Injury, Int. J. Care Injured 34 (2003) 467–470

Case report

Unusual fracture dislocation of the distal end of claviclein an adolescent

A.D. Acharya, N.K. Garg, C.E. Bruce∗Consultant Orthopaedic Surgeon, Alder Hey Children’s Hospital, Eaton Road, Liverpool L12 2AP, UK

Accepted 25 October 2001

1. Introduction

Fracture of the distal end of the clavicle is an uncommoninjury in children[1]. These fractures can usually be man-aged conservatively, even if the displacement is significant[2,3]. We present a case of Neer Type I fracture of the clav-icle with dislocation of the acromioclavicular (AC) joint,which required operative intervention. We have not foundany similar cases in the literature.

Fig. 1. AP radiograph of right shoulder.

∗ Corresponding author. Tel.:+44-151-252-5376;fax: +44-151-252-5921.E-mail address: cebruce@bigfoot.com (C.E. Bruce).

2. Case report

A 12-year-old right-handed boy presented with a historyof a fall on the point of right shoulder. A clinical diag-nosis of fracture of the distal end the clavicle was made.There was no evidence of associated injury and neurovas-cular examination of the upper limb was normal. X-rayexamination of the shoulder revealed a fracture of the clav-icle, lateral to the coracoid process with disruption of the

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468 A.D. Acharya et al. / Injury, Int. J. Care Injured 34 (2003) 467–470

acromioclavicular (AC) joint. A CT scan was performedto determine the fracture configuration, because it did notseem to correlate with any of the patterns described by Neer[4].

The CT scan showed that the lateral fragment was lyinganterior to the medial fragment and not aligned with the ACarticulation. Surgical exploration of the AC joint revealedthat the lateral clavicular fragment, devoid of any soft tis-sue attachment; was lying anterior to the periosteal tube ofthe clavicle and had been enucleated from within the tube.The soft tissues of the actual AC articulation were, how-ever, undisturbed. The distal fragment was returned to the

Fig. 2. (a–d) Images of the AC joint demonstrating anterior displacement of the lateral end of clavicle. Black arrow demonstrating the displaced fragmentand the white arrow demonstrating the AC joint.

periosteal tube and held by a single smooth K wire. Thiswas removed in the clinic after 3 weeks. The post-operativerecovery was uneventful and the patient had clinical and ra-diological union in 6 weeks. Follow-up examination at 1year showed that the surgical incision had healed with a hy-pertrophic scar, but the patient had made full functional re-covery regarding the activities of daily living. He had a fulland pain-free range of movement and normal power in theright shoulder. The constant score for right shoulder was 87compared to the unaffected left side score of 84. The Neerscore was 94 on the right side as compared to 100 on the leftside.

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Fig. 2. (Continued ).

3. Discussion

Fractures of the distal clavicle are less frequent than themore common middle third fracture pattern, especially inchildren [1]. In adults, clavicle fractures are classified ac-cording to the location of the fracture in relation to the cora-coclavicular ligament complex[4].

Type I injuries occur lateral to the ligament complexand are inherently stable. Type III injuries are intraarticularfractures of lateral end of clavicle. Type II injuries occurmedial to the coracoclavicular complex. The AC joint isintact but the medial fragment of clavicle is seperated fromunderlying coracoclavicular ligament. Thus, the resultantdeformity is marked.

The fracture presented here proved to be different fromboth the common paediatric pattern of injury and from theadult pattern. Plain radiographs suggested that the distalfragment was displaced from the AC joint and the subse-quent CT scan confirmed this. We have not come acrossany case report of a Neer Type I fracture with dislocationof AC joint.

The mechanism of injury is not clear; we suggest that,as the child fell on his side onto the point of the shoul-der, the clavicle fractured and the periosteal tube was tornanteriorly. With further continuation of momentum, theacromion and the medial clavicular fragment squeezedout the lateral fragment through the rent in the pe-riosteal tube, thus the fragment came to lie anteriorly.

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Fig. 3. Post-operative AP radiograph of right shoulder.

Fig. 4. AP radiograph of shoulder 6 months following operation showing radiological union.

CT scan was helpful in evaluating such an unusual injuryFigs. 1–4.

References

[1] Havranek P. Injuries of the distal clavicular physis in children. J PediatOrthopaed 1989;9:213–5.

[2] Canale ST. Fractures and dislocations of the shaft and epiphysis ofthe clavicle. In: Canale ST, Beaty JH, editors. Operative paediatricorthopaedics. St. Louis: Mosby Yearbook, 1991, p. 941–2.

[3] Miller ME, Ada JR. Injuries to the shoulder girdle. In: BrownerBD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma.Philadelphia: Saunders, 1992, p. 1291–310.

[4] Neer CS. Fractures of the clavicle. In: Rockwood CA Jr., GreenDP, editors. Fractures in adults. Philadelphia: J.B. Lippincottt, 1984,p. 707–13.