Fracture of distal end clavicle: A review

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ww.sciencedirect.comj o u rn a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 3Available online at wScienceDirectjournal homepage: www.elsevier .com/locate/ jcotReview ArticleFracture of distal end clavicle: A reviewBalaji Sambandam M.S. Orthopaedicsa,*, Rajat Gupta M.S. Orthopaedics,M.Ch. Orthopaedicsa, Santosh Kumar M.B;B.S.b,Lalit Maini M.S. Orthopaedicsca Senior Resident, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Indiab Third Year Post Graduate in Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi,Indiac Professor, Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Indiaa r t i c l e i n f oArticle history:Received 3 April 2014Accepted 16 May 2014Available online 19 June 2014Keywords:Fracture clavicleDistal end clavicleNeer type 2* Corresponding author.E-mail addresses: balajinimrotz@gmail.cohttp://dx.doi.org/10.1016/j.jcot.2014.05.0070976-5662/Copyright 2014, Delhi Orthopaea b s t r a c tManagement of fracture distal end clavicle has always puzzled the orthopaedic surgeons.Now-a-days with a relatively active lifestyle, patients want better results both cosmeticallyand functionally. Despite so much literature available for the management of this commonfracture, there is no consensus regarding the gold standard treatment for this fracture. Inthis article, we reviewed the literature on various techniques of management for thisfracture, both conservative as well as surgical, and their merits and demerits.Copyright 2014, Delhi Orthopaedic Association. All rights reserved.1. IntroductionFracture of distal end of the clavicle is an entity which al-ways creates a doubt in the mind of orthopaedic surgeons.With so many treatment options and numerous recom-mendations available in the literature, this is one of themost controversial fracture. Till date there is no gold stan-dard treatment recommendation for this injury. The un-stable nature of these fractures make them prone for nonunion and impeding the normal shoulder function. There-fore these fractures should be viewed as special injuries anda definitive line of management has to be outlined. Thisarticle reviews the existing literature and puts forward thepros and cons of various treatment modalities available forthis fracture.m, balajisambandam@yadic Association. All rights2. Material and methodsWe used three internet search engines e Pubmed, Cochraneand Medline. Following keywords were used e distal claviclefracture, Neer's type 2 fracture, Neer's type 5 fracture, Tensionband wiring, hook plate, coracoclavicular screws, Knowlespin, precontoured locking plate, coracoclavicular cerclage,suture anchors, tight rope for distal clavicle fracture, classifi-cation, surgical and conservative management, non union,complications of distal clavicle fracture. We got 160 relevantarticles in this search. Out of these we selected 50 articles. Ourinclusion criterias were1. Randomized control trials, case control studies and caseseries relevant to fracture distal end clavicle publishedfrom the year 2000 till date.hoo.com (B. Sambandam).reserved.mailto:balajinimrotz@gmail.commailto:balajisambandam@yahoo.comhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.jcot.2014.05.007&domain=pdfwww.sciencedirect.com/science/journal/09765662www.elsevier.com/locate/jcothttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 3662. Articles published in English language.3. Articles with 4 or more cases.Our exclusion criteria were1. Review articles and meta-analysis.Finally we had 40 level four studies, 7 level three studiesand 3 level two studies. There was no level one study.3. EpidemiologyFracture clavicle is one of the most commonly encounteredinjury in the emergency department. It accounts for 2.6%e4%of the total adult fractures.1e3 Clavicular fracture has bimodalage distribution. First peak occurs in young active adult malesless than thirty years of age. Usually they have a direct forceapplied to the shoulder as a result of a fall over the shoulderand less commonly by a fall over an outstretched hand. Sec-ond peak occurs in elderly females with osteoporotic bones.Distal end fractures occurmore commonly in these age group.Though fracture of the shaft is the commonest, lateral endfracture constitutes 21e28% of all clavicle fractures. Of these10e52% are displaced fractures.1e34. ClassificationMany workers had proposed their own classification systems,each having its own advantages and disadvantages. InitiallyAllman classified clavicle fractures into three types based onthe anatomical location without any prognostic significance.4Later Nordqvist and Petersson classified them further basedon displacement and comminution.2 A more useful classifi-cationwas proposed by Robinson from Edinburgh.1 He dividedthem into three basic types ofmedial fifth, lateral fifth and theintermediate three fifth which were further divided based ondisplacement, angulation, intra-articular extension andcomminution. For the distal end fracture per se, Craig's5 andNeer's6,7 classification is more helpful for prognosis andmanagement. While Craig's encompasses the whole clavicleNeer's is specific for the distal end fractures. Basically theseclassifications are based on the location of the fracture inrelation to the coracoclavicular ligament and their