Management of Distal Clavicle Fractures

Review Article Management of Distal Clavicle Fractures

Abstract Rahul Banerjee, MD Most clavicle fractures heal without difficulty. However, radiographic Brian Waterman, MD nonunion after distal clavicle fracture has been reported in 10% to 44% of patients. Type II distal clavicle fractures, which involve Jeff Padalecki, MD displacement, are associated with the highest incidence of William Robertson, MD nonunion. Several studies have questioned the clinical relevance of distal clavicle nonunion, however. Nonsurgical and surgical management provide similar results. The decision whether to operate may be influenced by the amount of fracture displacement and the individual demands of the patient. Surgical options to achieve bony union include transacromial wire fixation, a modified Weaver-Dunn procedure, use of a tension band, screw fixation, plating, and arthroscopy. Each technique has advantages and disadvantages; insufficient evidence exists to demonstrate that any one technique consistently provides the best results.

From the Department of ractures of the distal clavicle ac- not only which distal clavicle frac- Orthopaedic Surgery, University of Texas Southwestern Medical Center, Fcount for approximately 10% to tures require surgical fixation but Dallas, TX (Dr. Banerjee, 30% of all clavicle fractures.1 Man- also which fixation method is best. Dr. Padalecki, and Dr. Robertson), agement of distal clavicle fractures is and the Department of Orthopaedic often challenging because of the dif- Surgery and Rehabilitation, Texas Anatomy and Tech University Health Sciences ficulty in distinguishing subtle varia- Center, El Paso, TX (Dr. Waterman). tions in the fracture pattern that may Biomechanics Dr. Banerjee or an immediate family indicate fracture instability. Stable The clavicle serves as a strut connect- member has received research or fracture patterns generally heal un- ing the upper extremity to the appen- institutional support from Synthes, eventfully with nonsurgical manage- Smith & Nephew, Medtronic, and dicular skeleton. Fluid scapulotho- Stryker, and serves as a board ment, but unstable fracture patterns racic motion is dependent on a stable member, owner, officer, or are often associated with longer time relationship between the distal clavi- committee member of the American to union and notable nonunion rates. Academy of Orthopaedic Surgeons. cle and the scapula. This stability is Dr. Robertson serves as a paid Because of concern that nonsurgi- provided by the acromioclavicular consultant to ConMed Linvatec. cal management may result in non- (AC) joint capsule, AC ligaments, Neither of the following authors nor union, primary surgical management and coracoclavicular (CC) ligaments. any immediate family member has has been recommended for certain received anything of value from or The AC ligaments span the AC 2-6 owns stock in a commercial distal clavicle fracture patterns. joint, attaching to both the medial company or institution related However, these nonunions are often aspect of the acromion and the distal directly or indirectly to the subject of asymptomatic, and their clinical rele- extent of the clavicle and reinforcing this article: Dr. Waterman and 1,7 Dr. Padalecki. vance has been questioned. The use the AC joint capsule. These liga- of nonsurgical management is bol- ments serve as an important stabi- J Am Acad Orthop Surg 2011;19: 392-401 stered by the various complications lizer to horizontal (AP) motion at the that have historically been reported AC joint.8 This capsuloligamentous Copyright 2011 by the American following surgical fixation. As a re- Academy of Orthopaedic Surgeons. complex attaches to the distal aspect sult, there is uncertainty regarding of the clavicle approximately 6 mm

