What is the appropriate management for a distal clavicle fracture?

Management of Distal Clavicle Fractures

For displaced distal clavicle fractures with disruption of the coracoclavicular ligament complex (Type II), surgical treatment is strongly recommended, while non-displaced fractures (Type I and III) can be managed conservatively with sling immobilization. 1

Classification and Initial Assessment

The key to managing distal clavicle fractures is determining whether the coracoclavicular (CC) ligaments are intact or disrupted:

• Obtain upright radiographs (not supine) with multiple views to accurately assess displacement and ligament integrity 1, 2
• Type I fractures: Minimal displacement with intact CC ligaments 3
• Type II fractures: Displaced with disruption of CC ligament complex—these are unstable and prone to nonunion 1, 3
• Type III fractures: Intra-articular extension into the acromioclavicular joint with intact CC ligaments 3

The American Academy of Orthopaedic Surgeons emphasizes that Type II fractures have significantly higher nonunion rates with conservative management, making surgical intervention the preferred approach. 1

Treatment Algorithm

Non-Displaced Fractures (Types I and III)

Conservative management is appropriate and effective:

• Immobilize with a simple sling (preferred over figure-of-eight brace) 1
• Multimodal analgesia with NSAIDs and ice application 2
• Discontinue sling by 4 weeks for routine activities, but avoid lifting, pushing, or pulling 1
• Full weight-bearing activities allowed at 8-12 weeks based on radiographic healing 1, 2
• These fractures typically heal without complication when managed conservatively 3

Displaced Fractures with CC Ligament Disruption (Type II)

Surgical treatment is strongly indicated due to high nonunion rates (up to 15%) with conservative management: 1

The American Academy of Orthopaedic Surgeons provides a consensus statement specifically recommending surgical treatment for displaced lateral clavicle fractures with disruption of the coracoclavicular ligament complex. 1

Surgical Options

Multiple techniques are available, each with distinct advantages:

Hook Plate Fixation

• Demonstrates reliably high rates of osseous union with good functional outcomes 4
• Provides direct stabilization of the distal fragment 4
• Common pitfall: High rates of hardware removal required due to prominent implant and potential subacromial impingement 5

Coracoclavicular Ligament Reconstruction with Cortical Button Fixation

• Allows indirect fixation without prominent hardware 6
• Reconstructs the CC ligaments anatomically 6
• Lower hardware removal rates compared to hook plates 6

Anatomic Plate Fixation

• Manufacturer-contoured anatomic clavicle plates are preferred due to lower rates of implant removal or deformation 1
• Anterior inferior plating may lead to lower implant removal rates compared with superior plating 1

The choice between techniques depends on fracture pattern, bone quality, and surgeon experience, but all provide acceptable outcomes when properly indicated. 5

Critical Considerations and Pitfalls

Avoid misdiagnosing distal clavicle fractures as acromioclavicular separations:

• Distal clavicle fractures are often overlooked and may be difficult to distinguish from AC separations 3
• Careful radiographic assessment is essential to identify the fracture line and ligament integrity 3

Recognize high-risk features for nonunion:

• Displacement with loss of CC ligament integrity (Type II pattern) 1, 3
• Smoking significantly increases nonunion rates and leads to inferior clinical outcomes 1
• Complete displacement (>100% with no cortical contact) 2

Surgical complications to counsel patients about:

• High rates of hardware removal procedures, particularly with hook plates 5
• Need for implant removal is more common with non-precontoured plates 1
• Technical difficulty increases with delayed presentation 1

Special Populations

For adolescents (≤18 years):

• Nonsurgical management is generally preferred as primary treatment even for displaced fractures 7
• Surgical treatment has not demonstrated significant benefits over conservative management in this age group 7
• Reserve surgery for open fractures, polytrauma requiring early mobilization, or severely displaced fractures with >1.5cm shortening 7

For patients requiring rapid return to work or sport:

• Surgical treatment provides faster time to union and earlier return to function 1
• However, long-term patient-reported outcomes (beyond 1 year) are similar between surgical and nonsurgical approaches 1