmental history.

3 Clinical findings

On examination, he was alert, comfortable and healthy looking. Auscultation of the lung revealed equal breath sounds. Although he was a thin individual with prominent contralateral collar bone, only the medial end of his right clavicle was visible (Fig. 1a). He held his right shoulder in a protracted position (Fig. 1b), and refused shoulder range of motion due to pain. Neurovascular examination was unremarkable and there were no open wounds. There were no other areas of injury or pain.

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Fig. 1 Clinical photographs at presentation. 1a: The lateral end of patient's right clavicle was not visible despite his thin habitus. 1b: patient's right shoulder was held in a protracted position.

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4 Diagnostic assessment

Anterior-posterior and axial radiographs of his right clavicle revealed a completely displaced medial clavicle fracture, with inferior displacement of the distal end (Fig. 2). There was also an undisplaced fracture of the ipsilateral scapular body (Fig. 2). Initial chest radiograph did not pick up any pneumothorax or lung injury (Fig. 3). Computed Tomography scan of his right shoulder was performed the next day in view of the unusual location of the injury. This unexpectedly showed that the distal fragment of the displaced right clavicle fracture was embedded in the right upper lobe of the lung with associated pulmonary haemorrhage, contusion and a small right pneumothorax (Fig. 4a) The fracture was in close relation to a segmental pulmonary vessel (Fig. 4b). A repeat chest radiograph confirmed a small pneumothorax with an interpleural distance of 0.3cm (see Fig. 5).

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Fig. 2 Anteroposterior and axial views of the right clavicle showing a displaced medial clavicle with significant inferior displacement of the distal fragment. There is also an undisplaced scapular body fracture.

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Fig. 3 Chest XR on presentation did not pick up any pneumothorax or lung injury.

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Fig. 4 Preoperative CT scan. 4a: Intrapleural penetration of distal end of fracture with pulmonary haemorrhage/contusion, and small pneumothorax. 4b: Close proximity to segmental pulmonary vessels.

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Fig. 5 Repeat CXR the following day shows a small pneumothorax with interpleural distance of 0.33cm.

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5 Therapeutic intervention

Patient was advised for open reduction and internal fixation of the medial clavicle fracture in view of significant displacement of fracture ends, intrapleural penetration, and significant pain prohibiting shoulder range of motion. The scapula body fracture was undisplaced and hence treated conservatively. Cardiothoracic surgery service was consulted prior to planned surgery. They suggested for preoperative chest tube placement, and cardiothoracic service standby within hospital premises during surgery in the event of vessel laceration and massive intrathoracic haemorrhage.

Beach chair position was chosen over supine positioning to allow for easy manipulation of the right upper limb to facilitate fracture reduction. Single lung ventilation was used to decompress the right lung to aid removal of fracture fragment. A 16Fr right sided chest tube was inserted after induction of general anaesthesia. 15mls of fresh blood was drained through the chest tube upon insertion. Preoperative fluoroscopy was performed to ensure adequate imaging before sterile draping. A 10cm horizontal incision just inferior to the expected anatomical position of the undisplaced clavicle was made. Subcutaneous tissue, platysma muscle, and clavipectoral fascia was dissected with diathermy in line with the skin incision. After the clavipectoral fascia was incised, the lateral fragment was easily exposed as the energy of the injury had stripped the bone of its soft tissue attachments (Fig. 6a). AO bone holding clamp was used to elevate the lateral fragment out of the lung without any intrapleural dissection (Fig. 6b). Care was taken not to release the AO clamp before fracture end was fully extricated to avoid re-displacement and vessel laceration. The Synthes 3.5mm LCP Superior Clavicle Plate serendipitously fit the anterior contour of the reduced clavicle perfectly and was chosen for fixation of the fracture. Two medial and four lateral locking screws were inserted for stable fixation (Fig. 6c). Patient remained hemodynamically stable with standard ventilatory requirements throughout the procedure. The chest drain was also monitored throughout surgery for bloody efflux suggesting intrathoracic vessel laceration, but no further blood was drained after the initial 15mls.