392 Journal of the American Academy of Orthopaedic Surgeons Rahul Banerjee, MD, et al

9 medial to the AC joint. Figure 1 The CC ligaments (ie, trapezoid, conoid) originate at the base of the coracoid process of the scapula and insert on the undersurface of the distal clavicle. The trapezoid is the more lateral of the two ligaments and attaches to the distal clavicle approximately 2 cm from the AC joint.9 The conoid ligament, which is located more medially, attaches to the clavicle approximately 4 cm from the AC joint. These ligaments play a pivotal role in preventing superior displacement of the distal clavicle in relation to the acromion. The normal distance between the coracoid process and the undersurface of the clavicle (ie, CC interspace) is 1.1 to 1.3 cm.10 The clavicle also serves as an important origin and site of insertion for several muscles involved in motion of the shoulder and the cervical spine, including the sternocleidomas- Illustration of the Neer classiﬁcation of distal clavicle fractures. Type I fracture occurs distal to the coracoclavicular (CC) ligaments (ie, trapezoid, conoid) toid, anterior deltoid, and trapezius. and involves minimal fracture displacement. The acromioclavicular (AC) joint Depending on the fracture pattern, remains intact. Type IIA fracture occurs medial to the conoid ligament. Type these muscles can create deforming IIB fracture occurs between the CC ligaments and includes disruption of the forces. Neer4 described four deform- conoid ligament. The trapezoid ligament remains intact. Type III fracture occurs distal to the CC ligaments and extends into the AC joint. Type IV ing forces: weight of the arm; pull of fracture occurs in pediatric patients. The physis and epiphysis remain the pectoralis major, pectoralis mi- adjacent to the AC joint, but there is displacement at the junction of the nor, and latissimus dorsi muscles; metaphysis and physis. In type V fracture, a small inferior clavicular fragment scapular rotation; and pull of the tra- remains attached to the CC ligaments. pezius muscle on the proximal fragment. these soft-tissue attachments. fragment is detached from the CC Type III fractures are similar to ligaments. The distal fragment re- Classiﬁcation type I fractures in that they also oc- mains attached to the scapula via the cur distal to the CC ligaments. How- AC joint capsule. In type IIA frac- Neer5,11 and later, Craig,12 classified ever, type III fracture extends into ture, the fracture lies medial to the distal third clavicle fractures into the AC joint. Because the ligamen- conoid ligament. In type IIB fracture, three types based on the relationship tous structures remain intact, type III the fracture lies between the conoid of the fracture line to the CC liga- fractures are relatively stable and and trapezoid ligaments. The rela- ments and AC joint (Figure 1). Type typically are minimally displaced. tionship of the distal fragment to the I fractures occur lateral to the CC Persons with this injury may be at coracoid process may differ between ligaments but spare the AC joint. risk of posttraumatic AC joint ar- types IIA and IIB. The proximal fragment is stabilized thropathy because of the intra- In type IIA fractures, the distal to the coracoid process by the CC articular involvement. fragment remains connected to the ligaments and to the distal fragment Type II fractures are less stable coracoid process by the CC liga- by the deltotrapezial fascia. Type I than type I and III fractures, and ments, which are presumed to be in- fractures often are only minimally they present a treatment challenge. tact. With type IIB fractures, the CC displaced because of the presence of In all type II fractures, the proximal ligaments lie within the zone of in-

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Figure 2 tures were classified as type 3. These occur lateral to a vertical line drawn upward from the center of the coracoid process. Robinson grouped fractures into subgroups A and B based on displacement of the major fragments. Subtypes A and B were subdivided according to articular involvement. This classification was found to have substantial interob- server reliability (mean kappa value = 0.77) and excellent intraobserver reliability (average kappa value = 0.84).

