Introduction

Clavicle fractures represent 44% of shoulder girdle in-juries and 5% of all skeletal injuries [8]. The distal thirdof the clavicle is involved in approximately 10%–15% ofall clavicular fractures [2, 7, 8, 11]. The mechanisms ofclavicular fracture are a direct blow on the shoulder (94%)and a fall on the outstretched hand (6%), with no correlationbetween site of fracture and mechanism of injury [16].

Neer [11] classified these lateral fractures into two ma-jor categories depending upon the continuity of the cora-coclavicular ligaments. Type I is a stable fracture in whichthe coracoclavicular ligaments are intact; type II is an un-stable fracture with loss of ligamentous connection be-tween the coracoid and the proximal fragment.

The incidence of delayed union and non-union is highin type II fractures of the distal third because of the insta-bility associated with tearing of the coracoclavicular liga-ments [1, 7, 10–13]. Edwards [3] reports a rate of 45% de-layed union and 30% non-union.

Unlike fractures in which the coracoclavicular liga-ments are intact, distal-third fractures with concomitantcoracoclavicular ligamentous disruption often requireopen reduction and internal fixation [10]. Various tech-niques have been described but no single method has be-come generally accepted.

Case report

A 21-year-old male was injured by a direct blow while playinghockey. Clinically he complained of pain in his left shoulder andswelling was evident.

Radiographic examination showed a lateral-third fracture of theleft clavicle without injury to the acromioclavicular joint. The frac-ture line was oblique and ran top to bottom from lateral to medial,with the proximal fragment displaced towards the acromioclavic-ular joint and grossly separated from the lateral fragment (Fig.1).The coracoclavicular ligaments appeared to be intact since the dis-tance between the coracoid process and the clavicular site of at-tachment had not increased.

Abstract Clavicle fractures repre-sent 5% of all skeletal injuries, andthe distal third of the clavicle is in-volved in approximately 10%–15%of all these fractures. The incidenceof delayed union or non-union inNeer type II fractures of the distalthird of the clavicle is high. Theideal treatment for Neer type II frac-tures of the distal third of the clavi-cle is still open to controversy. Sev-eral treatments have been proposed,but there is no consensus about thetreatment of choice. The case re-ported here presents a unique type offracture of the lateral end of the clav-icle that, since a medial fragment is

involved, is a Neer type II fracture,but because of the nature of the frac-ture line the coracoclavicular liga-ments remained intact. Trans-bonysuture between the two fracture frag-ments was perfomed as the onlytreatment. This treatment has notbeen previously described and, al-though it has just been used in a sin-gle case, it appears to be an effec-tive, efficient and simple alternativefor the treatment of Neer type IIfractures of the distal third of theclavicle.

Key words Clavicle · Fracture · Trans-bony suture

SHOULDERKnee Surg, Sports Traumatol, Arthrosc(1999) 7 :132–134

© Springer-Verlag 1999

J. M. LópezC. TorrensV. LeónM. Marín

Unusual fracture of distal third of the clavicle in a hockey player: case report and a new approach to treatment

Received: 9 November 1997Accepted: 1 March 1998

J. M. López (Y)1 · C. Torrens · V. León ·M. MarínDepartment of Orthopaedics and Traumatology, Hospital de l’Esperança, C/ St. Josep de la Muntanya 12, E-08024 Barcelona, Spain

Mailing address:1 C/ Antoni de Capmany 55, Baixos 2a,E-08028 Barcelona, SpainTel.: +34-43 12 734Fax: +34-3-4179968

Surgical treatment was decided upon. The operation revealedthe interposition of trapezius muscle and absence of damage to thecoracoclavicular and acromioclavicular ligaments.

The fracture was reduced and held with a trans-bony suture be-tween the two fragments with a non absorbable suture (Perlon no. 4)

passed through holes made with a 3.2-mm drill (Fig. 2). Delto-trapezius fascia was imbricated over the fracture.

The arm was immobilised in a fixed sling for 4 weeks, afterwhich passive exercises were allowed.

After 6 weeks of surgical treatment the fracture appeared to beconsolidated in X-ray images. The patient had full range of mo-tion and returned to his pre-injury level of sporting activity in 10weeks.

After 12 months the patient was followed up clinically and ra-diologically. He had no complaints, and consolidation of the frac-ture without excessive callus was verified on X-ray (Fig. 3).

Discussion

Most authors agree that Neer type II fractures of outerthird of the clavicle often require surgical treatment be-cause of the high rate of non-union or delayed union [1, 3,7, 10–13]. The methods previously proposed [2, 4, 5, 11–13] are not without potential or proven complications. Mi-gration and osteoarthritis of the acromioclavicular joint[13] have been described for pinning with K-wires andthis requires a second surgical intervention to remove thematerial.

