Pediatric Posterior Sternoclavicular Joint Injuries

Incidence of Intraoperative Cardiothoracic Intervention During Open Surgery Following Acute Posterior Sternoclavicular Joint Injury: A Case Series and Review of the Literature

BACKGROUND

Acute posterior sternoclavicular joint injuries are rare but potentially lethal injuries-signs of mediastinal compression range from nonspecific to neurovascular compromise. Currently, orthopaedic experts recommend a cardiothoracic surgeon be placed on standby during open surgery for potential intraoperative complications. However, few studies have reported on how often cardiothoracic intervention is required.

METHODS

First, we identified patients in our institution by CPT codes 23530, 23525, and 23532 from January 1, 2002 to May 1, 2023. Demographic variables and intraoperative cardiothoracic intervention rates were collected. Second, we systematically reviewed the literature to identify articles on acute posterior sternoclavicular injury using PubMed, Embase, and CINAHL databases (through August 20, 2023). Exclusion criteria included conservative treatment, successful closed reduction, chronic injury (>6 wk) cadaver studies, reviews, and nonavailable text.

RESULTS

Thirteen local patients underwent open surgery for an acute posterior sternoclavicular joint injury, 11 males and 2 females with an average age of 18.2 years old (range: 15 to 32.4). The most common mechanism of injury was sports (n=9; 69.2%). Four (30.8%) patients had physical or radiographic evidence of mediastinal compression. No patients required intraoperative cardiothoracic intervention in our institution. The literature search yielded 132 articles and 512 open surgeries for acute posterior sternoclavicular joint injuries. Four patients required intraoperative cardiothoracic intervention, all of whom presented with polytrauma and/or clinical or radiographic signs of neurovascular compromise, giving a combined overall rate of 0.76%.

CONCLUSIONS

Expert opinion commonly recommends cardiothoracic backup during open surgery for acute posterior sternoclavicular joint injuries. On the basis of our local data and systematic literature review, we found an overall cardiothoracic intervention rate of 0.76%. In the presence of polytrauma and/or findings of neurovascular compromise, we suggest having cardiothoracic surgery on close standby during the procedure. However, a patient with an isolated acute posterior sternoclavicular joint injury and no clinical or radiographic findings of neurovascular compromise does not appear to require a cardiothoracic surgeon on standby. Ultimately, the decision to involve cardiothoracic backup during open surgery for an acute posterior sternoclavicular injury should be made on a case-by-case basis after a thorough physical and radiographic evaluation of the patient.

LEVEL OF EVIDENCE

Level III.

Youth soccer players: patterns of injury involving the primary growth plates of epiphyses

Youth soccer (football) is immensely popular internationally. Earlier participation, sport sub-specialization, and year-around practice have led to an increased incidence of injury from both acute trauma and repetitive overuse. The growth plates (physes) of the immature skeleton are particularly vulnerable to injury and delayed diagnosis can lead to future growth disturbance and long-term morbidity. Familiarity with the various components of the growth plate complex necessary for ensuring normal endochondral ossification is fundamental in understanding the various patterns of imaging findings following injury. This review discusses the zonal columnar arrangement of the growth plate proper and the contrasting function of the vasculature within the subjacent epiphysis and metaphysis. This is followed by an evidence-based discussion of the common patterns of injury involving the epiphyseal primary growth plate observed among youth soccer players: subcategorized into physeal fractures (direct injury) and physeal stress injuries (indirect insult to subjacent metaphysis). In this section, the role of imaging and characteristic imaging features will be discussed. While the normal physiologic and pathophysiologic mechanisms can be applied to other growth plates, such as primary growth plates underlying the apophyses and secondary growth plates surrounding the secondary ossificiation centers, which also undergo endochondral ossification, the current review is focused on injuries involving the primary growth plates underlying epiphyses.

