Review Question - QID 219847

This patient presents with a minimally displaced right Neer Type II distal clavicle fracture. Of the listed choices, the only RELATIVE indication is an unstable fracture pattern (Answer 2).

Distal clavicle fractures are typically produced by a direct compressive force to the lateral shoulder, similar to that for midshaft clavicle fractures. The Neer classification is typically used to describe the fracture location and the integrity of the coracoclavicular (CC) ligament complex (Illustration A). The integrity of the CC ligament complex also divides the subtypes into stable (Types I, III, and IV) and unstable (Types IIA, IIB, and V). Treatment is based on the stability of the CC ligament complex, with stable fractures generally undergoing nonoperative treatment and unstable fractures undergoing operative treatment. However, fracture stability is only a relative indication; absolute indications include open or impending open fractures, subclavian vessel injury, ipsilateral floating shoulder, and symptomatic nonunions.

Banerjee et al. published a 2011 JAAOS review on the management of distal clavicle fractures. The authors review the pathoanatomy, Neer classification, clinical and radiographic evaluation, indications, and treatment techniques. The article lists open fractures, skin compromise, associated vascular injury requiring surgery, and symptomatic nonunion as absolute indications for surgical intervention. However, the authors state that nondisplaced Type II fractures, despite being classified as “unstable,” may also be initially treated with a trial of nonoperative management with close radiographic follow-up to assess for progression of displacement and/or nonunion.

Sambandam et al. published a 2014 literature review of the various conservative and surgical distal clavicle fracture management techniques, focusing primarily on unstable Type II and V fractures. The authors performed an extensive literature search and sought to determine the advantages and disadvantages of various published treatment techniques. Forty Level 4, seven Level 3, and three Level 2 studies were included. No Level 1 studies were included after exclusion criteria were applied. These authors stressed the importance of operative treatment, as nonunion rates were high with conservative treatment. No significant differences were observed between operative construct types; however, nearly 10% of patients undergoing K-wire tension band wiring experienced loss of reduction. Implant-related complications were more common with rigid fixation techniques such as the hook plate, locking plate, and distal radius plates.

Figures A and B are AP and Zanca radiographs of a Neer Type II distal clavicle fracture. Illustration A is a depiction of the Neer classification for distal clavicle fractures.

Incorrect Answers:
Answers 1, 3, 4, and 5: These are all absolute indications for operative treatment.