Review Article Management of Distal Clavicle of Distal Clavicle Fractures Abstract Most clavicle fractures heal without difficulty. However, radiographic nonunion after distal clavicle fracture has

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<ul><li><p>Management of Distal ClavicleFractures</p><p>Abstract</p><p>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.</p><p>Fractures of the distal clavicle ac-count for approximately 10% to30% 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.</p><p>Because of concern that nonsurgi-cal management may result in non-union, primary surgical managementhas been recommended for certaindistal clavicle fracture patterns.2-6</p><p>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</p><p>not only which distal clavicle frac-tures require surgical fixation butalso which fixation method is best.</p><p>Anatomy andBiomechanics</p><p>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.</p><p>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</p><p>Rahul Banerjee, MD</p><p>Brian Waterman, MD</p><p>Jeff Padalecki, MD</p><p>William Robertson, MD</p><p>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).</p><p>Dr. Banerjee or an immediate familymember has received research orinstitutional support from Synthes,Smith &amp; 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.</p><p>J Am Acad Orthop Surg 2011;19:392-401</p><p>Copyright 2011 by the AmericanAcademy of Orthopaedic Surgeons.</p><p>Review Article</p><p>392 Journal of the American Academy of Orthopaedic Surgeons</p></li><li><p>medial to the AC joint.9</p><p>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</p><p>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.</p><p>Classification</p><p>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</p><p>these soft-tissue attachments.Type III fractures are similar to</p><p>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.</p><p>Type II fractures are less stablethan type I and III fractures, andthey present a treatment challenge.In all type II fractures, the proximal</p><p>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.</p><p>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-</p><p>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.</p><p>Figure 1</p><p>Rahul Banerjee, MD, et al</p><p>July 2011, Vol 19, No 7 393</p></li><li><p>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.</p><p>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-</p><p>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.</p><p>Robinson15 proposed an alternativeclassification for all clavicle fracturesbased on fracture location, displace-ment, and intra-articular involve-ment (Figure 2). Distal clavicle frac-</p><p>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).</p><p>Clinical Evaluation</p><p>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.</p><p>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</p><p>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.)</p><p>Figure 2</p><p>Management of Distal Clavicle Fractures</p><p>394 Journal of the American Academy of Orthopaedic Surgeons</p></li><li><p>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.</p><p>Radiographic Evaluation</p><p>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.</p><p>Management</p><p>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-</p><p>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 Neers original series.Neer defined delayed nonunion aslack of bone bridging for more than12 months after injury.4 This defini-tion has been used in subsequentstudies on distal clavicle fracture.</p><p>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</p><p>series used the Neer definition ofnonunion. Rokito et al7 reportednonunion in 7 of 16 patients treatednonsurgically for type II distal clavi-cle fractures.</p><p>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.</p><p>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</p><p>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-</p><p>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.</p><p>Figure 3</p><p>Rahul Banerjee, MD, et al</p><p>July 2011, Vol 19, No 7 395</p></li><li><p>veloped nonunion, but there was nodifference in mean Constant orAmerican Shoulder...</p></li></ul>