Clinical Evaluation

Most distal clavicle fractures are the result of a fall onto the distal clavicle Illustration of the Robinson classiﬁcation of distal clavicle fractures (type 3). or a direct blow to it.1,16 Direct impact Type A, cortical alignment fractures: 1, extra-articular; 2, intra-articular. Type occurs at the acromion, usually with B, displaced fractures: 1, extra-articular; 2, intra-articular. (Redrawn with permission from Robinson CM: Fractures of the clavicle in the adult: the arm in an adducted position, and Epidemiology and classiﬁcation. J Bone Joint Surg Br 1998;80[3]:476-484.) force is transmitted through the AC joint to the CC ligaments and the distal clavicle. Patients with distal clavicle jury. In Neer type IIB fractures, the taphysis. Depending on the degree of fractures typically present with shoul- conoid ligament is torn, but the trap- displacement, these patients are der pain. Associated injuries should be ezoid is presumed to remain attached treated with closed or open reduc- ruled out, such as other injuries to the to the distal fragment.12 This classifi- tion.14 In type V fracture, only a shoulder girdle, rib fracture, ipsilateral cation was developed before wide- small inferior cortical fragment re- upper extremity injury, and injury to spread use of MRI, and we are un- mains attached to the CC ligaments. the thorax or cervical spine. These are aware of any study that has Type V fractures are functionally particularly likely to occur in conjunc- confirmed the integrity of the trape- similar to type II injuries in that nei- tion with high-energy mechanisms. zoid and conoid ligaments in type ther the proximal nor the distal frag- Physical examination findings in- IIA and IIB injuries. Although in type ment is connected to the coracoid clude swelling, ecchymosis, and ten- II fractures, fracture displacement process via the CC ligaments. Al- derness over the distal clavicle, as may be obvious, the exact location though the ligaments may remain at- well as painful active and passive of the fracture and the integrity of tached to a free-floating bony frag- range of motion (ROM) of the the CC ligaments may be difficult to ment, the stability of the distal and shoulder. Fracture displacement may judge on plain radiographs. proximal fracture fragments is com- cause the proximal fragment to tent Type IV and V fractures were sub- promised. Although the Craig modi- the skin, with an appearance similar sequently added to the classifica- fication of the Neer classification to that of AC joint separation (Fig- tion.11 Type IV fractures are rare; system is widely used, no study has ure 3). Paresthesias resulting from they involve disruption of the perios- assessed the validity of this classifica- swelling or injury to the supraclavic- teal sleeve in the pediatric popula- tion through inter- and intraobserver ular nerves are common. Neurologic tion.13,14 These fractures are injuries reliability. examination of the shoulder and up- to the growth plate in which the Robinson15 proposed an alternative per extremity should be performed epiphysis and physis typically main- classification for all clavicle fractures and documented. Suprascapular tain their relationship to the shoulder based on fracture location, displace- nerve injury after distal clavicle frac- joint, resulting in apparent superior ment, and intra-articular involve- ture has been described.17 Weakness displacement of the clavicular me- ment (Figure 2). Distal clavicle frac- on external rotation with the arm in

394 Journal of the American Academy of Orthopaedic Surgeons Rahul Banerjee, MD, et al

Figure 3

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 bone ends. The patient was treated with a distal radius 2.4-mm locking plate and simultaneous coracoclavicular stabilization using suture. C, AP radiograph obtained 3 months postoperatively demonstrating fracture healing.

adduction and disproportionate re- tal clavicle fractures are typically series used the Neer definition of ports of pain could be indicative of nondisplaced and heal without diffi- nonunion. Rokito et al7 reported suprascapular nerve injury. Careful culty with nonsurgical management. nonunion in 7 of 16 patients treated examination of the remainder of the In contrast, type II fractures are of- nonsurgically for type II distal clavi- upper extremity, as well as the cervi- ten displaced and may have a higher cle fractures. cal spine and the thorax, is essential. rate of nonunion.4 Reported rates Risk factors for nonunion include of nonunion following nonsurgical displacement, that is, no residual cor- Radiographic Evaluation management of type II distal clavi- tical contact between the bone ends, cle fractures range from 28% to and advancing patient age.19 Robin- Radiographic evaluation should in- 44%1,4,5,7,11,19-21 (Table 1). Most stud- son et al19 noted that both of these clude true AP and axillary lateral ies define distal clavicle fracture non- factors are independently predictive views of the shoulder. A Zanca view union based on Neer’s original series. of nonunion. of the AC joint, which is obtained in Neer defined delayed nonunion as Because some patients remain 10° to 15° cephalic tilt, is also help- “lack of bone bridging for more than asymptomatic, the clinical impor- ful in evaluating for intra-articular 12 months after injury.”4 This defini- tance of distal clavicle nonunion has involvement.18 A radiograph show- tion has been used in subsequent been questioned. In the study by ing the bilateral clavicles and includ- studies on distal clavicle fracture. Deafenbaugh et al,21 none of the ing the AC joint is useful in assessing Deafenbaugh et al21 reported 3 three reported distal clavicle non- fracture displacement. These radio- nonunions in a series of 10 Neer type unions was symptomatic. Other graphs can provide an overall assess- II distal clavicle fractures. Nordqvist studies involving clinical assessment ment of fracture pattern, location, et al20 reported a 28% nonunion rate of patients with distal clavicular non- and displacement. (5 of 18). In their review of 43 type unions have indicated that 20% to II distal clavicle fractures, Edwards 34% were symptomatic and eventu- 22 1,20 Management et al noted that up to 75% of pa- ally required surgical fixation. tients treated nonsurgically devel- Closer evaluation of studies that Distal clavicle fractures may be man- oped a delayed union or nonunion. included outcomes scores in their aged nonsurgically or surgically. Of the 20 patients treated nonsurgi- analyses further clarifies the impact Most nondisplaced distal clavicle cally, 6 (30%) developed nonunion of distal clavicle nonunion. In the fractures are managed nonsurgically. (ie, lack of bony bridging after 12 small series by Rokito et al,7 7ofthe For example, Neer type I and III dis- months). The authors of these three 16 patients treated nonsurgically de-