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Fig. 6 Intraoperative images. 6a: extensive soft tissue stripping of the bone was discovered intraoperatively. 6b: A bone holding clamp was used to elevate the distal fragment out of the lung. 6c: Fracture was fixed with an anteriorly placed locking plate.

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6 Follow-up and outcomes

Postoperatively, patient remained stable with full saturations. Immediate postoperative chest XR showed a small pneumothorax with an interpleural distance of 0.5cm (Fig. 7). Chest drain was removed on postoperative day three after resolution of the pneumothorax. No further blood was drained from the thorax. Patient's pain improved postoperatively. He was discharged on postoperative day three.

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Fig. 7 Postoperative XR showing plate fixation of the clavicle and a small pneumothorax.

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7 Discussion

Unlike medial clavicle fractures in adults which are often the results of high energy motor vehicle accidents and accompanied by significant multi-system trauma,⁸ these fractures in children and adolescent are more likely to be isolated injuries that occur during sports.^2–4,9 Although rarely reported, the possibility of a severe complication such as pulmonary laceration as described in our case need to be considered despite the often seemingly benign initial presentation and mechanism of injury.

The medial end of the clavicle lies adjacent to pleura, subclavian vessels, and the brachial plexus. The pleura extends into the root of the neck, 3cm above midpoint of the clavicle and 1cm above midpoint of medial end of clavicle.¹⁴ Subclavian vessels and the associated brachial plexus lie behind the medial end of the clavicle.¹⁵ The proximity of and injury to these radiolucent structures are poorly appreciated on radiograph. Furthermore, posterior displacement of clavicle fractures, which can alarm clinicians to possibility of neurovascular or pleural injury, cannot be well seen on standard anterior-posterior and axial clavicle radiograph views. A high index of suspicion is required. We recommend obtaining a CT scan in significantly displaced medial clavicular fractures, especially when one end of the clavicle is displaced inferiorly. In the only other case of intrapleural penetration reported in literature, inferior displacement of clavicle fracture was similarly noted.⁸ Other signs of injuries to these critical structures include tachypnea and radiological pneumothorax in the setting of pleural injury,^8–10 unusually large hematoma over fracture site in the setting of subclavian vessel laceration,¹¹ and peripheral nerve dysfunction in the setting of brachial plexus injury.⁷ Even in the setting of complete subclavian artery transection, peripheral pulses can be palpable.¹¹

In the setting of pleural injury with pneumothorax, a chest drain should be inserted to remove air, blood, facilitate re-expansion of the lung, and allow the safe use of positive pressure ventilation during anaesthesia. When plating the medial clavicle, shoulder abduction to 90^o has been shown to increase the distance of neurovascular structure from the clavicle to improve safety of drilling and screw insertion.¹⁶ Superior plating has not been shown to be safer than anteroinferior plating.¹⁶ A retractor can be used to protect against overpenetration of drill bits or screws.¹⁷ In the event of a vascular injury, both open and endovascular methods of repair have been described with good outcome.^7,11

8 Conclusion

Intrapleural displacement of clavicle fracture can occur in the setting of seemingly low energy injury. An inferiorly displaced clavicle fracture should raise suspicion of this rare injury and a CT scan should be performed. After the insertion of a chest tube to relieve pneumothorax, open reduction and internal fixation of the clavicle fracture can be safely performed.

Financial support and sponsorship

This study and its authors received no financial support or sponsorship.

Informed consent

Consent has been obtained from the parents of the patient for publication of the case details.

Author’s contribution

All authors were involved in the clinical care of the patient as well as the preparation and vetting of this manuscript.

Ethical statement

IRB approval is not required for this case report. Informed consent has been obtained from patient's parents for publication of case details.