What is the recommended treatment for a moderate displaced distal clavicle fracture?

Treatment of Moderate Displaced Distal Clavicle Fractures

Surgical treatment is recommended for moderate displaced distal clavicle fractures as it provides higher union rates and better early patient-reported outcomes compared to nonsurgical management. 1

Classification and Rationale

Distal clavicle fractures can be classified based on their relationship to the coracoclavicular ligaments:

• Type I: Lateral to coracoclavicular ligaments (stable)
• Type II: Medial to coracoclavicular ligaments (unstable)

Moderate displaced distal clavicle fractures, particularly Type II, are considered unstable and have higher rates of nonunion with nonsurgical treatment. The American Academy of Orthopaedic Surgeons (AAOS) guidelines indicate that surgical treatment of displaced clavicle fractures is associated with higher union rates and better early patient-reported outcomes 1.

Surgical Treatment Options

Several surgical fixation methods are available for displaced distal clavicle fractures:

1. Plate and screw fixation: Recommended as first-line treatment based on highest quality evidence

   • Lower complication rates compared to other fixation methods 2
   • Superior UCLA scores compared to hook plating 2

2. Coracoclavicular fixation: Recommended as second-line treatment

   • Higher Constant Murley Scores compared to hook plating and tension band wiring 2
   • Options include tight rope, screw, or endobutton techniques

3. Modified tension band fixation:

   • Cost-effective option with good union rates
   • Mean American Shoulder and Elbow Surgeons score of 92 points in studies 3

4. Hook plating:

   • Effective but associated with higher complication rates
   • Often requires a second surgery for plate removal

Key Considerations

• Fracture displacement: Initial shortening ≥20 mm is significantly associated with nonunion (p<0.0001) and unsatisfactory results 4

• Patient factors: While the AAOS guidelines provide a strong recommendation for surgical treatment of displaced clavicle fractures, patient age, preinjury activity, symptoms, and desired level of postinjury activity should be considered in the decision-making process 1

• Rehabilitation: Early finger motion exercises are essential to prevent stiffness following surgical fixation 5

Nonsurgical Management

Nonsurgical management may be considered in select cases but carries higher risks:

• Higher nonunion rates (up to 15%) 1
• Potential for symptomatic malunion 1
• If chosen, sling immobilization is preferred over figure-of-eight braces 1

Complications to Monitor

• Nonunion (higher risk with nonsurgical treatment)
• Symptomatic malunion
• Hardware-related complications
• Infection (with surgical treatment)
• Limited range of motion

Follow-up Protocol

• Regular radiographic assessment to monitor union
• Evaluation of shoulder function and pain
• Assessment for hardware-related complications if surgical fixation was performed

Caution

• Smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Elderly patients may have different risk-benefit profiles for surgical versus nonsurgical management
• While long-term outcomes may be similar between surgical and nonsurgical treatment, early functional recovery is typically better with surgical management 1