intactness.Type 1 Neer's is a fracture lateral to the coracoclavicular lig-ament attachment, which has very minimal displacement.Type 2 is one which is medial to the ligament attachment. It isagain divided into 2A and 2B. In 2A both the conoid and thetrapezoid ligaments are attached to the distal fragment and in2B conoid is detached from the proximal fragment while thetrapezoid is attached to the distal fragment. Type 3 is onewithintra-articular extension. Type 4 occurs in children where aperiosteal sleeve gets avulsed from the inferior cortexwith theattached coracoclavicular ligament and the medial fragmentgets displaced upwards. Type 5 is similar to type 2 which in-volves an avulsion leaving behind an inferior cortical frag-ment attached to the coracoclavicular ligament. Type 2 and 5are the unstable ones which has many controversies in theirmanagement. In Type 2 fractures, the distal clavicle fragmentis subjected to the distal pull by the weight of the arm as wellas amedial pull by the strong pectoralmuscles and Latissimusdorsi, while the proximal fragment is dragged posteriorly bythe trapezius. These disturbing forces contribute to the frac-ture displacement and the unstable nature of Type 2 fractures(Table 1)5. Clinical and radiological assessmentWhile fracture of the shaft is a clear cut diagnosis madeclinically, diagnosis of the fracture of distal end of clavicle isnot so straight. It can be confusedwith acromioclavicular (AC)joint dislocation, AC joint osteoarthritis and rarely septicarthritis. Patient usually presents with pain and swellinglocally and supporting the elbow with the other hand.Tenderness and crepitus can be elicited. Sometimes spike ofthe medial fragment may be tenting the skin and rarely thefracture may be opened to the external environment. Neuro-vascular injury is more common in shaft fractures. A plainanteroposterior radiograph of the involved shoulder is usuallysufficient for the diagnosis but a 15 cephalad AP view and astress radiograph can be obtained to get additional informa-tion about the integrity of the coracoclavicular ligament.Stress view which is more commonly used in the assessmentof the coracoclavicular ligament in AC joint dislocation canalso be used in distal end fractures too. Five out of the fiftystudies chosen had stress radiograph in the diagnostic work-up.8e12 Here the patient is made to stand for the radiographwith 10e15 pounds held in the ipsilateral hand. Classificationof distal clavicle by Neer is based on simple anteroposteriorradiograph.6. TreatmentTreatment and outcome of the fracture of distal clavicle de-pends on displacement and injury to coracoclavicular liga-ment which makes the fracture unstable. Type 1 injuriesgenerally being stable without any displacement aremanagedconservatively with a sling to support the weight of the limb.Type 3 injuries are managed similarly which unites as such,but may lead on to AC joint arthrosis which will need surgicalresection of the distal fragment. Type 4 is just a periostealdisruption in children and bone fills the periosteal sleeveresulting in union and remodelling. Management of type 2 and5 are the most controversial topic. Both being similar ininstability and displacement can be considered together.Number of treatment modalities are available for their man-agement. Till date no gold standard technique has beendescribed.For bony union to occur both the fracture ends must bekept opposed. To counter the distractive forces acting on thefracture ends one of the two surgical principles can be doneeither alone or together e Both the fragments can be fixedinternally either with or without the inclusion of the acro-mion. The difficulty with this type of fixation is that the distalfragment will be very small to get a firm hold with any kind ofimplant. To counter this problem if we fix the acromion alongwith them, the normal rotational movement that occur in thehttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007Table 1 e Classifications of fracture clavicle.Allman Nordqvist & Petersson Craig Edinburgh (Robinson) NeerGroup 1: midthirdUndisplacedDisplaced comminutedType 1 : mid third Medial third(type 1)Non displaced (1A) 1A1 e Extra-articular1A2 e Intra-articularType 1: fracture lateral to the coracoclavicularligament attachment, which has very minimaldisplacementDisplaced (1B) 1B1 e Extra-articular1B2 e Intra-articularType 2: medial to the ligament attachment2A e both the conoid and the trapezoidligaments are attached to the distal fragment2B e conoid is detached from the proximalfragment while the trapezoid is attached tothe distal fragmentMiddle third(type 2)Cortical alignmentfractures (2A)2A1 e Undisplaced2A2 e AngulatedType 3: with intra-articular extensionGroup 2: lateralthirdUndisplacedDisplacedType 2: Distal 1/3 fracturesa. Minimally displacedb. Displaced fractures, fracturemedial to the CeC ligament1. Conoid and trapezoid intact2. Conoid torn, trapezoid intactc. Fractures into articular surfaced. Fractures in children, intact CeCligaments attached to periostealsleeve, proximal fragmentdisplacede. Comminuted fracturesDisplacedfractures (2B)2B1 e Simple or wedgecomminuted2B2 e Isolated orcomminuted segmentaType 4: occurs in children where a periostealsleeve gets avulsed from the inferior cortexwith the attached coracoclavicular ligamentand the medial fragment gets