Treatment for Distal Clavicle Fracture
For displaced distal clavicle fractures with disruption of the coracoclavicular (CC) ligament complex, surgical repair is recommended, while stable, non-displaced fractures can be managed conservatively with sling immobilization. 1
Treatment Algorithm Based on Fracture Stability
Step 1: Assess Fracture Stability and Displacement
The critical determinant is whether the CC ligament complex is disrupted:
- Displaced lateral (distal) clavicle fractures WITH CC ligament disruption (Neer Type II and V): These are inherently unstable and benefit from surgical repair 1, 2
- Non-displaced fractures WITHOUT CC ligament disruption: These can be treated conservatively with satisfactory outcomes 2
Step 2: Conservative Management (For Stable Fractures Only)
Use a simple sling for immobilization—NOT a figure-of-eight brace 1
- The American Academy of Orthopaedic Surgeons consensus statement explicitly recommends sling immobilization over figure-of-eight bracing for acute clavicle fractures 1
- Obtain upright radiographs to accurately assess displacement, as they are superior to supine films 1
Step 3: Surgical Management (For Unstable/Displaced Fractures)
The preferred surgical approach combines plate fixation with CC ligament reconstruction or uses CC fixation techniques 3, 4
Recommended Surgical Options (in order of preference):
Plate and screw fixation with CC reconstruction: Network meta-analysis shows this has the lowest complication risk (RR 0.37 compared to hook plates) and excellent functional outcomes 3
Coracoclavicular fixation alone (cortical button/endobutton/suture techniques): Achieves significantly higher Constant-Murley scores compared to hook plates (mean difference 2.98 points) and tension band wiring (mean difference 7.11 points) 3, 4
Cortical button fixation combined with CC ligament reconstruction: Demonstrates 100% union rate by 4 months with excellent UCLA and ASES scores 4
Surgical Techniques to AVOID:
- Hook plates should NOT be routinely used: They have a 62.5% hardware removal rate due to subacromial irritation, compared to only 16.2% with contoured clavicular plates 5
- Tension band wiring: Associated with inferior functional outcomes compared to CC fixation 3
Critical Pitfalls to Avoid
Common Mistake #1: Using Conservative Treatment for Unstable Fractures
- Unstable distal clavicle fractures (with CC ligament disruption) have high rates of symptomatic nonunion when treated conservatively 2, 5, 4
- Do not be misled by initial acceptable alignment—these fractures will lose reduction without surgical stabilization 2
Common Mistake #2: Choosing Hook Plate Fixation
- While hook plates achieve high union rates (98.6%), they require hardware removal in the majority of cases (62.5%) due to subacromial impingement 5
- This translates to an unacceptably high reoperation rate 5
Common Mistake #3: Ignoring Patient Functional Demands
- The decision for surgery should account for the patient's activity level and occupational requirements 2
- Even in elderly patients, consider surgical fixation if they have high functional demands
Expected Outcomes
With Appropriate Surgical Management:
- Union rate: 98.6-100% by 4 months 5, 4
- Mean time to radiographic union: 60 days (range 41-84 days) 4
- UCLA scores: Improvement from mean 5.36 preoperatively to 32.52 postoperatively 4
- ASES scores: Improvement from mean 16.23 to 88.11 postoperatively 4
Complications to Monitor:
- Adhesive capsulitis: Occurs in 14.2% with suture-only fixation (likely due to tethering effect) 5
- Hardware irritation: Highest with hook plates (62.5%), lowest with suture-only techniques (0%) 5
- Loss of fixation: Rare with modern techniques (<2%) 5
Special Considerations
Smoking Status
Limited evidence suggests tobacco smoking increases nonunion rates and leads to inferior clinical outcomes in clavicle fractures 1
Associated Injuries
Consider arthroscopic evaluation if glenohumeral pathology is suspected, as this allows simultaneous assessment and treatment of associated lesions 2