July 2011, Vol 19, No 7 395 Management of Distal Clavicle Fractures

Table 1 Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures No. of Pts With Neer No. of Pts Followed Study Level of Evidence Total No. of Pts Type II Fracture to End of Study

Neer4 IV (case series) 23 23 23

Deafenbaugh et al21 II (prospective study) 10 10 10 Edwards 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 = patients a 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 and radiographs.” 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 clavicle fractures. 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 was not 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, displaced and nondisplaced). veloped nonunion, but there was no tal clavicle fractures reflects that of management of closed displaced type difference in mean Constant or Neer’s original series. (2) Fracture II distal clavicle fracture must be ap- American Shoulder and Elbow Sur- displacement, as seen in most Neer proached on a case-by-case basis. geons (ASES) scores between those type II fractures, is associated with treated nonsurgically and those the development of nonunion. (3) Nonsurgical treated surgically. In the case series Radiographic nonunion does not al- Most distal clavicle fractures are by Robinson and Cairns,1 there was ways correlate with symptomatic managed nonsurgically. Sling immo- no significant difference in the Con- nonunion. (4) Patients who develop bilization for 2 weeks is instituted stant score or the Medical Outcomes symptomatic nonunion may or may for comfort, and shoulder motion is Study 36-Item Short Form score be- not require additional surgery. initiated as soon as the initial pain tween any of the three groups stud- Surgical management of distal ied: patients treated nonsurgically, clavicle fractures is indicated for improves. Repeat radiographs are patients who developed a nonunion, open fractures, skin compromise, obtained at 6-week follow-up to and patients who underwent delayed and associated vascular injury re- monitor for fracture displacement surgical treatment after the develop- quiring surgery. Because of the high and evidence of healing. These pa- ment of a nonunion. rate of nonunion, Neer4 and tients typically recover fully without Based on these data, several con- others2,3,6,23-45 have advocated pri- sequelae. Type I and type III frac- clusions may be reached regarding mary surgical management of distal tures are at risk of delayed-onset nonunion after distal clavicle frac- clavicle fracture. However, because symptomatic AC arthrosis,5 which ture: (1) The reported rate of radio- radiographic nonunion does not cor- can be managed with distal clavicle graphic nonunion of all types of dis- relate with symptomatic nonunion, resection, if necessary. Nondisplaced

396 Journal of the American Academy of Orthopaedic Surgeons Rahul Banerjee, MD, et al

Table 1 (continued) Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures No. of Symptomatic Management Average Follow-up Outcome Nonunions