displacedupwardsType 5: avulsion fracture leaving behind aninferior cortical fragment attached to thecoracoclavicular ligamentGroup 3: medialthirdUndisplaced Displaced Type 3: Proximal 1/3 fracturesa. Minimally displacedb. Displacedc. Intra-articulard. Epiphyseal separatione. ComminutedDistal third(type 3)Cortical alignmentfractures (3A)3A1 e Extra-articular3A2 e Intra-articularDisplacedfractures (3B)3B1 e Extra-articular3B2 e Intra-articularjournalofclinicalorthopaedicsandtrauma5(2014)65e7367lhttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 368AC joint during shoulder abduction and flexion will behampered and if the joint is violated then it predispose toarthritis. To avoid this removal of the implant at a later datebecomes necessary. The second type is bringing the fracturein opposition by fixing the displaced proximal fragment of theclavicle with the coracoid i.e. by reconstructing the torn cor-acoclavicular ligaments. This will be a rather invasive surgerynecessitating the exposure of coracoid and the neurovascularstructures near it.Treatment available can be broadly divided into1. Conservative management2. Rigid fixation e osteosynthesis with locking plate, hookplate fixation, fixation with distal radius locking plate,coracoclavicular screws, knowles pin fixation.3. Flexible fixation e simple k wire fixation, tension bandwiring, suture anchors, vicryl tape, dacron arterial graft forcoracoclavicular ligament reconstruction.In this article we reviewed the literature available in themanagement of these unstable distal clavicular fracture andgave an overview of outcome and complications of the varioustreatment modalities available. We compared each of thetreatment modality under the following aspects e function,time taken for union, complication and re-surgery andrevision.7. Level 4 studies7.1. Conservative treatmentThere is only one level 4 study with 101 patients where con-servative treatment was offered.13 Mean Constant score was93. 21 patients developed asymptomatic non union. 6 patientshad radiological findings suggestive of AC joint arthritiswithout any symptom. 11 patients had painful non union and3 patients developed painful AC joint arthritis and all 14 pa-tients needed surgical treatment at a later date. 5 patientsdeveloped subacromial impingement which needed steroidinjection.7.2. Precontoured locking platesThree level 4 studies with a total of 56 patients is availablewith this type of implant fixation for distal claviclefractures.14e16 All fractures united within 6e12 weeks exceptone which went to non union following a deep infection.These three studies used a number of scoring systemseUCLA(University of California and Los Angeles score), ASES(American Shoulder and Elbow Surgeons score), ConstantMurley score, DASH (Disabilities of the arm shoulder and handscore)and shoulder rating questionnaire. On an average allpatients had good to excellent results. There were two majorcomplications. One had a fracture at the medial end of theplate and one had deep infection which went to symptomaticnon union. In addition to these there were four minor com-plications e one superficial infection and three hardwaresymptoms. 10 out of 56 patients had a repeat surgery for plateremoval (4 for hardware symptoms, 2 for intra-articularposition of screws, 1 for deep infection and 3 had themremoved voluntarily).7.3. Hook plateThere are 10 level 4 studieswith 303 patients available on hookplate fixation.10,17e25 11 patients developed non union whilethe rest united within 7 weeks to 4 months, mostly requiringmore than 3 months. Functional assessment was done withConstant Murley score in 9 studies, DASH score and Oxfordshoulder in two studies, Japanese orthopaedic associationshoulder score, ASES and subjective shoulder value in onestudy each. Most of shoulder functions ranged from good toexcellent. There were 30 major complications e 16 dislocationof hook, 8 fracture medial end of the clavicle, 2 symptomaticnon union, 2 severe AC joint arthrosis, 1 rotator cuff tear, 1acromion fracture. Other minor complications include 46hardware symptoms, 27 acromial osteolysis, 7 superficialinfection, 7 asymptomatic non union, 5 minor AC jointarthrosis, 2 hypertrophic scar and 1 frozen shoulder. Allexcept 13 patients had their plates removed by a second sur-gery under general anaesthesia. These 13 patients refused re-surgery.7.4. Distal radius platesThere were seven level 4 studies with a total of 110 patientswhich used distal radius plate for fixation.11,12,26e30 Amongthese all except one study29 used an additional method to fixthe displaced clavicle to the coracoid. Fractures united within6e10 weeks. At follow up patients had excellent shoulderfunction as assessed by constant and DASH score. Few minorcomplications were observed e 22 hardware symptoms, 1imminent perforation, 2 non union with hardware failure and3 superficial infections. Of these patients with hardwaresymptoms and non union needed re-surgery.7.5. Coracoclavicular screwsThere were 3 studies with level 4 evidence on coracoclavicularscrew fixation for fracture distal end of clavicle comprising atotal of 59 patients.8,31,32 Union was achieved within 6e10weeks. All the three studies used a separate system for eval-uation of shoulder function e Constant Murley's, AmericanShoulder and Elbow Surgeons shoulder Index and