What is the management of a distal clavicle fracture?

Management of Distal Clavicle Fractures

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

Classification and Assessment

Proper management of distal clavicle fractures depends on accurate classification and assessment of stability:

• Distal clavicle fractures represent 10-30% of all clavicle fractures 2
• Key assessment: Determine if the coracoclavicular ligament complex is disrupted, as this significantly affects stability
• Obtain upright radiographs to accurately demonstrate fracture displacement 1
• Consider CT scan for complex or comminuted fractures 1

Treatment Algorithm

Non-displaced Fractures (Type I and III)

• Nonsurgical management with sling immobilization 1, 3
• Immobilize in a sling for comfort (preferred over figure-of-eight bracing) 1
• Early pendulum exercises as tolerated 1

Displaced Fractures with Coracoclavicular Ligament Disruption (Type II)

• Surgical fixation strongly recommended 1, 3, 4
• Rationale: High rates of nonunion and delayed union with nonsurgical management 4
• Surgical options include:
  1. Plate fixation (manufacturer-contoured anatomic plates preferred) 1
  2. Coracoclavicular ligament reconstruction with cortical button fixation 5
  3. Coracoclavicular reconstruction with Mersilene tape plus wire fixation 4

Urgent Surgical Indications

• Fractures with skin tenting require urgent ORIF to prevent skin necrosis and potential conversion to open fracture 1

Rehabilitation Protocol

1. Weeks 1-2: Sling immobilization with gentle passive range of motion exercises 1
2. Weeks 2-6: Progress to active-assisted range of motion 1
3. After 6 weeks: Begin strengthening exercises if radiographic healing is evident 1
4. Return to full activities: Typically at 3-4 months based on healing 1

Outcomes and Complications

• Surgical treatment of displaced distal clavicle fractures with coracoclavicular ligament disruption shows excellent functional outcomes 4
• Solid union can be achieved at approximately 3 months post-surgery 4
• Potential complications of surgical treatment include hardware irritation and need for hardware removal 5
• Despite higher nonunion rates with nonsurgical management of certain fractures, subjective and functional outcomes can still be good in selected cases 6

Special Considerations

• Counsel patients who smoke about increased nonunion risk and inferior outcomes 1
• Adolescent patients (≤18 years) may not benefit from surgical treatment compared to nonsurgical management, except when skin tenting is present 1
• Ensure adequate screw purchase in the distal fragment during plate fixation, as it is often small and osteoporotic 1
• Do not use low-intensity pulsed ultrasonography (LIPUS), as it does not accelerate healing or lower nonunion rates 1