A Mersilene suture brought around the base of thecoracoid process [12] with can produce fatigue/fracture ofthe coracoid process [9], while the same method using aDacron [5] suture there is the possibility of osteolysis atpoints of contact between the Dacron, the coracoid andthe clavicle, and, moreover, the dissection is more exten-sive than with other methods.

Internal fixation using plates [4] requires wide expo-sure and devascularisation of the clavicle and repeat sur-gery to remove the implant under general anaesthesia; it isalso associated with the possibility of refracture after im-plant removal.

Cerclage wire [13] is only possible in very obliquefractures and requires a second operation to remove thematerial under general anaesthesia. A coracoclavicularscrew [2] also requires a second surgical intervention toremove the implant.

In the case reported here, as the coracoclavicular liga-ments were undamaged and still attached to the distal frag-ment, the fracture was similar to the distal clavicular phy-seal injury seen in children when the central clavicularfragment comes out of the periosteal sleeve, like a bananafrom its skin, and the coracoclavicular ligaments remainundamaged and attached to the periosteal sleeve [6, 14, 15].

Considering the fracture as belonging to Neer type II,as far as the medial fragment is concerned, surgical treat-ment was decided upon to obtain reduction of the frag-ments and to prevent the possiblility of delayed union ornon-union of the fracture. Trans-bony suture with non-ab-sorbable suture between the two fragments of this Neertype II fracture of the distal third of the clavicle in addi-tion to deltotrapezius fascia imbrication proved to be asimple technique that does not require wide exposure ordissection, avoids a second surgical intervention, allows

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Fig. 1 Radiographic examination showing a lateral-third fractureof the left clavicle without injury to the acromioclavicular joint orcoracoclavicular ligaments

Fig. 2 Trans-bony suture between the two fragments of the fracture

Fig. 3 Radiographic examination performed 12 months after sur-gical treatment, showing consolidation without excessive callus

3

11

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early mobilisation and early return to sporting activities ina young patient and only requires initial immobilisation ina fixed sling to prevent suture failure.

Trans-bony suture as the only treatment for these frac-tures has not been previously reported but appears to be

an effective, efficient and simple alternative for the treat-ment of Neer type II fractures of the distal third of theclavicle.

1.Allman F (1967) Fractures and liga-mentous injuries of the clavicle and itsarticulation. J Bone Joint Surg [Am] 49:774–784

2.Ballmer FT (1991) Coracoclavicularscrew fixation for unstable fractures ofthe distal clavicle. J Bone Joint Surg[Br] 73:291–294

3.Edwards DJ (1992) Fractures of thedistal clavicle: a case for fixation. In-jury 23:44–46

4.Eskola A (1987) Outcome of operativetreatment in fresh lateral clavicularfracture. Ann Chir Gynaecol76:167–169

5.Goldberg JA (1997) Type 2 fracturesof the distal clavicle: a new surgicaltechnique. J Shoulder Elbow Surg6:380–382

6.Havráneck P (1989) Injuries of distalclavicular physis in children. J PediatrOrthop 9:213–215

7.Heppenstall RB (1975) Fractures anddislocations of the distal clavicle. Or-thop Clin North Am 6:477–485

8.Herscovici D (1995) Injuries of theshoulder girdle. Clin Orthop 318:54–60

9.Moneim MS, Balduini FC (1982)Coracoid fracture as a complication ofsurgical treatment by coracoclaviculartape fixation. Clin Orthop 168:133–135

10.Neer CS (1960) Nonunion of the clavi-cle. JAMA 172:96–101

11.Neer CS (1968) Fractures of the distalthird of the clavicle. Clin Orthop 58:43–50

12.Neer CS (1984) Fractures of the clavi-cle. In: Rockwood CA, Green DP (eds)Fractures in adults, vol 1, 2nd edn.Lippincott, Philadelphia

13.Neviaser RJ (1987) Injuries to the clav-icle and acromioclavicular joint. Or-thop Clin North Am 18:433–438

14.Ogden JA (1984) Distal clavicular phy-seal injury. Clin Orthop188:68–73

15.Rockwood CA (1984) Fractures anddislocations of the end of the clavicle,scapula and glenohumeral joint. In:Rockwood CA, Wilkins KE, King RE(eds) Fractures in children. Lippincott,Philadelphia, pp 624–647

16.Stanley D, Trowbridge EA, Norris SH(1988) The mechanism of clavicularfracture, a clinical and biomechanicalanalysis. J Bone Joint Surg [Br] 70:461–464

References