simpleshoulder test questionnaire. Though a comparison cannotmade between these scoring system all patients on an averagehad good to excellent functional scores. All patients neededscrew removal which was done under local anaesthesia.Three patients hadminor complications. One had a superficialinfection which resolved with treatment, two had screw backout and one non co-operative patient had implant failurewhich led on to malunion. But none of them had anycompromise with the function.7.6. Flexible coracoclavicular fixationFour level 4 studies with 82 patients were available using thismethod.9,33e35 All but one united within 6e23 weeks. Onepatient had asymptomatic fibrous non union. Two studieshttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u rn a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 3 69used Constant Murley scoring system and the other two usedUCLA score and Karlsson's criteria. Nearly all patients hadexcellent results with few of them having good results. Fewminor complications occurred. One developed frozen shoul-der, one asymptomatic non union, two minor infections, onetitaniumwire breakage and one uncomfortable subcutaneoustenting of the mersilene tape. No major re-surgery needed.Few of the above mentioned infected and broken fixationmaterial needed removal under local anaesthesia.7.7. Arthroscopic treatmentThere were four level 4 studies available with a total of 39patients.36e39 All but one fracture united, the one hadasymptomatic non union. Function was assessed with a va-riety of scoring system like the Constant Murley, DASH, UCLAand AAOS (American Academy of Orthopaedic Surgeonsscore). All had good to excellent results. There were 5 minorcomplications e 2 frozen shoulder, 1 symptomatic AC jointarthritis, 1 superficial infection and 1 asymptomatic nonunion. No one needed re-surgery.7.8. Intra-medullary fixationFour level 4 studies with a total of 69 patients were found onintra-medullary fixation for distal clavicle fractures.40e43Among these two studies used Knowles pins and the othertwo used 4.5 mm AO/ASIF screw. One of the studies that usedKnowles pin fixed the fracture trans-acromially and the restdid it extra-acromially. Time for bony union ranged from 6 to12weeks and no patient had non union. Functional evaluationwas done with UCLA scores in two studies, and the other twoused Constant Murley and Oxford shoulder score. On anaverage patients in all the studies had excellent function asassessed with the above scoring system. No serious compli-cation occurred. 5 of the patients had minor complications.One had a delayed superficial infection, three had irritation ofthe thread and hub of the Knowles pin, one patient in thestudy with trans-acromial Knowles pin fixation had AC jointarthrosis, which was mildly symptomatic and did not prog-ress during a five year follow up.7.9. Tension band fixationThere were four level 4 studies that employed tension bandfixation.44e47 Of these 3 used suture material and one studyused K wires and SS wires with 34 and 12 patients respec-tively. Fracture union occurred within 6e16 weeks. Functionas assessed with Constant Murley scoring was excellent. Nocomplication occurred and no re-surgery was necessary.8. Level 3 studies8.1. Hook plate compared with K wire tension bandwiringThere are three level 3 studies with a total of 207 patients inthis category.48e50 141 patients were treated with hook platesand 66 were treated with K wire tension band wiring of which10 were extra-articular and the rest were trans-articular.Average Constant Murley score was 90 for the hook plategroup and 86 for the TBW group. In the hook plate group 8 hadperi-prosthetic fractures, 6 implant related complications and2 non union of which onewas symptomatic. In the TBW group15 patients had K wire migration, 14 had loss of reduction, 5had superficial infection, 2 had asymptomatic non union andone patient had wire breakage. All hook plates and almost allK wires needed implant removal.8.2. Coracoclavicular sutures compared with nonoperative managementWehad one comparative studywith 16 patients treatedwith asling and 14 with coracoclavicular sutures.51 Osseous unionoccurred by 8e12 weeks in the non operative group and 6e10weeks in the operative group. No significant differenceoccurred in function as measured with UCLA, ASES andConstant Scores. 7 of the patients treated non operativelyshowed non union of which two were symptomatic. But noneneeded surgery. The other group had no complication and nore-surgery was needed.8.3. Hook plate compared with distal radius platingwith coracoclavicular fixationThere was a single study comparing 10 hook plate fixationwith 5 distal radius plating with coracoclavicular fixation.52Coracoclavicular fixation was achieved with either endo-button device, suture anchors or coracoid cerclage. There wasno significant difference in functional scorings between thetwo group although return to recreational activity was early inthe second group. Complication was more with hook plate,with 5 acromial osteolysis and hook migration, 3 asymptom-atic AC joint degeneration, 1 AC joint superior subluxation and1 non union. The other group had 3 asymptomatic AC jointsuperior subluxation. Also 9 out of the ten patients neededhook plate removal whereas distal radius plate did not needremoval.8.4. Hook plate compared with locking plate with sutureaugmentationOne study compared hook plate fixation with superior lockingplate plus suture augmentation.53 22 patients were fixed withhook plate and 16 patients were fixed with locking plate andaugmented with coracoclavicular sutures. Functionaloutcome as assessed by ASES was almost similar (72.4 forhook plate group and 77.1 for locking plate group). Compli-cations were significantly higher in hook plate group with 3peri-implant fracture, 1 infection and 1 hardware failurewhereas only one case of surgical infection occurred in lock-ing plate group. 