review article management of distal clavicle...

Management of Distal ClavicleFractures

Abstract

Most clavicle fractures heal without difficulty. However, radiographicnonunion after distal clavicle fracture has been reported in 10% to44% of patients. Type II distal clavicle fractures, which involvedisplacement, are associated with the highest incidence ofnonunion. Several studies have questioned the clinical relevance ofdistal clavicle nonunion, however. Nonsurgical and surgicalmanagement provide similar results. The decision whether tooperate may be influenced by the amount of fracture displacementand the individual demands of the patient. Surgical options toachieve bony union include transacromial wire fixation, a modifiedWeaver-Dunn procedure, use of a tension band, screw fixation,plating, and arthroscopy. Each technique has advantages anddisadvantages; insufficient evidence exists to demonstrate that anyone technique consistently provides the best results.

Fractures of the distal clavicle ac-count for approximately 10% to

30% of all clavicle fractures.1 Man-agement of distal clavicle fractures isoften challenging because of the dif-ficulty in distinguishing subtle varia-tions in the fracture pattern that mayindicate fracture instability. Stablefracture patterns generally heal un-eventfully with nonsurgical manage-ment, but unstable fracture patternsare often associated with longer timeto union and notable nonunion rates.

Because of concern that nonsurgi-cal management may result in non-union, primary surgical managementhas been recommended for certaindistal clavicle fracture patterns.2-6

However, these nonunions are oftenasymptomatic, and their clinical rele-vance has been questioned.1,7 The useof nonsurgical management is bol-stered by the various complicationsthat have historically been reportedfollowing surgical fixation. As a re-sult, there is uncertainty regarding

not only which distal clavicle frac-tures require surgical fixation butalso which fixation method is best.

Anatomy andBiomechanics

The clavicle serves as a strut connect-ing the upper extremity to the appen-dicular skeleton. Fluid scapulotho-racic motion is dependent on a stablerelationship between the distal clavi-cle and the scapula. This stability isprovided by the acromioclavicular(AC) joint capsule, AC ligaments,and coracoclavicular (CC) ligaments.

The AC ligaments span the ACjoint, attaching to both the medialaspect of the acromion and the distalextent of the clavicle and reinforcingthe AC joint capsule. These liga-ments serve as an important stabi-lizer to horizontal (AP) motion at theAC joint.8 This capsuloligamentouscomplex attaches to the distal aspectof the clavicle approximately 6 mm

Rahul Banerjee, MD

Brian Waterman, MD

Jeff Padalecki, MD

William Robertson, MD

From the Department ofOrthopaedic Surgery, University ofTexas Southwestern Medical Center,Dallas, TX (Dr. Banerjee,Dr. Padalecki, and Dr. Robertson),and the Department of OrthopaedicSurgery and Rehabilitation, TexasTech University Health SciencesCenter, El Paso, TX (Dr. Waterman).

Dr. Banerjee or an immediate familymember has received research orinstitutional support from Synthes,Smith & Nephew, Medtronic, andStryker, and serves as a boardmember, owner, officer, orcommittee member of the AmericanAcademy of Orthopaedic Surgeons.Dr. Robertson serves as a paidconsultant to ConMed Linvatec.Neither of the following authors norany immediate family member hasreceived anything of value from orowns stock in a commercialcompany or institution relateddirectly or indirectly to the subject ofthis article: Dr. Waterman andDr. Padalecki.

J Am Acad Orthop Surg 2011;19:392-401

Copyright 2011 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

392 Journal of the American Academy of Orthopaedic Surgeons

medial to the AC joint.9

The CC ligaments (ie, trapezoid,conoid) originate at the base of thecoracoid process of the scapula andinsert on the undersurface of the dis-tal clavicle. The trapezoid is themore lateral of the two ligamentsand attaches to the distal clavicleapproximately 2 cm from the ACjoint.9 The conoid ligament, which islocated more medially, attaches tothe clavicle approximately 4 cm fromthe AC joint. These ligaments play apivotal role in preventing superiordisplacement of the distal clavicle inrelation to the acromion. The normaldistance between the coracoid pro-cess and the undersurface of the clav-icle (ie, CC interspace) is 1.1 to 1.3cm.10

The clavicle also serves as an im-portant origin and site of insertionfor several muscles involved in mo-tion of the shoulder and the cervicalspine, including the sternocleidomas-toid, anterior deltoid, and trapezius.Depending on the fracture pattern,these muscles can create deformingforces. Neer4 described four deform-ing forces: weight of the arm; pull ofthe pectoralis major, pectoralis mi-nor, and latissimus dorsi muscles;scapular rotation; and pull of the tra-pezius muscle on the proximal frag-ment.

