What is the recommended treatment for a mildly distracted distal clavicle fracture?

Management of Mildly Distracted Distal Clavicle Fractures

For mildly distracted distal clavicle fractures, nonsurgical management with sling immobilization is recommended as the first-line treatment, as these fractures typically heal well without surgical intervention when displacement is minimal. 1

Assessment and Classification

• Proper evaluation should include upright radiographs, which are superior for demonstrating the true degree of displacement in clavicle fractures compared to supine radiographs 1
• Distal clavicle fractures represent 10-30% of all clavicle fractures 2
• Assessment of stability is essential for determining appropriate treatment:
  • Evaluate for coracoclavicular ligament disruption
  • Assess degree of displacement between fracture fragments
  • Consider the functional demands of the patient

Treatment Recommendations

Nonsurgical Management (First-line for mildly distracted fractures)

• Sling immobilization is preferred over figure-of-eight brace for most clavicle fractures 1
• Duration of immobilization: 3-6 weeks
• Active finger motion exercises should begin immediately to prevent stiffness
• Progressive range of motion exercises after the immobilization period

Surgical Indications

• According to the AAOS, "displaced lateral fractures with disruption of the coracoclavicular ligament complex may benefit from surgical repair" 1
• Consider surgical intervention for:
  • Significantly displaced fractures (not just mildly distracted)
  • Type II distal clavicle fractures with coracoclavicular ligament disruption 3
  • Fractures with high functional demands from the patient

Evidence-Based Considerations

The 2023 AAOS Clinical Practice Guideline provides expert opinion that displaced lateral clavicle fractures with disruption of the coracoclavicular ligament complex may benefit from surgical repair 1. However, this recommendation is based on expert opinion rather than high-quality evidence, as the guideline notes an "absence of reliable evidence" specifically for lateral clavicle fractures.

For mildly distracted fractures, the risk-benefit analysis favors nonsurgical management since:

1. Nonsurgical management avoids surgical complications
2. Mild displacement typically doesn't compromise healing or functional outcomes
3. The AAOS notes that many clavicle fractures can be managed successfully without surgery when there is minimal displacement 1

Potential Complications

• Nonsurgical management: potential for nonunion (though rare with minimal displacement), malunion
• Surgical management: hardware irritation requiring removal, infection, neurovascular injury

Follow-up Protocol

• Clinical and radiographic follow-up at 2-3 weeks to ensure proper alignment is maintained
• Additional follow-up at 6 weeks to assess healing progress
• Progressive rehabilitation after immobilization period

Clinical Pearls

• The distinction between "mildly distracted" and "significantly displaced" is important - truly displaced fractures with coracoclavicular ligament disruption may require surgery
• Sling immobilization is more comfortable and equally effective compared to figure-of-eight bandages for most clavicle fractures 1
• Patient's age, activity level, and occupation should be considered when making treatment decisions, though these factors don't override the primary recommendation for nonsurgical management of mildly distracted fractures