13 patients needed hook plate removalwhereas only 4 patients needed locking plate removal.8.5. Trans-acromial pins with and without tension bandwireOne study compared the results of fracture distal clavicle fixedwith trans-acromial pins with (15 patients) and without (14http://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 370patients) tension band wire.54 Functional outcome asmeasured by UCLA score and the time required for bony unionwas almost similar between the two groups. But there was asignificant difference in the complication rate e 6 patients inthe group without tension band wire had skin erosion and pinmigration which needed removal within the third post-operative day, whereas only one patient had similar in theother group, that too after 3 months.9. Level 2 studies9.1. Hook plate compared with tension band wiringOne level 2 study with 65 patients compared fixation of distalclavicle with hook plate (35 patients) and trans-acromialtension band wiring (TBW) (30 patients).55 Oxford shoulderscore at 3 months was worse in the hook plate group butbecame comparable at 6 months. Mean time for union was14.2 weeks for the hook plate group whereas it was 13.8 weeksfor the TBW group. 9 patients in the hook plate group hadsubacromial erosion while 5 patients in the TBW groupshowed K wire migration externally. Routine removal ofimplant was done after one year.9.2. Cadaveric studiesThere were two cadaveric studies with level 2 evidence.56,57 Inone study56 15 cadeveric shoulders were used to create distalclavicle fractureswhichwere fixedwith 4 different techniquesand the strength of each fixation was compared. Cor-acoclavicular suturing, distal clavicle locking plate, distalclavicle locking plate with coracoclavicular suture augmen-tation and hook plating are the four techniques which wereemployed. They found that therewas no significant differencein the biomechanical strength of these techniques but modeof failurewasworse in the hook plate and suturee augmentedplate groups, where a secondary fracture almost alwaysoccurred when the fixation failed. In another cadaveric studydone by Madsen et al57 the stability of distal clavicle fracturefixed with superior locking plate was compared with thecombined fixation of the same with coracoclavicular sutureanchor and superior locking plate. 6 fresh frozen shoulderwasused in each group. Addition of a coracoclavicular suture an-chor improved the stability of fixation as evidenced by theincreased amount of force needed to disrupt the fixation. Alsothe mode of failure was simple where anchor pull outoccurred in 4 and distal clavicle split occurred in 1, while in theother group without suture augmentation failure occurred bydistal clavicle split in 3 and AC joint displacement in 1.10. DiscussionManagement of distal clavicle had taken various turns eversince Neer's observation of the highly unstable nature of thefracture and the high rate of non union associated with it.6,7There will be very few fractures in orthopaedics which hasso many treatment options available yet still there is no goldstandard treatment for this peculiar fracture. We reviewedthese methods and made a comparison of the following pa-rameterse time for union, functional outcome, complicationsand the need for re-surgery.Starting with conservativemanagement treatment optionsincludes many rigid and flexible fixation methods. Thoughthere is a debate in the exact figure, rate of non union isdefinitely much more when this fracture is managed conser-vatively. Therewas one level 4 studywhere therewas 10%nonunion rate and one level 3 study where conservative man-agement was compared with flexible coracoclavicular fixationwhich again showed increased non union rate of almost up to50%.7,45 It seems operative intervention is definitely needed asobserved in older studies.6,7Plating is one of the surgical option for this fracture. But thedistal fragment will be too small to be rigidly held with ordi-nary plates. Special pre-contoured superior locking plateswere particularly developed for this purpose. The lateral endof the plates has multiple 2.7 mm locking screw holes, indiverging configuration for the best possible hold. This allowearly mobilization. Out of the 56 patients there was only onemajor complication directly related to the implant e fractureat the medial end of the plate. Also functional outcome wasgood. This implant neither cross the AC joint nor hinders therotational movement of clavicle at the AC joint makingimplant removal unnecessary. But due to impingement, 10patients needed plate removal and this had to be done undergeneral anaesthesia. Similarly in one level 3 study where acomparison was made with hook plate this technique provedto be better with no implant related complications