12 nonsurgical 4 moa 8 delayed union (67%), 4 4 nonunion (33%) 4 excision NR N/A NR 7 ORIF 3 mob All united 0 Nonsurgical 14.3 mo 3 nonunion (30%) 0 20 nonsurgical 3 y 9 delayed union (45%), 6 6 nonunion (30%) 23 surgical 21 mo All united 0 Nonsurgical 15 y 5/18 nonunion (28%) 2 16 nonsurgical 53.5 mo 7 nonunion (44%) 2 14 ORIF 59.8 mo All united 0 72 nonsurgical, 3 excision, 6.2 y 32/86 nonunion (37%)f 11 11 delayed surgery Nonsurgical 24 wk 25.4% nonunionh NR

N/A = not applicable, NR = not reported, ORIF = open reduction and internal fixation, Pts = patients a 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 and radiographs.” 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 clavicle fractures. 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 was not 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, displaced and nondisplaced). type II fractures may also be man- tions, including nonunion, AC decrease complications.24-26 aged nonsurgically. However, the arthrosis, and Kirschner wire (K- CC ligament repair or reconstruc- likelihood of subsequent displace- wire) migration. Although Eskola tion without supplemental fixation ment and possible nonunion should et al46 reported good or satisfactory has been reported.6,27 Webber and be recognized, discussed with the pa- outcomes in 22 of 23 patients, 26% Haines6 described CC ligament re- tient, and monitored with repeat ra- experienced a complication or non- construction using a Dacron graft in diographs at 6 weeks. union following transacromial wir- 11 patients. All fractures united by ing. Late migration of the wires into an average of 43.5 days postopera- Surgical the cervical spine, trachea, vascular tively. At a mean follow-up of 4.6 A variety of methods of surgical structures, lung, and abdomen has years, the average Constant score management of distal clavicle frac- been reported.47-49 Modifications was 98.9. tures has been proposed, including have led to a reduction in unsatisfac- The modified Weaver-Dunn proce- transacromial wire fixation, a modi- tory results and complications asso- dure is primarily used for AC dislo- fied Weaver-Dunn procedure, use ciated with transacromial wire fixa- cation, but it also has been advo- of a tension band, CC screw fixation. Good results have been cated for the management of distal tion, plate fixation, and arthro- reported with the use of a transacro- clavicle fractures.50 This procedure is scopic treatment. Neer4 recom- mial Knowles pin rather than usually reserved for cases in which mended transacromial wire fixation K-wires.23,24 Transacromial fixation the distal clavicle fragment can be of distal clavicle fractures. This com- supplemented with CC ligament easily excised and the coracoacro- monly used technique has been asso- repair or reconstruction has also mial ligament can be transferred ciated with a high rate of complica- been shown to improve results and to the distal end of the proximal

July 2011, Vol 19, No 7 397 Management of Distal Clavicle Fractures

Figure 4

A, AP radiograph of the right shoulder in a 56-year-old woman who sustained a closed distal clavicle fracture after a fall. B, The patient was initially treated nonsurgically and developed painful nonunion. She then underwent ﬁxation with a 2.7-mm plate, which allowed placement of three screws into the distal fragment. The ﬁxation was augmented with coracoclavicular 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.

clavicle fragment. to the coracoid process. Successful clavicle fragment. All eight patients K-wire fixation with a supplemen- healing of the distal clavicle has been who were available for follow-up tary tension band wire has also been reported in several small case achieved bony union. The mean suggested for fixation of type II dis- series.22,32-34 This technique has also Constant score was 96. tal clavicle fractures.51 In this been performed using a cannulated If the distal fragment is too small method, K-wires are placed on the screw.35 More recently, Fazal et al36 to hold screws, a plate that hooks superior aspect of the clavicle, avoid- reported a 100% union rate using under the acromion may be used ing the AC joint. The tension band is this technique in 30 patients. A sec- (Figure 5). Kashii et al38 reported on placed around the wires. In one se- ond procedure is required to remove 34 patients with distal clavicle frac- ries, 11 of 12 patients achieved pain- the screw following union. tures treated with an AC hook plate. less union with this approach.52 Oth- Small and mini-fragment locking Although all patients achieved bony ers have reported similar success plates may be used to stabilize distal union, the hook caused acromial rates with modified tension band clavicle fractures (Figures 3 and 4). fracture in one patient and rotator techniques using suture.28-30 Symp- These plates allow fixation of the cuff tear in another. Good union tomatic hardware is a potential com- distal clavicle fragment without rates with the hook plate were re- plication, particularly when tension crossing the AC joint. Kalamaras ported in two other studies, but band wiring is used.31 et al37 used a distal radius locking asymptomatic osteolysis of the acro- In CC screw fixation, open reduc- plate on nine patients with distal mion and migration of the hook into tion and internal fixation of the dis- clavicle fracture. The 2.4-mm lock- the acromion were frequently en- tal clavicle fragment is performed by ing screws in the distal portion of the countered.39,40 With the hook plate, a temporarily fixing the distal clavicle plate were used to capture the distal second procedure is required for