Classification

Neer5,11 and later, Craig,12 classifieddistal third clavicle fractures intothree types based on the relationshipof the fracture line to the CC liga-ments and AC joint (Figure 1). TypeI fractures occur lateral to the CCligaments but spare the AC joint.The proximal fragment is stabilizedto the coracoid process by the CCligaments and to the distal fragmentby the deltotrapezial fascia. Type Ifractures often are only minimallydisplaced because of the presence of

these soft-tissue attachments.Type III fractures are similar to

type I fractures in that they also oc-cur distal to the CC ligaments. How-ever, type III fracture extends intothe AC joint. Because the ligamen-tous structures remain intact, type IIIfractures are relatively stable andtypically are minimally displaced.Persons with this injury may be atrisk of posttraumatic AC joint ar-thropathy because of the intra-articular involvement.

Type II fractures are less stablethan type I and III fractures, andthey present a treatment challenge.In all type II fractures, the proximal

fragment is detached from the CCligaments. The distal fragment re-mains attached to the scapula via theAC joint capsule. In type IIA frac-ture, the fracture lies medial to theconoid ligament. In type IIB fracture,the fracture lies between the conoidand trapezoid ligaments. The rela-tionship of the distal fragment to thecoracoid process may differ betweentypes IIA and IIB.

In type IIA fractures, the distalfragment remains connected to thecoracoid process by the CC liga-ments, which are presumed to be in-tact. With type IIB fractures, the CCligaments lie within the zone of in-

Illustration of the Neer classification of distal clavicle fractures. Type I fractureoccurs distal to the coracoclavicular (CC) ligaments (ie, trapezoid, conoid)and involves minimal fracture displacement. The acromioclavicular (AC) jointremains intact. Type IIA fracture occurs medial to the conoid ligament. TypeIIB fracture occurs between the CC ligaments and includes disruption of theconoid ligament. The trapezoid ligament remains intact. Type III fractureoccurs distal to the CC ligaments and extends into the AC joint. Type IVfracture occurs in pediatric patients. The physis and epiphysis remainadjacent to the AC joint, but there is displacement at the junction of themetaphysis and physis. In type V fracture, a small inferior clavicular fragmentremains attached to the CC ligaments.

Figure 1

Rahul Banerjee, MD, et al

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jury. In Neer type IIB fractures, theconoid ligament is torn, but the trap-ezoid is presumed to remain attachedto the distal fragment.12 This classifi-cation was developed before wide-spread use of MRI, and we are un-aware of any study that hasconfirmed the integrity of the trape-zoid and conoid ligaments in typeIIA and IIB injuries. Although in typeII fractures, fracture displacementmay be obvious, the exact locationof the fracture and the integrity ofthe CC ligaments may be difficult tojudge on plain radiographs.

Type IV and V fractures were sub-sequently added to the classifica-tion.11 Type IV fractures are rare;they involve disruption of the perios-teal sleeve in the pediatric popula-tion.13,14 These fractures are injuriesto the growth plate in which theepiphysis and physis typically main-tain their relationship to the shoulderjoint, resulting in apparent superiordisplacement of the clavicular me-

taphysis. Depending on the degree ofdisplacement, these patients aretreated with closed or open reduc-tion.14 In type V fracture, only asmall inferior cortical fragment re-mains attached to the CC ligaments.Type V fractures are functionallysimilar to type II injuries in that nei-ther the proximal nor the distal frag-ment is connected to the coracoidprocess via the CC ligaments. Al-though the ligaments may remain at-tached to a free-floating bony frag-ment, the stability of the distal andproximal fracture fragments is com-promised. Although the Craig modi-fication of the Neer classificationsystem is widely used, no study hasassessed the validity of this classifica-tion through inter- and intraobserverreliability.

Robinson15 proposed an alternativeclassification for all clavicle fracturesbased on fracture location, displace-ment, and intra-articular involve-ment (Figure 2). Distal clavicle frac-

tures were classified as type 3. Theseoccur lateral to a vertical line drawnupward from the center of the cora-coid process. Robinson groupedfractures into subgroups A and Bbased on displacement of the majorfragments. Subtypes A and B weresubdivided according to articular in-volvement. This classification wasfound to have substantial interob-server reliability (mean kappa value= 0.77) and excellent intraobserverreliability (average kappa value =0.84).

Clinical Evaluation

Most distal clavicle fractures are theresult of a fall onto the distal clavicleor a direct blow to it.1,16 Direct impactoccurs at the acromion, usually withthe arm in an adducted position, andforce is transmitted through the ACjoint to the CC ligaments and the dis-tal clavicle. Patients with distal claviclefractures typically present with shoul-der pain. Associated injuries should beruled out, such as other injuries to theshoulder girdle, rib fracture, ipsilateralupper extremity injury, and injury tothe thorax or cervical spine. These areparticularly likely to occur in conjunc-tion with high-energy mechanisms.

