a direct blow to the clavicle Indications for operative management of clavicle fractures are evolving While skeletally immature patients have a high rate of fracture healing and good remodeling, recent evidence in the adult literature suggests there may be superior outcomes in patients treated operatively for completely displaced midshaft fractures Skeletally mature adolescents, with their higher activity level and functional expectations, may potentially benefit from this interventional approach, but large, high-level studies about displaced clavicle fractures in this age group are lacking Routine operative treatment is not currently recommended for pediatric closed, displaced clavicle fractures without threat to skin integrity Clinical Considerations Clinical recognition Children may present with shoulder pain and cradling of the injured arm; however not uncommonly, these fractures can go unnoticed until a large callus forms Then, the fracture gradually remodels over the next to 12 months The most common fracture type in younger patients is a greenstick fracture of the midshaft, attributable to the thick periosteum of this part of the bone Older children and adolescents are at higher risk for complete displacement, which is suggested on physical examination by a lowering of the affected shoulder, local swelling, and point tenderness Medial injuries to the sternoclavicular joint, suggested by localized pain and swelling or a palpable anterior or posterior displacement, are typically physeal injuries secondary to the strong ligaments that anchor the clavicle to the sternum and the relative weakness of the physis The lateral aspect of the clavicle is anchored by the coracoclavicular and AC ligaments, and thus, fracture through the physis is more common than dislocation ( Fig 111.9 ) Lateral physeal separation presents clinically as pain with all movements of the shoulder Typically, the proximal fracture fragment is displaced superiorly, and the radiographic appearance suggests AC separation However, the periosteum remains whole inferiorly with its ligamentous connections intact With severe displacement, the skin may be tented over the AC joint Special note should be made of the “floating shoulder,” an unstable fracture resulting from a glenoid neck fracture combined with an ipsilateral clavicle fracture, such that there is no stable bony connection between the upper extremity and the trunk