398 Journal of the American Academy of Orthopaedic Surgeons Rahul Banerjee, MD, et al

Figure 5 initiated. When pain has improved and there are early signs of fracture consolidation, active ROM is allowed. For the patient with displaced type II distal clavicle fracture or displaced type IV or V fracture, treatment se- lection is based on the degree of displacement and a discussion with the patient. Robinson et al19 defined displacement (ie, no residual cortical contact between the bone ends) as a A, AP radiograph of the right shoulder in a 60-year-old man who sustained a risk factor for nonunion. For pa- displaced distal clavicle fracture in a fall. He was treated with open reduction and internal ﬁxation using a distal clavicle hook plate. B, AP radiograph tients with displacement, we offer obtained 5 months postoperatively demonstrating fracture healing. The plate surgical treatment but counsel them was removed 9 months postoperatively. that the current evidence suggests equivalent outcomes between surgical and nonsurgical treatment. plate removal, which may cause ad- retrospectively compared K-wire fix- Our preferred surgical manage- ditional morbidity. ation with the use of a clavicular ment technique is internal fixation of Plate fixation may be supple- hook plate (22 and 17 patients, re- the distal clavicle fracture with sup- mented with CC screw fixation spectively). Although both methods plementary CC fixation (Figures 3 through the plate or with CC liga- restored shoulder function, K-wire and 4). If the distal clavicle fragment ment repair or reconstruction. Sup- fixation was associated with wire mi- is large enough to hold screws, we plemental CC fixation may also be gration in 12 patients, loss of reduc- use a small, low-profile locking plate achieved with sutures or suture an- tion in 7, infection in 3, and non- and perform open anatomic fracture 3 chors. Recently, Herrmann et al de- union in 2. In the group treated with reduction. The coracoid process is scribed the use of a locking T-plate in clavicle hook plates, one patient sus- identified to allow for suture pas- addition to suture anchors placed tained a clavicle fracture, and two sage. The fixation is supple- into the coracoid in eight patients. mented by CC stabilization, which is fractures went on to nonunion. More The sutures were placed around the achieved with sutures placed around recently, Lee et al31 retrospectively re- clavicle and over the plate. Bony the coracoid process and either viewed patients treated with either union was achieved in 6 weeks in the around or through a small hole in clavicular hook plates or tension- seven patients who were available the clavicle, proximal to the fracture. band wiring (32 and 20 patients, re- for follow-up; the mean Constant For cases in which the size or qual- spectively). Hook plating was associ- score was 93.3. ity of the distal fracture fragment is ated with a lower complication rate Arthroscopic techniques for the insufficient for plate application, we and a lower rate of symptomatic management of distal clavicle frac- recommend CC stabilization using hardware. In addition, it better facili- tures have also been reported. These nonabsorbable suture such as Ethi- tated return to work and athletic ac- techniques employ some of the same bond (Ethicon, Somerville, NJ), Fi- tivity. strategies used in arthroscopically as- berWire (Arthrex, Naples, FL), or sisted CC ligament reconstruction Mersilene (Ethicon). This approach following AC joint separation. Pub- Authors’ Preferred requires exposure of the coracoid lished reports are limited to small Management process. Two strands of suture are case series and technical notes, and passed around the coracoid process. all involve arthroscopic CC stabiliza- We recommend primary nonsurgical The ends of the suture are then tion using suture, a double-button management of type I, type III, and passed through a small drill hole in device, or the Tightrope system (Ar- nondisplaced type II distal clavicle the proximal clavicle fragment. The threx, Naples, FL).41-44 fractures. Patients are treated with distal clavicle is reduced, and the Only two studies to date have di- sling immobilization for 2 weeks. first suture is tied. Once reduction is rectly compared two methods of sur- During this period, supine passive confirmed visually and radiographi- gical management. Flinkkilä et al45 ROM and active-assisted ROM are cally, the second suture is tied. The