Physical examination findings in-clude swelling, ecchymosis, and ten-derness over the distal clavicle, aswell as painful active and passiverange of motion (ROM) of theshoulder. Fracture displacement maycause the proximal fragment to tentthe skin, with an appearance similarto that of AC joint separation (Fig-ure 3). Paresthesias resulting fromswelling or injury to the supraclavic-ular nerves are common. Neurologicexamination of the shoulder and up-per extremity should be performedand documented. Suprascapularnerve injury after distal clavicle frac-ture has been described.17 Weaknesson external rotation with the arm in

Illustration of the Robinson classification of distal clavicle fractures (type 3).Type A, cortical alignment fractures: 1, extra-articular; 2, intra-articular. TypeB, displaced fractures: 1, extra-articular; 2, intra-articular. (Redrawn withpermission from Robinson CM: Fractures of the clavicle in the adult:Epidemiology and classification. J Bone Joint Surg Br 1998;80[3]:476-484.)

Figure 2

Management of Distal Clavicle Fractures


adduction and disproportionate re-ports of pain could be indicative ofsuprascapular nerve injury. Carefulexamination of the remainder of theupper extremity, as well as the cervi-cal spine and the thorax, is essential.

Radiographic Evaluation

Radiographic evaluation should in-clude true AP and axillary lateralviews of the shoulder. A Zanca viewof the AC joint, which is obtained in10° to 15° cephalic tilt, is also help-ful in evaluating for intra-articularinvolvement.18 A radiograph show-ing the bilateral clavicles and includ-ing the AC joint is useful in assessingfracture displacement. These radio-graphs can provide an overall assess-ment of fracture pattern, location,and displacement.

Management

Distal clavicle fractures may be man-aged nonsurgically or surgically.Most nondisplaced distal claviclefractures are managed nonsurgically.For example, Neer type I and III dis-

tal clavicle fractures are typicallynondisplaced and heal without diffi-culty with nonsurgical management.In contrast, type II fractures are of-ten displaced and may have a higherrate of nonunion.4 Reported ratesof nonunion following nonsurgicalmanagement of type II distal clavi-cle fractures range from 28% to44%1,4,5,7,11,19-21 (Table 1). Most stud-ies define distal clavicle fracture non-union based on Neer’s original series.Neer defined delayed nonunion as“lack of bone bridging for more than12 months after injury.”4 This defini-tion has been used in subsequentstudies on distal clavicle fracture.

Deafenbaugh et al21 reported 3nonunions in a series of 10 Neer typeII distal clavicle fractures. Nordqvistet al20 reported a 28% nonunion rate(5 of 18). In their review of 43 typeII distal clavicle fractures, Edwardset al22 noted that up to 75% of pa-tients treated nonsurgically devel-oped a delayed union or nonunion.Of the 20 patients treated nonsurgi-cally, 6 (30%) developed nonunion(ie, lack of bony bridging after 12months). The authors of these three

series used the Neer definition ofnonunion. Rokito et al7 reportednonunion in 7 of 16 patients treatednonsurgically for type II distal clavi-cle fractures.

Risk factors for nonunion includedisplacement, that is, no residual cor-tical contact between the bone ends,and advancing patient age.19 Robin-son et al19 noted that both of thesefactors are independently predictiveof nonunion.

Because some patients remainasymptomatic, the clinical impor-tance of distal clavicle nonunion hasbeen questioned. In the study byDeafenbaugh et al,21 none of thethree reported distal clavicle non-unions was symptomatic. Otherstudies involving clinical assessmentof patients with distal clavicular non-unions have indicated that 20% to34% were symptomatic and eventu-ally required surgical fixation.1,20

Closer evaluation of studies thatincluded outcomes scores in theiranalyses further clarifies the impactof distal clavicle nonunion. In thesmall series by Rokito et al,7 7 of the16 patients treated nonsurgically de-

A, Clinical photograph of a displaced left distal clavicle fracture in a 21-year-old woman who fell onto her left shoulder.B, Preoperative AP radiograph demonstrating fracture displacement with no residual cortical contact between the boneends. The patient was treated with a distal radius 2.4-mm locking plate and simultaneous coracoclavicular stabilizationusing suture. C, AP radiograph obtained 3 months postoperatively demonstrating fracture healing.

Figure 3


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veloped nonunion, but there was nodifference in mean Constant orAmerican Shoulder and Elbow Sur-geons (ASES) scores between thosetreated nonsurgically and thosetreated surgically. In the case seriesby Robinson and Cairns,1 there wasno significant difference in the Con-stant score or the Medical OutcomesStudy 36-Item Short Form score be-tween any of the three groups stud-ied: patients treated nonsurgically,patients who developed a nonunion,and patients who underwent delayedsurgical treatment after the develop-ment of a nonunion.

Based on these data, several con-clusions may be reached regardingnonunion after distal clavicle frac-ture: (1) The reported rate of radio-graphic nonunion of all types of dis-

tal clavicle fractures reflects that ofNeer’s original series. (2) Fracturedisplacement, as seen in most Neertype II fractures, is associated withthe development of nonunion. (3)Radiographic nonunion does not al-ways correlate with symptomaticnonunion. (4) Patients who developsymptomatic nonunion may or maynot require additional surgery.

