What is the recommended treatment for a mildly distracted fracture fragment with an intact acromioclavicular joint?

Management of Mildly Distracted Fracture Fragment with Intact Acromioclavicular Joint

For a mildly distracted fracture fragment with an intact acromioclavicular joint, conservative management with rigid immobilization is the recommended first-line treatment approach.

Initial Assessment and Treatment Decision

Conservative Management (Primary Approach)

• Immobilization: Rigid immobilization with a cast is strongly recommended over removable splints 1
  • Duration: 3-6 weeks
  • Position: Wrist in neutral position (for upper limb fractures)
• Active finger motion exercises: Begin immediately following diagnosis to prevent stiffness 2, 1
• Ice application: During the first 3-5 days for symptomatic relief 1

Indications for Surgical Intervention

Consider surgical fixation only if the fracture meets any of these criteria:

• Postreduction radial shortening >3 mm
• Dorsal tilt >10°
• Intra-articular displacement 2
• DRUJ instability despite adequate immobilization
• Large displaced base fractures involving >50% of the styloid 1

Imaging Recommendations

• Initial imaging: True lateral radiograph to assess alignment 2
• Follow-up imaging: Radiographic follow-up at 3 weeks and at cessation of immobilization 1
• For complex cases: MRI without IV contrast is beneficial after initial negative radiographs to prevent delayed diagnosis 2
• CT scan: Consider for complex intra-articular fractures to improve diagnostic accuracy 1

Rehabilitation Protocol

1. Immobilization phase (3-6 weeks):

   • Maintain rigid immobilization
   • Continue active finger motion exercises
   • Ice for pain control

2. Post-immobilization phase:

   • Progressive range of motion exercises
   • Gradual return to activities 1
   • Progressive weight bearing as tolerated
   • Strengthening exercises

Monitoring and Follow-up

• Re-evaluation: All patients with unremitting pain during follow-up should be reevaluated 2
• Home exercise program: A directed home exercise program is an option for patients after the immobilization period 2
• Monitoring for complications:
  • Malunion or delayed union (from inadequate immobilization)
  • Stiffness and reduced range of motion (from excessive immobilization) 1

Special Considerations

• For acromioclavicular joint injuries, the intact status is favorable for conservative management 3, 4
• Low-intensity pulsed ultrasonography (LIPUS) should NOT be used as it does not accelerate healing or lower rates of nonunion 2
• Non-union of styloid fractures is common but typically does not affect functional outcomes 1

Treatment Algorithm

1. Assess fracture characteristics:

   • Degree of displacement
   • Intra-articular involvement
   • Stability of reduction

2. If minimally displaced with stable reduction:

   • Proceed with conservative management

3. If meets surgical criteria or fails conservative management:

   • Consider surgical fixation options

4. For all patients:

   • Begin active finger motion immediately
   • Monitor for pain and complications
   • Progress to rehabilitation after immobilization period

This approach prioritizes functional outcomes while minimizing unnecessary surgical intervention for fractures that can heal adequately with conservative management.