whereas 4of the 22 patients with hook plate fixation had severe implantrelated complications.53 Also re-surgery for implant removalwas lesser. Sometimes the AC joint can remain mal-reducedeven after anatomical reduction. To counter this one of thestudies added a suture anchor or a simple non absorbablesuture for coracoclavicular fixation.15 In few cases they used ascrew through the plate and fixed it to the coracoid. Loss offixation in the distal fragment leading to implant failure, entryof screw into the AC joint and infection due to an extensivedissection are some of the possible complications.AO hook plate for distal clavicular fracture was first intro-duced in 1997 in Europe.24 This was designed to overcome theshortcomings of other available implants. With a small distalfragment normal plate, fixation will be difficult and the im-plants which are used for fixation between clavicle and cora-coid or the clavicle and acromion will restrict full shoulderrange of motion till union and implant removal there bydelaying rehabilitation and increases the chances of implantbreakage if the initial precautions are not followed. Hook platehas a small hook which levers under the acromion withoutany need for fixation in the distal fragment. The mechanics ofhook plate is such that it has no rotational stiffness and allownormal rotation at the AC joint allowing undisturbed bonehealing. AC joint is left undisturbed. But abduction of the armbeyond 90 is not allowed because this causes the sub-acromial structures to come in contact with the hook there bygetting damaged. Increased incidence of complications likesubacromial impingement, rotator cuff ruptures, acromionfractures, acromial osteolysis and pain originating from thehook hole enlargement and the need for general anaesthesiafor its removal is becoming a major concern. This is the mosthttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u rn a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 3 71frequently studied technique for fracture distal end claviclewith ten level 4 studies and six level 3/2 stud-ies.10,17e25,48e50,52,53,55 In studies with level 4 evidence thoughfunctional outcomewas good complication ratewas highwith10% of the patients had some major complication.10,17e25 Inthree level 3 studies hook plate was compared with wiringwhere therewas slightly better function and less complicationrates but major complications occurred with the hook platepatients.48e50 In other two level 3 studies hook plate wascompared with distal radius plate and locking plate wherehook plate seemed to have higher complication rate and re-surgery rate for implant removal.52,53 One level 2 studycomparing hook plate with tension band wiring showed boththe techniques to have comparable results.55 Overall it seemsthat in spite of giving good functional outcome hook platetend to produce major complications and there is a definiteneed for implant removal which again puts the patient underrisk of one more general anaesthesia.Distal radius plate can also be used to fix distal claviclefracture. The broad part of the T plate suits well for the distalfragment and three to four screws can be inserted into itgetting a firm hold. Available level 4 studies showed a 22%implant related complications, although they are minor, andthe same number of patients needed implant removal undergeneral anaesthesia.11,12,26e30 As already mentioned the onelevel 3 studywhich compared this implantwith the hook plateshowed it to have lesser complication and re-surgery rate.52Technically speaking there should be no need for implantremoval as there is no breach into the AC joint. But hardwaresymptoms and implant failure can occur which needs animplant removal surgery. All the studies concerning distalradius plate except one29 used coracoclavicular sutures toaugment the fixation and prevent screw back out.Simple isolated coracoclavicular fixation with flexiblematerials can be used in isolation also. This neutralizes thedeforming forces and bring the fracture fragments together sothat union takes place. Mersilene tape, Ethibond sutures, ti-tanium cables, dacron graft etc. are used for this purpose.Studies with this type of fixation showed excellent resultswithout any major complications. No need for hardwareremoval and sparing of the AC joint are the major advantageof this procedure. Stress riser in the coracoid and secondaryfracture was a concern. But this being a flexible fixation thechance for such a complication is remote. Also this is partic-ularly seen in cases of AC joint dislocation, whereas in distalclavicle fracture after fracture union stress becomes concen-trated on the bone relieving the fixation material. Extensivedissection to reach the coracoid is a disadvantage of thistechnique. Recently coracoclavicular fixation for fracturedistal end clavicle is being done arthroscopically. Afterentering the joint the scope is passed through the rotator in-terval and with endobuttons and tight rope coracoclavicularfixation is done. This type of fixation again neutralizes thedisplacement and brings the fracture fragments together. Thisprocedure does not open the AC joint and there is no need forimplant removal at a later date. Four level 4 studies which areavailable showed good functional outcome with few minorcomplications and no need for re-surgery.9,33e35 This