Management of Posterior Sternoclavicular Joint Dislocation in a Teenager After a Direct Elbow Strike to His Clavicle: A Case Report

Posterior dislocation of the sternoclavicular joint is a rare orthopedic injury and may result in complications with high mortality due to the location of the joint, accompanied by neurovascular, tracheal, and esophageal injuries. Therefore, an immediate diagnosis and treatment are necessary to prevent complications. In this case, a 13-year-old male patient received an elbow strike to the left clavicle while playing football. The patient presented to the emergency department with complaints of pain, a gap and deformity in the superior and medial part of his sternum, and numbness in his left upper extremity. For this orthopedic emergency, which is difficult to recognize on direct radiographs, a computed tomography was done, which detected a left sternoclavicular joint posterior dislocation. A closed reduction procedure was performed on the patient under sedation in the operating theatre. A serendipity view with the fluoroscopy showed a successful closed reduction. A shoulder arm sling was applied and the patient was followed regularly. In the fourth week, the shoulder arm sling was removed and exercises were started to increase joint movements. In the sixth week, muscle strengthening exercises were started and in the eighth week, a full range of motion was reached with full muscle strength without any deformity. In this case, possible mortal complications were prevented with early intervention in the posterior dislocation of the sternoclavicular joint. This case report shows that with timely rehabilitation, it is possible to achieve full joint range of motion of the shoulder and full muscle strength without deformity or the need for surgery.

Physeal injuries of the clavicle: pediatric counterparts to adult acromioclavicular and sternoclavicular joint separations

The epiphyses at the medial and lateral ends of the clavicle are small, ossify relatively late, and may not fuse until early adulthood. Because of this unique anatomy, pediatric and young adult injuries that involve the clavicle often differ from the patterns typically seen in older adults. Clavicular trauma that affects the acromioclavicular joint laterally or sternoclavicular joint medially often results in a physeal fracture and as such, can go unrecognized or be mistaken for a joint dislocation. Radiographic assessment is challenging, particularly when the epiphysis is not yet ossified. However, MR imaging allows for visualization of the cartilage, periosteum and perichondrium, and ligaments of the affected joints. Lateral clavicle physeal injuries can be categorized by the Dameron and Rockwood system, the pediatric correlate to the Rockwood classification of adult acromioclavicular joint injuries. Medial clavicle physeal fractures, similar to adult sternoclavicular joint dislocations, may result in anterior or posterior displacement. Because of their great ability to heal and remodel, clavicular physeal fractures respond better to conservative management than true acromioclavicular or sternoclavicular joint dislocations. Therefore, it is essential to recognize the true nature of these injuries, as there are implications for successful treatment and appropriate prognosis.

Posterior sternoclavicular joint dislocation with thoracic costovertebral joints fracture-dislocations: A case report

Case

A 59-year-old man presented with posterior sternoclavicular joint dislocation concomitant with fracture-dislocations of multiple thoracic costovertebral joints caused by traumatic injury. The posterior sternoclavicular joint dislocation was treated using an ultra-high molecular weight polyethylene fiber cable and the joint was stabilized. The degree of malpositioning of the thoracic costovertebral joints was difficult to reduce.

Conclusion

The patient achieved an excellent shoulder range of motion at 12 months postoperatively; however, chronic shoulder stiffness and posterior neck discomfort persisted.

Emergent Management of Traumatic Posterior Sternoclavicular Joint Dislocation: A Case Report and Literature Review

Sternoclavicular joint (SCJ) dislocation is a rare but serious orthopedic injury. Posterior dislocations are more concerning due to the SCJ’s proximity to visceral structures such as the trachea, esophagus, subclavian vessels, and brachial plexus. Due to the potential long-term sequelae of missed diagnosis, clinical suspicion should be high when a patient presents with a compression-type injury to the shoulder girdle and pain or deformity to the SCJ. 

Here we present a case of a 15-year-old soccer player who presented to the emergency department (ED) after a fall onto his right shoulder with additional compound injuries. A posterior SCJ dislocation diagnosis was suspected and confirmed after a computed tomography scan. A successful closed reduction was done in the ED after consultation with cardiothoracic and orthopedic surgery. 

This case adds to the body of literature describing diagnosis and management of posterior SCJ dislocations.

Pediatric Posterior Sternoclavicular Dislocation Closed Reduction and Management

Posterior sternoclavicular joint (SCJ) dislocations are rare shoulder girdle injuries. Despite the paucity of cases, posterior SCJ dislocations pose an important threat to patient safety because of the proximity of the medial clavicle to the mediastinum, resulting in possible compression and/or injury to these structures. Current guidelines recommend attempting closed reduction in the acute setting followed by open reduction if closed reduction is unsuccessful. This video highlights a case of posterior SCJ dislocation in a pediatric patient who presented with dyspnea after a football injury.

