What is the treatment for a fracture of the distal left clavicle?

Treatment of Distal Left Clavicle Fracture

Surgical treatment is recommended for displaced distal clavicle fractures with disruption of the coracoclavicular ligament complex, as these fractures may benefit from surgical repair. 1

Classification and Assessment

Distal clavicle fractures represent 10-30% of all clavicle fractures and require careful assessment of stability for proper treatment planning:

• Imaging: Upright radiographs are superior for demonstrating the degree of displacement compared to supine views 2
• Classification: Most commonly classified using Neer's system:
  • Type I: Minimal displacement, intact coracoclavicular ligaments
  • Type II: Displaced with disrupted coracoclavicular ligaments (unstable)
  • Type III: Intra-articular extension into acromioclavicular joint

Treatment Algorithm

1. Non-Displaced Distal Clavicle Fractures (Type I and III)

• Conservative management with sling immobilization 3
• Good healing potential with symptomatic treatment
• Monitor for 3 weeks with ongoing radiographic evaluation

2. Displaced Distal Clavicle Fractures with Ligamentous Disruption (Type II)

• Surgical intervention recommended 1, 3
• High risk of nonunion with conservative treatment due to displacement and ligamentous disruption
• Surgical options:
  • Plate fixation with manufacturer-contoured anatomic plates 2
  • Coracoclavicular ligament reconstruction techniques 4, 5
  • Arthroscopic stabilization for minimally invasive approach 5

Surgical Considerations

• Plate Selection: Manufacturer-contoured anatomic plates are preferred due to lower rates of implant removal and deformation 2
• Fixation Technique: Consider indirect fixation with coracoclavicular ligament reconstruction to avoid prominent hardware complications 4
• Arthroscopic Options: Arthroscopic stabilization can be considered as a minimally invasive approach that also allows assessment of associated glenohumeral injuries 6, 5

Post-Treatment Management

• Immobilization with sling is preferred over figure-of-eight brace in most cases 1
• Follow-up radiographs to assess healing progression
• Gradual return to activities based on clinical and radiographic evidence of healing

Common Pitfalls and Caveats

• Misdiagnosis: Distal clavicle fractures are often overlooked or misdiagnosed as acromioclavicular separations 3
• Nonunion Risk: Type II fractures have a high nonunion rate with conservative treatment due to the displacement and ligamentous disruption 3, 6
• Hardware Complications: Traditional fixation methods like hook plates may have high complication rates including hardware prominence and need for removal 4
• Functional Outcomes: Even with radiographic nonunion, some patients may achieve satisfactory functional outcomes with conservative management 7

The most recent evidence from the American Academy of Orthopaedic Surgeons (2023) supports surgical intervention for displaced distal clavicle fractures with disruption of the coracoclavicular ligament complex to improve union rates and functional outcomes 1.