Surgical management of distalclavicle fractures is indicated foropen fractures, skin compromise,and associated vascular injury re-quiring surgery. Because of the highrate of nonunion, Neer4 andothers2,3,6,23-45 have advocated pri-mary surgical management of distalclavicle fracture. However, becauseradiographic nonunion does not cor-relate with symptomatic nonunion,

management of closed displaced typeII distal clavicle fracture must be ap-proached on a case-by-case basis.

NonsurgicalMost distal clavicle fractures aremanaged nonsurgically. Sling immo-bilization for 2 weeks is institutedfor comfort, and shoulder motion isinitiated as soon as the initial painimproves. Repeat radiographs areobtained at 6-week follow-up tomonitor for fracture displacementand evidence of healing. These pa-tients typically recover fully withoutsequelae. Type I and type III frac-tures are at risk of delayed-onsetsymptomatic AC arthrosis,5 whichcan be managed with distal clavicleresection, if necessary. Nondisplaced

Table 1

Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures

Study Level of Evidence Total No. of PtsNo. of Pts With Neer

Type II FractureNo. of Pts Followed

to End of Study

Neer4 IV (case series) 23 23 23

Deafenbaugh et al21 II (prospective study) 10 10 10Edwards et al22 IV (case series) 43 43 43c

Nordqvist et al20 IV (case series) 110 23 18d

Rokito et al7 IV (case series) 30 30 30

Robinson and Cairns1 IV (case series) 101 90 86e

Robinson et al19 I (prospective study) 263 99 84g

N/A = not applicable, NR = not reported, ORIF = open reduction and internal fixation, Pts = patientsa In the nonsurgical group, no fracture was “united by callus prior to 16 weeks after injury.”b In the surgical group, “[h]eavy labor was resumed at the third month.”c Only 38 patients were reviewed clinically and radiographically. The authors state, “[T]he remaining 5 had adequate case notes andradiographs.”d Only 18 of the 23 patients with Neer type II distal clavicle fractures were evaluated radiographically at final follow-up.e 86 of the original 101 patients were available for follow-up, but the authors do not specify how many of these were Neer type II claviclefractures.f This rate is based on all 86 lateral or distal clavicle fractures; the authors do not specify Neer classification.g 84 lateral end clavicle fractures were followed for 24 weeks. Although 42 fractures were displaced, the number of Neer type II fractures wasnot reported.h The authors report a 25.4% nonunion rate for displaced lateral end clavicle fractures but an overall nonunion rate of 11.5% (ie, displacedand nondisplaced).



type II fractures may also be man-aged nonsurgically. However, thelikelihood of subsequent displace-ment and possible nonunion shouldbe recognized, discussed with the pa-tient, and monitored with repeat ra-diographs at 6 weeks.

SurgicalA variety of methods of surgicalmanagement of distal clavicle frac-tures has been proposed, includingtransacromial wire fixation, a modi-fied Weaver-Dunn procedure, useof a tension band, CC screw fixa-tion, plate fixation, and arthro-scopic treatment. Neer4 recom-mended transacromial wire fixationof distal clavicle fractures. This com-monly used technique has been asso-ciated with a high rate of complica-

tions, including nonunion, ACarthrosis, and Kirschner wire (K-wire) migration. Although Eskolaet al46 reported good or satisfactoryoutcomes in 22 of 23 patients, 26%experienced a complication or non-union following transacromial wir-ing. Late migration of the wires intothe cervical spine, trachea, vascularstructures, lung, and abdomen hasbeen reported.47-49 Modificationshave led to a reduction in unsatisfac-tory results and complications asso-ciated with transacromial wire fixa-tion. Good results have beenreported with the use of a transacro-mial Knowles pin rather thanK-wires.23,24 Transacromial fixationsupplemented with CC ligamentrepair or reconstruction has alsobeen shown to improve results and

decrease complications.24-26

CC ligament repair or reconstruc-tion without supplemental fixationhas been reported.6,27 Webber andHaines6 described CC ligament re-construction using a Dacron graft in11 patients. All fractures united byan average of 43.5 days postopera-tively. At a mean follow-up of 4.6years, the average Constant scorewas 98.9.

The modified Weaver-Dunn proce-dure is primarily used for AC dislo-cation, but it also has been advo-cated for the management of distalclavicle fractures.50 This procedure isusually reserved for cases in whichthe distal clavicle fragment can beeasily excised and the coracoacro-mial ligament can be transferredto the distal end of the proximal

Table 1 (continued)

Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures

Management Average Follow-up OutcomeNo. of Symptomatic

Nonunions

12 nonsurgical 4 moa 8 delayed union (67%),4 nonunion (33%)

4

4 excision NR N/A NR7 ORIF 3 mob All united 0Nonsurgical 14.3 mo 3 nonunion (30%) 020 nonsurgical 3 y 9 delayed union (45%),

6 nonunion (30%)6

23 surgical 21 mo All united 0Nonsurgical 15 y 5/18 nonunion (28%) 216 nonsurgical 53.5 mo 7 nonunion (44%) 214 ORIF 59.8 mo All united 072 nonsurgical, 3 excision,

