What are the indications for surgery in a distal clavicle (collarbone) fracture?

Surgical Indications for Distal Clavicle Fractures

Surgical treatment is strongly recommended for displaced distal clavicle fractures with disruption of the coracoclavicular ligament complex to improve union rates and functional outcomes. 1

Key Indications for Surgery

Distal clavicle fractures often require surgical intervention in the following scenarios:

1. Disruption of coracoclavicular ligaments

   • Fractures with coracoclavicular ligament disruption have high nonunion rates (up to 33.3%) with nonsurgical treatment 2
   • These fractures correspond to Neer type II distal clavicle fractures

2. Significant displacement

   • Displacement of one or more shaft width
   • Shortening of more than 1 cm in length

3. Skin tenting

   • Urgent surgical intervention through open reduction and internal fixation (ORIF) is necessary to prevent skin necrosis and potential conversion to an open fracture 1

4. High physical activity requirements

   • Patients with demanding occupational or athletic needs benefit from surgical stabilization

Preoperative Assessment

• Obtain upright radiographs to accurately demonstrate fracture displacement (superior to supine views) 1
• Consider CT scan for complex or comminuted fractures to better understand the fracture pattern

Surgical Options

Several surgical techniques have shown good results for distal clavicle fractures:

1. Plate Fixation

   • Preferred for comminuted fractures 1
   • Manufacturer-contoured anatomic plates are recommended due to lower rates of implant removal and deformation
   • Anterior inferior plating may lead to lower implant removal rates compared to superior plating

2. Coracoclavicular Stabilization

   • Low complication rate (4.8%) compared to hook plates (40.7%) 2
   • Techniques include:
     • Mersilene tape fixation 3, 4
     • Suture anchor placement 5
     • Cortical button fixation with coracoclavicular ligament reconstruction 6

3. Intramedullary Fixation

   • Alternative option with low complication rate (2.4%) 2
   • May be less suitable for comminuted fractures

Outcomes and Complications

• Surgical treatment results in significantly lower nonunion rates (1.6%) compared to nonsurgical treatment (33.3%) 2
• However, surgical treatment has higher overall complication rates (22.2%) than nonsurgical treatment (6.7%) 2
• Complication rates vary by technique:
  • Hook plate: 40.7%
  • K-wire plus tension band wiring: 20.0%
  • Coracoclavicular stabilization: 4.8%
  • Intramedullary fixation: 2.4%
  • Interfragmentary fixation: 6.3% 2

Rehabilitation Protocol

• Immobilize in a sling for comfort (preferred over figure-of-eight bracing)
• Begin gentle pendulum exercises as tolerated
• Progress to active-assisted range of motion at 2-6 weeks
• Start strengthening exercises after 6 weeks if radiographic healing is evident
• Return to full activities typically at 3-4 months based on healing 1

Special Considerations

• Counsel smoking patients about increased nonunion risk and inferior outcomes 1
• Be cautious with adolescent patients (≤18 years), as they may not benefit from surgical treatment compared to nonsurgical management, except in cases with skin tenting 1
• Do not use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing or lower nonunion rates 1