What is the recommended treatment for a comminuted left third clavicle fracture?

Treatment of Comminuted Left Third Clavicle Fracture

For a comminuted lateral (distal) third clavicle fracture, surgical treatment with plate fixation is recommended if there is disruption of the coracoclavicular ligament complex, while non-displaced fractures can be managed conservatively with sling immobilization. 1

Initial Assessment

The critical first step is determining whether the coracoclavicular (CC) ligament complex is disrupted, as this fundamentally changes management:

• Obtain upright radiographs rather than supine films, as they better demonstrate the true degree of displacement and ligament injury 1
• Assess for displacement >100% (no cortical contact between fragments), which requires urgent orthopedic follow-up 1
• Evaluate for shortening exceeding 1.5cm, which is an indication for surgical intervention 1

Treatment Algorithm Based on Fracture Characteristics

Surgical Indications (Type II Lateral Fractures)

Proceed with surgical fixation if:

• Displaced lateral fracture with disruption of the coracoclavicular ligament complex 1
• Significant displacement with no cortical contact between fragments 1
• Shortening >1.5cm 1

Conservative Management (Type I and III Lateral Fractures)

Non-operative treatment is appropriate for:

• Non-displaced or minimally displaced fractures 1, 2
• Fractures without CC ligament disruption 2

Surgical Approach When Indicated

Plate fixation is the preferred surgical method for comminuted fractures:

• Use manufacturer-contoured anatomic clavicle plates, which have lower rates of implant removal or deformation 1
• Consider anterior inferior plating over superior plating, as it may lead to lower implant removal rates 1
• Plate fixation is particularly beneficial in the presence of fracture comminution compared to intramedullary nailing 3

The comminuted nature of this fracture makes plate fixation more advantageous than intramedullary nailing for achieving stable fixation 3.

Conservative Management Protocol

If non-operative treatment is chosen:

• Immobilize with a sling (preferred over figure-of-eight brace) 1
• Allow immediate shoulder mobilization as tolerated 4
• No attempt at reduction of displaced fragments is necessary for stable fractures 4
• Continue sling use for approximately 3 weeks 2

Critical Pitfalls and Considerations

Common mistakes to avoid:

• Lateral third fractures are often overlooked and may be difficult to distinguish from acromioclavicular separations 2
• Type II lateral fractures (with CC ligament disruption) are frequently undertreated conservatively, leading to nonunion 2
• Conservative treatment of displaced comminuted fractures may result in higher nonunion rates (up to 15%), symptomatic malunion affecting shoulder strength, and longer time to return to work 1

Important patient factors:

• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes 1
• Displacement ≥21mm and shortening ≥15mm correlate with impaired functional outcomes when treated conservatively 4
• Comminution pattern significantly affects functional outcomes with non-operative treatment 4

Expected Outcomes

Surgical treatment provides:

• Higher union rates compared to conservative management 1
• Better early patient-reported outcomes 1
• Faster recovery and earlier return to work 1
• Shorter time to union 5

Long-term outcomes:

• Patient-reported outcomes and satisfaction are similar between surgical and nonsurgical approaches at long-term follow-up 1
• However, this applies primarily to appropriately selected cases, not severely displaced or comminuted fractures 1

Post-Treatment Rehabilitation (If Surgery Performed)

• Discontinue sling use by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 1
• Allow full weight-bearing activities between 8-12 weeks based on radiographic healing 1
• Monitor for complications requiring hardware removal, particularly with non-precontoured plates 1