11 delayed surgery6.2 y 32/86 nonunion (37%)f 11

Nonsurgical 24 wk 25.4% nonunionh NR

N/A = not applicable, NR = not reported, ORIF = open reduction and internal fixation, Pts = patientsa In the nonsurgical group, no fracture was “united by callus prior to 16 weeks after injury.”b In the surgical group, “[h]eavy labor was resumed at the third month.”c Only 38 patients were reviewed clinically and radiographically. The authors state, “[T]he remaining 5 had adequate case notes andradiographs.”d Only 18 of the 23 patients with Neer type II distal clavicle fractures were evaluated radiographically at final follow-up.e 86 of the original 101 patients were available for follow-up, but the authors do not specify how many of these were Neer type II claviclefractures.f This rate is based on all 86 lateral or distal clavicle fractures; the authors do not specify Neer classification.g 84 lateral end clavicle fractures were followed for 24 weeks. Although 42 fractures were displaced, the number of Neer type II fractures wasnot reported.h The authors report a 25.4% nonunion rate for displaced lateral end clavicle fractures but an overall nonunion rate of 11.5% (ie, displacedand nondisplaced).


July 2011, Vol 19, No 7 397

clavicle fragment.K-wire fixation with a supplemen-

tary tension band wire has also beensuggested for fixation of type II dis-tal clavicle fractures.51 In thismethod, K-wires are placed on thesuperior aspect of the clavicle, avoid-ing the AC joint. The tension band isplaced around the wires. In one se-ries, 11 of 12 patients achieved pain-less union with this approach.52 Oth-ers have reported similar successrates with modified tension bandtechniques using suture.28-30 Symp-tomatic hardware is a potential com-plication, particularly when tensionband wiring is used.31

In CC screw fixation, open reduc-tion and internal fixation of the dis-tal clavicle fragment is performed bytemporarily fixing the distal clavicle

to the coracoid process. Successfulhealing of the distal clavicle has beenreported in several small caseseries.22,32-34 This technique has alsobeen performed using a cannulatedscrew.35 More recently, Fazal et al36

reported a 100% union rate usingthis technique in 30 patients. A sec-ond procedure is required to removethe screw following union.

Small and mini-fragment lockingplates may be used to stabilize distalclavicle fractures (Figures 3 and 4).These plates allow fixation of thedistal clavicle fragment withoutcrossing the AC joint. Kalamaraset al37 used a distal radius lockingplate on nine patients with distalclavicle fracture. The 2.4-mm lock-ing screws in the distal portion of theplate were used to capture the distal

clavicle fragment. All eight patientswho were available for follow-upachieved bony union. The meanConstant score was 96.

If the distal fragment is too smallto hold screws, a plate that hooksunder the acromion may be used(Figure 5). Kashii et al38 reported on34 patients with distal clavicle frac-tures treated with an AC hook plate.Although all patients achieved bonyunion, the hook caused acromialfracture in one patient and rotatorcuff tear in another. Good unionrates with the hook plate were re-ported in two other studies, butasymptomatic osteolysis of the acro-mion and migration of the hook intothe acromion were frequently en-countered.39,40 With the hook plate, asecond procedure is required for

A, AP radiograph of the right shoulder in a 56-year-old woman who sustained a closed distal clavicle fracture after afall. B, The patient was initially treated nonsurgically and developed painful nonunion. She then underwent fixation witha 2.7-mm plate, which allowed placement of three screws into the distal fragment. The fixation was augmented withcoracoclavicular stabilization using Mersilene tape. AP radiograph (C) and postoperative photographs (D through G)obtained 3 months postoperatively demonstrating healing and return to preinjury level of function.

Figure 4



plate removal, which may cause ad-ditional morbidity.

Plate fixation may be supple-mented with CC screw fixationthrough the plate or with CC liga-ment repair or reconstruction. Sup-plemental CC fixation may also beachieved with sutures or suture an-chors. Recently, Herrmann et al3 de-scribed the use of a locking T-plate inaddition to suture anchors placedinto the coracoid in eight patients.The sutures were placed around theclavicle and over the plate. Bonyunion was achieved in 6 weeks in theseven patients who were availablefor follow-up; the mean Constantscore was 93.3.

Arthroscopic techniques for themanagement of distal clavicle frac-tures have also been reported. Thesetechniques employ some of the samestrategies used in arthroscopically as-sisted CC ligament reconstructionfollowing AC joint separation. Pub-lished reports are limited to smallcase series and technical notes, andall involve arthroscopic CC stabiliza-tion using suture, a double-buttondevice, or the Tightrope system (Ar-threx, Naples, FL).41-44

Only two studies to date have di-rectly compared two methods of sur-gical management. Flinkkilä et al45

retrospectively compared K-wire fix-ation with the use of a clavicularhook plate (22 and 17 patients, re-spectively). Although both methodsrestored shoulder function, K-wirefixation was associated with wire mi-gration in 12 patients, loss of reduc-tion in 7, infection in 3, and non-union in 2. In the group treated withclavicle hook plates, one patient sus-tained a clavicle fracture, and twofractures went on to nonunion. Morerecently, Lee et al31 retrospectively re-viewed patients treated with eitherclavicular hook plates or tension-band wiring (32 and 20 patients, re-spectively). Hook plating was associ-ated with a lower complication rateand a lower rate of symptomatichardware. In addition, it better facili-tated return to work and athletic ac-tivity.