Functional impact of osteosuture in medial bilateral clavicular physeal fracture in teenagers

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Medial bilateral clavicular physeal fracture.

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Pediatric orthopaedic surgery.

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Thoracic paediatric traumatology.

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Functional impact of osteosuture.

Introduction

Proximal physeal fracture of the medial clavicular physis is a rare specific injury occurring in the immature skeletal. Several studies describe unilateral cases with posterior or anterior displacement and the following complications (vascular and mediastinal compression). An immediate diagnosis and management are necessary to avoid complications. The clinical diagnostic might be obvious or difficult, pain and swelling in the sternoclavicular joint area, sometimes a deformity and focal tenderness. A chest X-Ray may help and a three-dimensional reconstructed computed tomography scan has to be done to evaluate the lesions before surgery. The imaging is useful to confirm and specify the diagnostic and the displacement.

Presentation of case

This case report presents 4 cases of proximal physeal fracture of the medial clavicular physis in 2 male-teenagers with bilateral displacement, one posterior and the other asymmetric.

Discussion

After reviewing the literature of the unilateral clavicular physeal fracture, we can conclude that the ideal management of these injuries has not been well described. An open reduction associated an osteosuture with non-resorbable suture was performed. One-year follow-up, both of them had full recovery without any functional impact or any complains. This management of the proximal physeal fracture of the medial clavicle on children shows an excellent result according our cases and the literature.

Conclusion

The purpose of this study is to evaluate the functional impact of osteosuture in medial bilateral clavicular physeal fracture in teenagers after 1-year follow-up.

Outcomes After Surgical Fixation of Posterior Sternoclavicular Physeal Fractures and Dislocations in Children

BACKGROUND

Acute sternoclavicular fractures and dislocations (SCFDs) are a rare but important injury in pediatric patients. SCFDs are either true dislocations, or more commonly, physeal fractures in children. The reduction is advised given the proximity to surrounding vascular structures, and some authors advocate for routine fixation given rates of redisplacement after closed reduction. The purpose of the current study was to provide validated long-term functional outcome data following open reduction and surgical fixation of pediatric SCFDs, as well as provide injury and demographic information.

METHODS

This is a retrospective observational study with a subset of patients reporting functional outcomes. Patients under the age of 18 that had surgically managed acute posterior SCFD from 1990 to 2018 were included. A retrospective chart review was performed to obtain demographic, clinical, and surgical details. Patients with a minimum of 6-month follow-up were contacted to assess outcomes. Functional outcomes of interest included QuickDash, Visual Analog Scale pain rating, Single Assessment Numeric Evaluation of shoulder function, and PROMIS Upper Extremity questionnaire. Statistical analysis included descriptive statistics.

RESULTS

A total of 37 patients that sustained an acute posterior SCFD during the study period were included. The average age at the time of injury was 15.2±2.1 years and 89% were male. Patient-reported outcomes were obtained for 14 patients with a mean follow-up of 4.5 years. The mean QuickDash score was 5.1/100 with 0 being normal, and the mean Visual Analog Scale pain rating was 0.7/10. The mean Single Assessment Numeric Evaluation score was 96% with 100% being completely normal. The mean PROMIS score was 55 with 50 being the mean of the relevant reference population. Approximately 29% (4/14 patients) stated that their injury negatively affected their ability to participate in sports.

CONCLUSIONS

There is a paucity of literature on functional outcomes after surgical management of pediatric acute posterior SCFD. Functional outcomes after surgery were satisfactory in this cohort with most patients being able to perform major activities of daily living. Additional future studies with larger cohorts and comparative groups are needed to better understand outcomes in this population.

LEVEL OF EVIDENCE

Level IV.

Dislocations of the acromioclavicular and sternoclavicular joint in children and adolescents: A retrospective clinical study and big data analysis of routine data

Background

Dislocations of the sternoclavicular joint (anterior/posterior) and acromioclavicular joint (SCJ and ACJ, respectively) are rare injuries in childhood/adolescence, each having its own special characteristics. In posterior SCJ dislocation, the concomitant injuries in the upper mediastinum are most important complication, while in anterior SCJ dislocation there is a risk of permanent or recurrent instability.

Methods

In a retrospective analysis from seven pediatric trauma centers under the leadership of the Section of Pediatric Traumatology of the German Trauma Society, children (<18 years) were analyzed with focus on age, gender, trauma mechanism, diagnostics, treatment strategy and follow-up results. Additional epidemiological big data analysis from routine data was done.