proce-dure is technically demanding, requiring significant skills andanatomical knowledge. Difficulty arises when placing thefixation in the coracoid as it should be in the centre to avoidcoracoid fracture and also the neurovascular structures alongthe medial side should be simultaneously warded off.Coracoclavicular screws were initially used for treating ACjoint dislocations. Today its application has been extended todistal clavicle fractures. It basically nullifies the deformingforces acting on the fracture fragments and keeps themapproximated indirectly until union. There were no majorcomplications in the available studies and the functionaloutcome was also satisfactory.8,31,32 This fixation method hassome limitations too although not encountered in the abovestudies. Though the fracture site need not be opened always,access to coracoid is needed there by having a chance to injurethe neurovascular structures beneath it. Also full range ofmotion is restricted until screw removal to avoid screw cut outor fracture of the coracoid. Second surgery to remove theimplant is a must.Intra-medullary fixation is also possible for fracture distalend clavicle. Advantage of intra-medullary fixation over extra-medullary implant is a smaller incision, lesser soft tissuehandling, relative protection of supra-clavicular nerves andabove all these implants could be removed under localanaesthesia. Similarly intra-medullary fixation also seemed tohave no major complications with good functional outcome.Among the very few minor complications AC joint arthrosisoccurred only when trans-acromial fixation was doneimplying that this can be avoided by going extra-acromially.Also the hardware related symptoms occurred only withKnowles pin and not with AO/ASIF screw. This is probablybecause the hub of the Knowles pin is larger than the head ofthe screw and the tip is more sharper. Also the screw has alarger diameter offering a more rigid fixation. These factorsmake us believe that extra-acromial fixation with AO/ASIFscrewwill be the ideal intra-medullary technique. All patientshad their implant removed under local anaesthesia after bonyunion. Problemwith this technique is the length and directionof the screw should be perfect otherwise the cortex will bebreached and cause irritation. Implant migration andbreakage are also a possibility.Fixationwith Kwires and applying a tension band is an ageold technique for distal clavicle fracture. This is usually doneextra-acromially but sometimes the distal fragment will be sosmall that trans-acromial tension band wiring has to be done.Removal of the implant is always needed in trans-acromialfixation because it hinders the rotational movement of clav-icle at the AC joint. Usage of this technique needed no severesoft tissue stripping and no heavy hardware has to be inser-ted. Technique is also simple. If at all necessary the implantcan be removed under local anaesthesia. If not applied trans-acromially AC joint also can be spared. K wire migration is amajor concern, particularly with osteoporotic bones. 10e15%of the patients in the available studies had implantmigration.48e50,54,55 This can be avoided if the wire is bentdistally so that even if it migrates it does so exteriorly. Furtherin studies in which suture materials were used for tensionband wiring no re-surgery or complications wererecorded.44e46All the techniques showed not much difference in the timerequired for union but union rate was less when conserva-tively treated. The chance for implant failure was more withhttp://dx.doi.org/10.1016/j.jcot.2014.05.007http://dx.doi.org/10.1016/j.jcot.2014.05.007j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a uma 5 ( 2 0 1 4 ) 6 5e7 372K wire tension band wiring with almost 10% of the patientswent for loss of reduction in the three level 3 studies.48e50Rest of the fixation techniques showed minimal failure rate.In the two cadaveric studies strength of the fixation tech-niques showed no great difference.56,57 Functional outcomescannot be accurately compared as a variety of assessmenttechniques were employed in the available studies. Anyways,all the techniques had good to excellent functional outcomesas assessed by various shoulder scoring systems. Complica-tion rate was particularly higher when rigid fixation tech-niques were employed. Major complications like peri-implantfracture occurred more commonly with hook plate fixation.AC joint arthrosis and rotator cuff tear though commonlyanticipated with hook plate were not frequent. Generallyimplant related complications are more common with rigidfixation techniques like the hook plate, locking plate and thedistal radius plates. Although flexible fixation techniquesseemed to be weak, such is not the case as seen by the veryfew failure rate. On a whole, coracoclavicular screw fixationand flexible coracoclavicular fixations had fewer complica-tions. Removal of the implant is also an important parameterto consider. Most of the rigid implants needed implantremoval either for biomechanical reason or due to hardwaresymptoms and this puts the patient under the risk of generalanaesthesia. Tension band wires and coracoclavicular screwsthough needs removal can be done under local anaesthesia.Occurrence of infection was not different between the tech-niques against our belief that infection rate depends on theinvasiveness