Authors’ PreferredManagement

We recommend primary nonsurgicalmanagement of type I, type III, andnondisplaced type II distal claviclefractures. Patients are treated withsling immobilization for 2 weeks.During this period, supine passiveROM and active-assisted ROM are

initiated. When pain has improvedand there are early signs of fractureconsolidation, active ROM is al-lowed.

For the patient with displaced typeII distal clavicle fracture or displacedtype IV or V fracture, treatment se-lection is based on the degree of dis-placement and a discussion with thepatient. Robinson et al19 defined dis-placement (ie, no residual corticalcontact between the bone ends) as arisk factor for nonunion. For pa-tients with displacement, we offersurgical treatment but counsel themthat the current evidence suggestsequivalent outcomes between surgi-cal and nonsurgical treatment.

Our preferred surgical manage-ment technique is internal fixation ofthe distal clavicle fracture with sup-plementary CC fixation (Figures 3and 4). If the distal clavicle fragmentis large enough to hold screws, weuse a small, low-profile locking plateand perform open anatomic fracturereduction. The coracoid process isidentified to allow for suture pas-sage. The fixation is supple-mented by CC stabilization, which isachieved with sutures placed aroundthe coracoid process and eitheraround or through a small hole inthe clavicle, proximal to the fracture.

For cases in which the size or qual-ity of the distal fracture fragment isinsufficient for plate application, werecommend CC stabilization usingnonabsorbable suture such as Ethi-bond (Ethicon, Somerville, NJ), Fi-berWire (Arthrex, Naples, FL), orMersilene (Ethicon). This approachrequires exposure of the coracoidprocess. Two strands of suture arepassed around the coracoid process.The ends of the suture are thenpassed through a small drill hole inthe proximal clavicle fragment. Thedistal clavicle is reduced, and thefirst suture is tied. Once reduction isconfirmed visually and radiographi-cally, the second suture is tied. The

A, AP radiograph of the right shoulder in a 60-year-old man who sustained adisplaced distal clavicle fracture in a fall. He was treated with open reductionand internal fixation using a distal clavicle hook plate. B, AP radiographobtained 5 months postoperatively demonstrating fracture healing. The platewas removed 9 months postoperatively.

Figure 5


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fixation is supplemented by a dorsalsuture tension band placed throughthe incision, as described by Levy.30

Surgeons who are trained in shoulderarthroscopy may perform the proce-dure arthroscopically.

Postoperatively, the patient isplaced in a sling for 6 weeks. Supinepassive and active-assisted ROM ex-ercises are begun immediately. ActiveROM is started at 6 weeks, withprogression to strengthening exer-cises 6 to 12 weeks postoperatively.Patients are typically restricted fromengaging in heavy labor and sportsfor 12 weeks.

Summary

Most distal clavicle fractures may bemanaged nonsurgically. Type II distalclavicle fractures are associated withradiographic nonunion in up to 44%of cases. Fracture displacement is as-sociated with a higher risk of non-union. However, the clinical rele-vance of this nonunion may beminimal, and initial nonsurgicalmanagement may be warranted. Al-though surgical management of distalclavicle fractures has been described,current evidence suggests equivalentoutcomes between surgical and nonsur-gical management. Additionally, nosingle surgical technique has beenshown to be superior to the others. Aprospective randomized study compar-ing surgical and nonsurgical manage-ment of type II distal clavicle fracturesis necessary to better determine the op-timal treatment.

References

Evidence-based Medicine: Levels ofevidence are listed in the table ofcontents. In this article, reference 19 isa level I study. Reference 21 is a level IIstudy. References 31 and 45 are levelIII studies. References 1-7, 13, 14,

16, 20, 22-30, 32-40, 43, 44, and 52are level IV studies. Reference 10 islevel V expert opinion.

References printed in bold type indi-cate those published within the past5 years.

1. Robinson CM, Cairns DA: Primarynonoperative treatment of displacedlateral fractures of the clavicle. J BoneJoint Surg Am 2004;86(4):778-782.

2. Hessmann M, Kirchner R, BaumgaertelF, Gehling H, Gotzen L: Treatment ofunstable distal clavicular fractures withand without lesions of the acromio-clavicular joint. Injury 1996;27(1):47-52.

3. Herrmann S, Schmidmaier G, Greiner S:Stabilisation of vertical unstable distalclavicular fractures (Neer 2b) usinglocking T-plates and suture anchors.Injury 2009;40(3):236-239.