Results

In total 24 cases with an average age of 14.4 years (23 boys, 1 girl) could be evaluated (7x ACJ dislocation type ≥ Rockwood III; 17x SCJ dislocation type Allman III, including 12 posterior). All ACJ dislocations were treated surgically. Postoperative immobilization lasted 3–6 weeks, after which a movement limit of 90 degrees was recommended until implant removal. Patients with SCJ dislocation were posterior dislocations in 75%, and 15 of 17 were treated surgically. One patient had a tendency toward sub-dislocation and another had a relapse. Conservatively treated injuries healed without complications. Compared to adults, SCJ injuries were equally rarely found in children (< 1% of clavicle-associated injuries), while pediatric ACJ dislocations were significantly less frequent (p<0.001).

Conclusions

In cases of SCJ dislocations, our cohort analysis confirmed both the heterogeneous spectrum of the treatment strategies in addition to the problems/complications based on previous literature. The indication for the operative or conservative approach and for the specific method is not standardized. In order to be able to create evidence-based standards, a prospective, multicenter-study with a sufficiently long follow-up time would be necessary due to the rarity of these injuries in children. The rarity was emphasized by our routine data analysis.

Open Reduction and Suture Fixation of Acute Sternoclavicular Fracture-Dislocations in Children

Background

Acute sternoclavicular fracture-dislocation is associated with high-energy trauma and is being increasingly recognized in children¹. These injuries are associated with compression of mediastinal structures and can be life-threatening¹. The management of acute sternoclavicular fracture-dislocation includes closed reduction or open surgical stabilization; however, limited success is reported with closed reduction^2,3. To our knowledge, there are no detailed descriptions of open reduction and suture fixation of acute sternoclavicular fracture-dislocation in children.

Description

Following diagnosis of acute sternoclavicular fracture-dislocation, the timing of surgical treatment is determined according to several patient and surgical factors. Among patients with hemodynamic instability, respiratory compromise, or evidence of asymmetric perfusion, surgical treatment is needed on an emergency basis. In the absence of these factors, surgical treatment can be performed on an urgent basis. It is important to communicate with vascular or thoracic surgeons prior to proceeding to the operating room because of the rare case in which advanced surgical access or vascular repair is required. In the operating room, general anesthesia and large-bore intravenous access are required. Patients are positioned supine on a radiolucent table, and a small bump is placed between the scapulae to elevate the medial aspect of the clavicle. The contralateral sternoclavicular joint and medial aspect of the clavicle should be prepared into the sterile field, as well as both sides of the groin in case vascular access is needed. A 6 to 8-cm incision is centered on the medial aspect of the clavicle, extending to the manubrium. Standard dissection to the clavicle is performed, and care is taken to maintain the integrity of the sternoclavicular ligament complex. Circumferential dissection of the medial clavicular metaphysis is usually required in order to mobilize the dislocated fragment. Reduction of the physeal fracture usually requires axial traction and extension of the ipsilateral shoulder with the aid of a reduction clamp on the medial clavicular metaphysis. In some cases, a Freer elevator can be placed between the metaphysis and epiphysis to shoehorn the clavicle from posterior to anterior. Once reduced, the fracture-dislocation is usually stable; however, the reduction is augmented with suture fixation. The sternoclavicular joint capsule should be repaired if disrupted, and the incision should be closed in layers. Postoperatively, the arm is placed in a sling, and range of motion is commenced at 4 weeks.

Alternatives

Alternative management of acute sternoclavicular fracture-dislocation includes closed reduction, plate fixation⁴, and ligament reconstruction⁵.

Rationale

In our experience, closed reduction is often unsuccessful, which is consistent with the experiences reported by other authors^2,3. In addition, suture fixation is sufficient and plate fixation is not required because this injury is relatively stable following reduction. Lastly, ligament reconstruction with use of autograft or allograft may be indicated but is more relevant in chronic cases with injury or attenuation of the sternoclavicular ligament complex. Open reduction allows for direct visualization of the fracture reduction, and suture fixation allows for increased stability without the need for hardware or secondary surgical procedures.

Expected Outcomes

We expect patients to achieve full range of motion and strength without any joint instability as reported by Waters et al.³.