of the technique. But most of these observationsare made from the large number of level 4 studies and fewlevel 3/2 studies. There is not a single level 1 study available.Further, non uniformities of the studies made comparisondifficult.11. ConclusionDistal clavicular fracture due to its unstable nature needsoperative fixation. The purpose of fixation is to avoid thedeforming forces acting on the fragments which can be donewith flexible or rigid fixation. Though function achieved wasnearly equal doing a flexible and semirigid fixations like openor arthroscopic coracoclavicular fixation, tension bandingwith sutures and coracoclavicular screws seems to avoidmostof the implant related secondary complications. Further rigidfixations need a major re-surgery for implant removalwhereas flexible fixation, if at all needed implant removal canbe done with a simple surgery under local anaesthesia.Further studies with higher levels of evidences are needed tomake out the single definitive treatment of this specialfracture.Conflicts of interestNo benefits in any form have been received or will be receivedfrom a commercial party related directly or indirectly to thesubject of this article.r e f e r e n c e s1. Robinson CM. Fractures of the clavicle in the adult.Epidemiology and classification. J Bone Joint Surg Br.1998;80:476e484.2. Nordqvist A, Petersson C. The incidence of fractures of theclavicle. Clin Orthop Relat Res. 1994;300:127e132.3. Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology ofclavicle fractures. J Shoulder Elbow Surg. 2002;11:452e456.4. Allman Jr FL. Fractures and ligamentous injuries of the clavicleand its articulation. J Bone Joint Surg Am. 1967;49:774e784.5. Craig EV. Fractures of the clavicle. In: Rockwood CA,Matsen FA, eds. The Shoulder. Philadelphia: WB Saunders;1990:367e412.6. Neer CS. Fractures of the distal clavicle with detachment ofthe coracoclavicular ligaments in adults. J Trauma.1963;3:99e110.7. Neer CS. Fractures of the distal third of the clavicle. ClinOrthop. 1968;58:43e50.8. Macheras G, Kateros KT, Savvidou OD, et al. Coracoclavicularscrew fixation for unstable distal clavicle fractures.Orthopaedics. July 2005;28(7):693e696.9. Webber MC, Haines JF. The treatment of lateral claviclefractures. Injury. 2000;31:175e179.10. Renger RJ, Roukema GR, Reurings JC, et al. The clavicle hookplate for Neer type 2 lateral clavicle fractures. J Orthop Trauma.2009;23:570e574.11. Sclliemann B, Roblenbroich S, Schneider KN. Surgicaltreatment of vertically unstable lateral clavicle fractures(Neer 2b) with locked plate fixation and coracoclavicularligament reconstruction. Arch Orthop Trauma Surg.2013;133:935e939.12. Herrmann S, Schmidmaier G, Greiner S. Stabilisation ofvertical unstable distal clavicular fractures (Neer 2b) usinglocking T e plates and suture anchor. Injury. 2009;40:236e239.13. Robinson CM, Cairns DA. Primary nonoperative treatment ofdisplaced lateral fractures of the clavicle. J Bone Joint Surg Am.Apr 2004;86A(4):778e782.14. Lee SK, Lee JW, Song DG, Choy WS. Precontoured lockingplate fixation for displaced lateral clavicle fractures.Orthopedics. Jun 2013;36(6):801e807.15. Anderson JR, Willis MP, Nelson R, Mighell MA. Precontouredsuperior locking plating of distal clavicle fractures: a newstrategy. Clin Orthop Relat Res. 2011;469:3344e3350.16. Tiren D, Joseph P, Vroemen AM. Superior clavicle plate withlateral extension for displaced lateral clavicle fractures: aprospective study. J Orthopaed Traumatol. 2013;14:115e120.17. Meda PV, Machani B, Sinopidis C, et al. Clavicular hook platefor lateral end fractures e A prospective study. Injury.2006;37:277e283.18. Flinkkila T, Ristiniemi J, Lakovaara M, Hyvonen P, leppilahti J.Hook plate fixation of unstable lateral clavicle fractures. ActaOrthop. 2006;77(4):644e649.19. Good DW, Lui DF, Leonard M, Morris S, McElwain JP. Claviclehook plate fixation for displaced displaced lateral thirdclavicle fractures(Neer type 2): a functional outcome study.J Shoulder Elbow Surg. 2012;21:1045e1048.20. Lee KW, Lee SK, Kim KJ, et al. Arthroscopic-assisted lockingcompression plate clavicular hook fixation for unstablefractures of the lateral end of the clavicle: a prospectivestudy. Int Orthop. 2010;34:839e845.21. Tambe AD, Motkur P, Qamar A, Drew S, Turner SM. Fracturesof distal third of the clavicle treated by hook plating. 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of distal end clavicle: A review1 Introduction2 Material and methods3 Epidemiology4 Classification5 Clinical and radiological assessment6 Treatment7 Level 4 studies7.1 Conservative treatment7.2 Precontoured locking plates7.3 Hook plate7.4 Distal radius plates7.5 Coracoclavicular screws7.6 Flexible coracoclavicular fixation7.7 Arthroscopic treatment7.8 Intra-medullary fixation7.9 Tension band fixation8 Level 3 studies8.1 Hook plate compared with K wire tension band wiring8.2 Coracoclavicular sutures compared with non operative management8.3 Hook plate compared with distal radius plating with coracoclavicular fixation8.4 Hook plate compared with locking plate with suture augmentation8.5 Trans-acromial pins with and without tension band wire9 Level 2 studies9.1 Hook plate compared with tension band wiring9.2 Cadaveric studies10 Discussion11 ConclusionConflicts of interestReferences

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