4. Neer CS II: Fracture of the distal claviclewith detachment of the coracoclavicularligaments in adults. J Trauma 1963;3:99-110.

5. Neer CS II: Fractures of the distal thirdof the clavicle. Clin Orthop Relat Res1968;58:43-50.

6. Webber MC, Haines JF: The treatmentof lateral clavicle fractures. Injury 2000;31(3):175-179.

7. Rokito AS, Zuckerman JD, Shaari JM,Eisenberg DP, Cuomo F, Gallagher MA:A comparison of nonoperative andoperative treatment of type II distalclavicle fractures. Bull Hosp Jt Dis 2002-2003;61(1-2):32-39.

8. Fukuda K, Craig EV, An KN, CofieldRH, Chao EY: Biomechanical study ofthe ligamentous system of theacromioclavicular joint. J Bone JointSurg Am 1986;68(3):434-440.

9. Renfree KJ, Riley MK, Wheeler D, HentzJG, Wright TW: Ligamentous anatomyof the distal clavicle. J Shoulder ElbowSurg 2003;12(4):355-359.

10. Bearden JM, Hughston JC, Whatley GS:Acromioclavicular dislocation: Methodof treatment. J Sports Med 1973;1(4):5-17.

11. Neer C II: Fractures and dislocations ofthe shoulder, in Rockwood CA Jr, GreenDP, eds: Fractures in Adults. Philadel-phia, PA, J.B. Lippincott, 1984, pp 711-712.

12. Craig EV: Fractures of the clavicle, inRockwood CA Jr, Green DP, BucholzRW, Heckman JD, eds: Rockwood andGreen’s Fractures in Adults, ed 4.Philadelphia, PA, Lippincott-Raven,1996, pp 1109-1193.

13. Katznelson A, Nerubay J, Oliver S:Dynamic fixation of the avulsed clavicle.J Trauma 1976;16(10):841-844.

14. Ogden JA: Distal clavicular physealinjury. Clin Orthop Relat Res 1984;(188):68-73.

15. Robinson CM: Fractures of the claviclein the adult: Epidemiology andclassification. J Bone Joint Surg Br 1998;80(3):476-484.

16. Stanley D, Trowbridge EA, Norris SH:The mechanism of clavicular fracture: Aclinical and biomechanical analysis.J Bone Joint Surg Br 1988;70(3):461-464.

17. Huang KC, Tu YK, Huang TJ, Hsu RW:Suprascapular neuropathy complicatinga Neer type I distal clavicular fracture: Acase report. J Orthop Trauma 2005;19(5):343-345.

18. Zanca P: Shoulder pain: Involvement ofthe acromioclavicular joint: Analysis of1,000 cases. Am J Roentgenol RadiumTher Nucl Med 1971;112(3):493-506.

19. Robinson CM, Court-Brown CM,McQueen MM, Wakefield AE:Estimating the risk of nonunionfollowing nonoperative treatment of aclavicular fracture. J Bone Joint Surg Am2004;86(7):1359-1365.

20. Nordqvist A, Petersson C, Redlund-Johnell I: The natural course of lateralclavicle fracture: 15 (11-21) yearfollow-up of 110 cases. Acta OrthopScand 1993;64(1):87-91.

21. Deafenbaugh MK, Dugdale TW, StaeheliJW, Nielsen R: Nonoperative treatmentof Neer type II distal clavicle fractures: Aprospective study. Contemp Orthop1990;20(4):405-413.

22. Edwards DJ, Kavanagh TG, FlanneryMC: Fractures of the distal clavicle: Acase for fixation. Injury 1992;23(1):44-46.

23. Fann CY, Chiu FY, Chuang TY, ChenCM, Chen TH: Transacromial Knowlespin in the treatment of Neer type 2 distalclavicle fractures: A prospectiveevaluation of 32 cases. J Trauma 2004;56(5):1102-1105.

24. Wang SJ, Wong CS: Extra-articularknowles pin fixation for unstable distalclavicle fractures. J Trauma 2008;64(6):1522-1527.

25. Bezer M, Aydin N, Guven O: Thetreatment of distal clavicle fractures withcoracoclavicular ligament disruption: Areport of 10 cases. J Orthop Trauma2005;19(8):524-528.

26. Chen CH, Chen WJ, Shih CH: Surgicaltreatment for distal clavicle fracture withcoracoclavicular ligament disruption.J Trauma 2002;52(1):72-78.



27. Goldberg JA, Bruce WJ, Sonnabend DH,Walsh WR: Type 2 fractures of the distalclavicle: A new surgical technique.J Shoulder Elbow Surg 1997;6(4):380-382.

28. Mall JW, Jacobi CA, Philipp AW, PeterFJ: Surgical treatment of fractures of thedistal clavicle with polydioxanone suturetension band wiring: An alternativeosteosynthesis. J Orthop Sci 2002;7(5):535-537.

29. Badhe SP, Lawrence TM, Clark DI:Tension band suturing for the treatmentof displaced type 2 lateral end claviclefractures. Arch Orthop Trauma Surg2007;127(1):25-28.