Important Tips

There is an inherent risk of vascular injury with open reduction and suture fixation. This risk is mitigated with perioperative planning and consultation with vascular or thoracic surgeons. General surgeons should always be available when these procedures are performed in case of vascular issues or emergencies.It is sometimes difficult to reduce the dislocation, but additional maneuvers allow for controlled reduction of the displaced clavicle, such as using a Freer elevator and serrated clamp.Assessing fracture reduction can be difficult intraoperatively. Including the contralateral sternoclavicular joint in the sterile surgical field can be helpful in assessing fracture reduction and osseous contour.

Posteriorly displaced salter halter fracture-dislocation at the sternoclavicular joint with associated thoracic outlet syndrome: A case report

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Posterior sternoclavicular joint fracture-dislocations are a rare and often-missed injury in trauma.

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Posterior displacement at the SCJ is a true emergency and can be associated with compression of vital structures and thoracic outlet syndrome.

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Closed or open reduction of these injuries is generally advised but is associated with considerable risk.

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Conservative management can be successful in the presence of physeal injury but has never been described in the setting of thoracic outlet syndrome.

Introduction

Posterior sternoclavicular joint fracture-dislocations are a rare and often missed diagnosis. They represent <1% of shoulder girdle injuries and are nine times less common than anterior dislocations. These injuries can be associated with life-threatening complications such as compression of the superior mediastinal structures including the great vessels and brachial plexus.

Presentation of Case

This case describes a 23-year-old woman who was initially discharged from the emergency department but represented 8 days later with symptoms of venous and neurogenic thoracic outlet syndrome as a result of posterior displacement of a Salter 2 fracture-dislocation at the sternoclavicular joint. Multidisciplinary consensus and patient preference resulted in the conservative management of her injuries with intensive rehabilitation and close outpatient follow-up.

Discussion

The evidence regarding this rare injury is evolving. It currently suggests all posteriorly displaced fracture-dislocations at the sternoclavicular joint are reduced. Closed reduction is often unsuccessful and open reduction is high risk and must be undertaken in the presence of a cardiothoracic surgeon which may not always be appropriate or in line with patient preferences. There are limited reports of successful conservative management of these injuries and none in the setting of thoracic outlet syndrome.

Conclusion

This unique case report is the first to describe outcomes of a conservatively managed, posteriorly displaced fracture-dislocation at the sternoclavicular joint with associated venous and neurogenic thoracic outlet syndrome. This information will benefit select patients.

The management of Salter-Harris type II fracture with associated posterior sternoclavicular joint displacement using a locking compression plate: A 14-year-old adolescent's case report

RATIONALE

Posterior sternoclavicular joint dislocations (PSCJDs) are particularly rare injuries, accounting for 3% to 5% of sternoclavicular joint dislocations. With very few cases reported in the literature, these injuries are often misdiagnosed and imaging is not always clear, thus making physicians often unaware of them. The present case report aims to investigate a rare case involving a clavicular Salter-Harris II fracture with associated posterior displacement of the diaphysis, a term coined a "pseudodislocation."

PATIENT CONCERNS

We present a case of a 14-year-old adolescent who sustained a traumatic injury to the shoulder while falling during a soccer match. His main concern was about recovery time and the return to daily life activities.

DIAGNOSES

Multiple imaging studies imaging (X-rays, computed tomography, magnetic resonance imaging) revealed a Salter-Harris II fracture of the right clavicle with posterior displacement of the diaphysis.

INTERVENTIONS

The patient underwent primary surgery to reduce the fracture, using an articular locking compression plate, and secondary surgery to remove the hardware.

OUTCOMES

Following the removal of the hardware at 60 days after the initial surgery and a number of cycles of physiotherapy the patient reported a pain-free range of motion with slight limitation at extremes. Full return to recreational and everyday life activities were achieved at 3 months from the initial surgery.

LESSONS

The PSCJDs are challenging injuries, as they are surrounded by delicate structures inside the mediastinum. Attention must be taken while diagnosing and treating these injuries as the risk of complications and iatrogenic injuries is high. To the author's knowledge, this case is one of the first of its kind described in the literature where we have a Salter-Harrys type II fracture associated with a posterior pseudodislocation of the lateral clavicle. Given the positive results of the case, we recommend the above-mentioned treatment protocol in PSCJD with associated Salter-Harris II fractures in adolescent patients.