July 2011, Vol 19, No 7 399 Management of Distal Clavicle Fractures fixation is supplemented by a dorsal 16, 20, 22-30, 32-40, 43, 44, and 52 13. Katznelson A, Nerubay J, Oliver S: suture tension band placed through are level IV studies. Reference 10 is Dynamic fixation of the avulsed clavicle. J Trauma 1976;16(10):841-844. the incision, as described by Levy.30 level V expert opinion. 14. Ogden JA: Distal clavicular physeal Surgeons who are trained in shoulder References printed in bold type indi- injury. Clin Orthop Relat Res 1984; arthroscopy may perform the proce- cate those published within the past (188):68-73. dure arthroscopically. 5 years. 15. Robinson CM: Fractures of the clavicle Postoperatively, the patient is in the adult: Epidemiology and 1. Robinson CM, Cairns DA: Primary classification. J Bone Joint Surg Br 1998; placed in a sling for 6 weeks. Supine nonoperative treatment of displaced 80(3):476-484. passive and active-assisted ROM ex- lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86(4):778-782. 16. Stanley D, Trowbridge EA, Norris SH: ercises are begun immediately. Active The mechanism of clavicular fracture: A ROM is started at 6 weeks, with 2. Hessmann M, Kirchner R, Baumgaertel clinical and biomechanical analysis. progression to strengthening exer- F, Gehling H, Gotzen L: Treatment of J Bone Joint Surg Br 1988;70(3):461- unstable distal clavicular fractures with 464. cises 6 to 12 weeks postoperatively. and without lesions of the acromio- 17. Huang KC, Tu YK, Huang TJ, Hsu RW: Patients are typically restricted from clavicular joint. Injury 1996;27(1):47- 52. Suprascapular neuropathy complicating engaging in heavy labor and sports a Neer type I distal clavicular fracture: A for 12 weeks. 3. Herrmann S, Schmidmaier G, Greiner S: case report. J Orthop Trauma 2005; Stabilisation of vertical unstable distal 19(5):343-345. clavicular fractures (Neer 2b) using locking T-plates and suture anchors. 18. Zanca P: Shoulder pain: Involvement of Summary Injury 2009;40(3):236-239. the acromioclavicular joint: Analysis of 1,000 cases. Am J Roentgenol Radium 4. Neer CS II: Fracture of the distal clavicle Ther Nucl Med 1971;112(3):493-506. Most distal clavicle fractures may be with detachment of the coracoclavicular 19. Robinson CM, Court-Brown CM, managed nonsurgically. Type II distal ligaments in adults. J Trauma 1963;3:99- 110. McQueen MM, Wakefield AE: clavicle fractures are associated with Estimating the risk of nonunion radiographic nonunion in up to 44% 5. Neer CS II: Fractures of the distal third following nonoperative treatment of a of the clavicle. Clin Orthop Relat Res clavicular fracture. J Bone Joint Surg Am of cases. Fracture displacement is as- 1968;58:43-50. 2004;86(7):1359-1365. sociated with a higher risk of non- 6. Webber MC, Haines JF: The treatment 20. Nordqvist A, Petersson C, Redlund- union. However, the clinical rele- of lateral clavicle fractures. 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