30. Levy O: Simple, minimally invasivesurgical technique for treatment of type2 fractures of the distal clavicle.J Shoulder Elbow Surg 2003;12(1):24-28.

31. Lee YS, Lau MJ, Tseng YC, Chen WC,Kao HY, Wei JD: Comparison of theefficacy of hook plate versus tensionband wire in the treatment of unstablefractures of the distal clavicle. IntOrthop 2009;33(5):1401-1405.

32. Ballmer FT, Gerber C: Coracoclavicularscrew fixation for unstable fractures ofthe distal clavicle: A report of five cases.J Bone Joint Surg Br 1991;73(2):291-294.

33. Yamaguchi H, Arakawa H, KobayashiM: Results of the Bosworth method forunstable fractures of the distal clavicle.Int Orthop 1998;22(6):366-368.

34. Macheras G, Kateros KT, Savvidou OD,Sofianos J, Fawzy EA, PapagelopoulosPJ: Coracoclavicular screw fixation forunstable distal clavicle fractures.Orthopedics 2005;28(7):693-696.

35. Jin CZ, Kim HK, Min BH: Surgicaltreatment for distal clavicle fractureassociated with coracoclavicularligament rupture using a cannulated

screw fixation technique. J Trauma2006;60(6):1358-1361.

36. Fazal MA, Saksena J, Haddad FS:Temporary coracoclavicular screwfixation for displaced distal claviclefractures. J Orthop Surg (Hong Kong)2007;15(1):9-11.

37. Kalamaras M, Cutbush K, Robinson M:A method for internal fixation ofunstable distal clavicle fractures: Earlyobservations using a new technique.J Shoulder Elbow Surg 2008;17(1):60-62.

38. Kashii M, Inui H, Yamamoto K: Surgicaltreatment of distal clavicle fracturesusing the clavicular hook plate. ClinOrthop Relat Res 2006;447:158-164.

39. Tambe AD, Motkur P, Qamar A, DrewS, Turner SM: Fractures of the distalthird of the clavicle treated by hookplating. Int Orthop 2006;30(1):7-10.

40. Muramatsu K, Shigetomi M, MatsunagaT, Murata Y, Taguchi T: Use of the AOhook-plate for treatment of unstablefractures of the distal clavicle. ArchOrthop Trauma Surg 2007;127(3):191-194.

41. Nourissat G, Kakuda C, Dumontier C,Sautet A, Doursounian L: Arthroscopicstabilization of Neer type 2 fracture ofthe distal part of the clavicle.Arthroscopy 2007;23(6):674.e1-4.

42. Baumgarten KM: Arthroscopic fixationof a type II-variant, unstable distalclavicle fracture. Orthopedics 2008;31(12):pii:orthosupersite.com/view.asp?rID=32937.

43. Checchia SL, Doneux PS, Miyazaki AN,Fregoneze M, Silva LA: Treatment ofdistal clavicle fractures using anarthroscopic technique. J ShoulderElbow Surg 2008;17(3):395-398.

44. Pujol N, Philippeau JM, Richou J,Lespagnol F, Graveleau N, Hardy P:

Arthroscopic treatment of distal claviclefractures: A technical note. Knee SurgSports Traumatol Arthrosc 2008;16(9):884-886.

45. Flinkkilä T, Ristiniemi J, Hyvönen P,Hämäläinen M: Surgical treatment ofunstable fractures of the distal clavicle: Acomparative study of Kirschner wire andclavicular hook plate fixation. ActaOrthop Scand 2002;73(1):50-53.

46. Eskola A, Vainionpää S, Pätiälä H,Rokkanen P: Outcome of operativetreatment in fresh lateral clavicularfracture. Ann Chir Gynaecol 1987;76(3):167-169.

47. Regel JP, Pospiech J, Aalders TA,Ruchholtz S: Intraspinal migration of aKirschner wire 3 months after clavicularfracture fixation. Neurosurg Rev 2002;25(1-2):110-112.

48. Tsai CH, Hsu HC, Huan CY, Chen HT,Fong YC: Late migration of threadedwire (schanz screw) from right distalclavicle to the cervical spine. J Chin MedAssoc 2009;72(1):48-51.

49. Lyons FA, Rockwood CA Jr: Migrationof pins used in operations on theshoulder. J Bone Joint Surg Am 1990;72(8):1262-1267.

50. Anderson K: Evaluation and treatmentof distal clavicle fractures. Clin SportsMed 2003;22(2):319-326, vii.

51. Heim U, Pfeiffer KM: Internal Fixationof Small Fractures: TechniqueRecommended by the AO-ASIF Group,ed 3. New York, NY, Springer-Verlag,1987.

52. Kao FC, Chao EK, Chen CH, Yu SW,Chen CY, Yen CY: Treatment of distalclavicle fracture using Kirschner wiresand tension-band wires. J Trauma 2001;51(3):522-525.


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review article management of distal clavicle...

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