Evaluation and Management of Traumatic Conditions in the Athlete

The athletic training room is filled with a multitude of conditions encompassing many different specialties of medicine. When it comes to traumatic injuries in the training room, many of them are not musculoskeletal in nature. Ultrasound in the training room can help identify serious and subtle solid-organ injury and small pneumothoraces. The discussion of these conditions follows a simple outline that helps identify injury/conditions through a proper history and physical. Evidence-based treatment/management/return to play guidelines are discussed.

Anterior buttress plate is successful for treating posterior sterno-clavicular dislocation

PURPOSE

Traumatic posterior instability of the sternoclavicular joint is a potentially life-threatening injury. In contrast to the low incidence there is a plethora of different strategies to treat this lesion. It was the objective of this retrospective analysis to evaluate and further develop current strategies.

METHODS

In this retrospective analysis all posterior dislocations that were diagnosed and treated between 2011 and 2018 were included. In this 7 year period, eight male patients (median age 32 years) were operated.

RESULTS

Three patients were not diagnosed at the primary institution and were referred later. Five patients were treated with an anterior buttress plate with clavicular stabilisation only. One patient was stabilized with a temporary sternoclavicular arthrodesis. Two patients were operated using an autologous tendon graft. All of the patients underwent an immediate postoperative CT-scan that documented the anatomical articulation. All patients treated with a plate underwent implant removal. A final CT examination after removal documented the maintenance of the anatomic alignment.

CONCLUSIONS

The buttress plate technique with clavicular screw fixation is a sufficient treatment to restore and preserve a normal sternoclavicular alignment. The technique finds its indication in unidirectional posterior instability.

LEVEL OF EVIDENCE

IV.

Temporary Sternoclavicular Stabilization Using an Innovative Blocking Technique with Kirschner Wires for the Treatment of Posterior Sternoclavicular Joint Injury in Adolescent Patients: A Report of Two Cases

CASE

A 15-year-old boy with a posterior physeal fracture-dislocation of the medial aspect of the clavicle and a 14-year-old boy with a posterior sternoclavicular joint dislocation were successfully treated with temporary sternoclavicular stabilization using an innovative blocking technique with Kirschner wires.

CONCLUSION

When treating posterior sternoclavicular joint injuries, posterior instability should be securely stabilized. Temporary blocking stabilization of the sternoclavicular joint using Kirschner wires does not rigidly fix the sternoclavicular joint, but it prevents posterior displacement of the proximal aspect of the clavicle. This stabilizing technique is a simple, safe, and viable treatment option for adolescent patients with a posterior sternoclavicular joint injury.

Successful repair of thoracic outlet syndrome in a growing young patient due to posterior sternoclavicular joint dislocation

Posterior sternoclavicular dislocation is an extremely rare injury, usually related to heavy trauma, such as a traffic accident. The anatomical proximity of vital mediastinal structures often discourages a closed reduction during emergency situations. In this case report, we present a 17-year-old male patient who was admitted to our emergency department after having fallen down a flight of stairs five days previously. He was eventually found to have thoracic outlet syndrome. Chest computed tomography (CT) and shoulder magnetic resonance imaging (MRI) showed a posterior dislocation of the right clavicular head with all sternoclavicular joint ligaments ruptured; a hematoma around the clavicular shaft; compression of the right brachiocephalic, subclavian, and internal jugular veins; compression of the brachial plexus; and the right hemopneumothorax. Emergent open reduction with sutures and simultaneous plate stabilization was conducted for the posterior sternoclavicular dislocation, and thoracic outlet syndrome was completely resolved by the seventh postoperative day. The plate was removed six months after the open reduction. Complete range of motion in the shoulder and no pain were achieved without any complications. Unlike other techniques, this technique, using both sutures reduction and simultaneous plate stabilization, will offer excellent results, especially in a growing, young patient.

Shoulder Injuries in Pediatric Athletes

Shoulder injuries in pediatric athletes are typically caused by acute or overuse injuries. The developing structures of the shoulder lead to injury patterns that are distinct from those of adult athletes. Overuse injuries often affect the physeal structures of the proximal humerus and can lead to pain and loss of sports participation. Shoulder instability is common in pediatric athletes, and recurrence is also a concern in this population. Fractures of the proximal humerus and clavicle are typically treated with conservative management, but there is a trend toward surgical intervention.