The authors are from the Department of Kinesiology, University of Connecticut, Storrs, CT.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Kelly D. Pagnotta, ATC, PES, Department of Kinesiology, University of Connecticut, 2095 Hillside Road, U-1110, Storrs, CT 06269-1110; e-mail: Kelly.Pagnotta@uconn.edu.
Clavicle fractures most commonly involve the middle-third and distal clavicle (80%)1,2 and represent 5% of all fractures.1 Medial end fractures account for only 5% of clavicle fractures.3,4 Moreover, most documented medial clavicle fractures occur in older men as a result of motor vehicle accidents.3 The subject of this case report sustained an injury caused by a direct blow to the clavicle. This case highlights the anatomic complexity of the region and the time frame for ossification of the clavicle. The need for imaging of the region following injury to achieve an accurate diagnosis, particularly in high school and collegiate athletes, is reviewed. Although rare in athletes, structural displacement in the sternoclavicular region risks damaging vital structures, and thus requires comprehensive evaluation and management.
A 6-foot tall, 190-pound, 17-year-old male high school football player was hit in the anterior aspect of the shoulder while cradling the football with his right arm during a tackling drill. The athlete felt an immediate pop and pain in the sternoclavicular region and presented with an obvious deformity (Figure 1). During the on-field evaluation, the athlete reported exquisite pain over the deformity. There was no tenderness or complaint of pain at the shaft or lateral clavicle or acromioclavicular joint. Due to the severity of pain, only circulatory and neurological functions were evaluated. The athlete’s arm and shoulder were immobilized, ice was applied to the anterior shoulder, and his parents were notified before transport to a local hospital. The athlete’s circulation and neurological status were monitored while he awaited transport.
Figure 1. Sternoclavicular Joint Deformity.
Initial radiographs suggested a sternoclavicular joint dislocation and an orthopedic specialist was called for a consultation. After reviewing the radiographs, an attempt was made to reduce the dislocation. After local anesthetics were administered, manual traction of the glenohumeral joint was applied while the orthopedic surgeon applied a posterior force directly on the medial clavicle. Attempts at reduction were unsuccessful, and a computed tomography scan was ordered to determine whether soft tissue was blocking the reduction. The scan revealed that a small fragment of the medial clavicle was still attached to the sternum, and the remainder of the clavicle had dislocated anteriorly from the fracture site (Figure 2). The athlete was then provided with pain medication and referred to his orthopedic doctor for follow-up evaluation and care.
Figure 2. Computed Tomography Scan Showing the Clavicular Fracture (arrow) of the High School Football Player.
Clavicle fractures are common in contact sports, such as football, hockey, and lacrosse.2 A significant portion of these fractures involve the lateral or middle-third of the clavicle and are caused by a direct blow by falling on an outstretched hand or by falling on the lateral shoulder. This case involved a medial end clavicle fracture sustained following a direct hit to the anterior shoulder girdle.
Sport-associated clavicle fractures are suspected when the patient describes a mechanism of injury, as noted above, and presents with pain, deformity, crepitus with arm movement, and point tenderness.2,5 Medial clavicle fractures present in a similar manner, as previously described; however, the major difference is the mechanism of injury, which is most commonly blunt force trauma due to a motor vehicle accident. The mechanism of injury in the current case was atypical for clavicle fracture in sports, and the proximity of the deformity and the area of greatest tenderness combined with imaging that did not identify fracture led to a diagnosis of sternoclavicular joint dislocation.
The physis at the medial end of the clavicle is the last physis to ossify,6,7 typically closing between 20 to 30 years of age.8 In a radiographic study of 873 participants, Schmeling et al8 determined that the mean age of full ossification of the medial clavicular epiphyseal cartilage was 26.7±2.3 and 26.7±2.6 years for men and women, respectively. Therefore, medial end clavicular fractures are more likely sources of deformity than sternoclavicular joint dislocations in this age group. Although most clavicle fractures can be confirmed via standard radiograph using an AP view, computed tomography4–6,9 may be warranted to differentiate medial clavicle fractures from sternoclavicular joint dislocation and to investigate the integrity of neurovascular structures and the magnitude of the displacement.6,9,10
In the current case, once the attempted reduction was unsuccessful, a computed tomography scan was ordered, revealing a comminuted proximal third clavicular fracture (Figure 2) involving the epiphyseal plate with posterior displacement. Although no additional structural harm was incurred in this case, the patient’s age and gender should have raised the index of suspicion for a fracture. Plain radiographs may not reveal medial clavicle fractures,4–6,9 as occurred in this case. However, the other factors were highly suggestive of fracture.
The authors believe that computed tomography is warranted when plain radiographs do not identify a fracture in cases of deformity in the sternoclavicular region following trauma in high school and collegiate boys and men. Radiographs are the logical first step in diagnosis; however, computed tomography is recommended due to its ability to adequately provide information on the neighboring structures and alignment of floating fragments6,7 when the radiographs are unremarkable. Furthermore, the computed tomography scan should be completed before attempting to reduce the deformity because it is more likely that the deformity is the result of fracture than sternoclavicular joint dislocation.7
This case highlights the challenges posed by medial end clavicle fractures. The deformity and pain mimic those associated with sternoclavicular joint dislocation. In this case, the mechanism did not involve a fall on the outstretched arm, which is a common cause of clavicle fracture, particularly in male football players. However, recalling that the physis at the medial clavicle is the last to ossify,6–8 as well as the limitations of plain radiographs in identifying epiphyseal fractures, a high index of suspicion of fracture should have led to a computed tomography scan before reduction of the deformity was attempted.
- Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007;15:239–248.
- Anderson MK, Parr GP, Hall SJ. Foundations of Athletic Training: Prevention, Assessment, and Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
- Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg. 2007;16:49–54. doi:10.1016/j.jse.2006.05.010 [CrossRef]
- Low AK, Duckworth DG, Bokor DJ. Operative outcome of displaced medial-end clavicle fractures in adults. J Shoulder Elbow Surg. 2008;17:751–754. doi:10.1016/j.jse.2008.01.139 [CrossRef]
- Pujalte GG, Housner JA. Management of clavicle fractures. Curr Sports Med Rep. 2008;7:275–280.
- Lampasi M, Bochicchio V, Bettuzzi C, Donzelli O. Sternoclavicular physeal fracture associated with adjacent clavicle fracture in a 14-year-old boy: A case report and literature review. Knee Surg Sports Traumatol Arthrosc. 2008;16:699–702. doi:10.1007/s00167-008-0495-0 [CrossRef]
- Lewonowski K, Bassett GS. Complete posterior sternoclavicular epiphyseal separation: A case report and review of the literature. Clin Orthop. 1990;281:84–88.
- Schmeling A, Schulz R, Reisinger W, Muhler M, Werecke KD, Geserick G. Studies on the time frame for ossification of the medial clavicular epiphyseal cartilage in conventional radiography. Int J Legal Med. 2004;118:5–8. doi:10.1007/s00414-003-0404-5 [CrossRef]
- Bartonícek J, Fric V, Lunácek L., Fractures of sternal end of the clavicle: current concept review. Rozhl Chir. 2008;87:480–485.
- Destouet JM, Gilula LA, Murphy WA, Sagel SS. Computed tomography of the sternoclavicular joint and sternum. Radiology. 1981;138:123–128.