Skeletal trauma in children: what is different?

Abstract

Shoulder injuries are very common in all pediatric age groups. Very often, the shoulder is hit directly, or one falls on the shoulder so that it absorbs forces directly. These forces also usually are transmitted to the clavicle. This is an important point to remember, especially in terms of what happened to our patient. Indeed, our patient was tender over the clavicle; but, it is interesting that, very often, clinicians fail to palpate the clavicle with shoulder injuries, and yet this is very important. Why is this important? It is important because the clavicle often is the bone to take the brunt of the traumatic force. In terms of clavicular injuries, one of the first considerations is the most common overt or greenstick fracture of the clavicle. Another common consideration is an acromioclavicular separation. In other cases, there may be dislocation of the clavicle medially; but probably more common than all of these manifestations, except for the overt fracture of the clavicle, is the so-called plastic or bending fracture of the clavicle. This fracture is very common throughout the pediatric age range, including the adolescent. What happens in these cases is that the axial load forces exerted on the shoulder are transmitted to the clavicle and the clavicle bends. In some cases, it bends enough to produce a greenstick fracture (cousin of the plastic bending fracture); if one sees the fracture, there is no problem with diagnosis; but if no fracture line is seen, it is interesting how often the fact that the clavicle is bent is overlooked. In terms of the clavicle in almost every normal individual, with well-positioned radiographs, the clavicles look exactly the same. In this regard, however, it is best that the clavicles both be included on the same imaging study and not imaged separately. It is much more difficult to detect subtle bending fractures under the latter circumstance. On the other hand, when both clavicles and shoulders are included on the same image, accomplishing a diagnosis of a bending fracture is much easier. In this regard, in our patient, one should note that there is a distinct bend of the lateral end of the left clavicle as compared to the normal right clavicle (Fig. 2). This represents a plastic bending fracture. Emerg Radiol (2009) 16:35–36 DOI 10.1007/s10140-008-0718-1