Summary Distal clavicle fractures are traumatic injuries usually caused by direct trauma to the shoulder from a fall in adults. Diagnosis is confirmed with standard shoulder radiographs and a 15° cephalic tilt view (zanca view). Treatment is immobilization or surgery, depending on the displacement and stability of the distal clavicle, as determined by whether coracoclavicular (CC) ligaments (trapezoid and conoid) are intact. Epidemiology Incidence common clavicle fractures account for 2.6-4% of all adult fractures Demographics more commonly in older or osteoportic patients less common in pediatric patients Anatomic location 10-25% of all clavicle fractures occur in the distal third segment Etiology Pathophysiology mechanism similar mechanism to midshaft clavicle fractures login to view 1 more bullet pathoanatomy fracture displacement corresponds to login to view 5 more bullets deforming forces include Associated conditions rare but may include floating shoulder scapulothoracic dissociation login to view 1 more bullet rib fracture pneumothorax neurovascular injury Anatomy Acromioclavicular joint anatomy AC joint stability static stabilizers acromioclavicular (AC) ligament login to view 8 more bullets coracoclavicular (CC) ligaments (trapezoid and conoid) login to view 9 more bullets capsule dynamic stabilizers deltoid trapezius Classification Neer Classification Type I Extra-articular fracture occurring lateral to CC ligaments Conoid and/or trapezoid ligament remains intact Minimal displacement Stable Nonoperative Type IIA Fracture occurs medial to CC ligaments Conoid and trapezoid ligament remain intact Significant medial clavicle displacement Unstable - Up to 56% nonunion rate with nonoperative management Operative Type IIB two fracture patterns (1) fracture occurs either between CC ligaments - Conoid ligament torn - Trapezoid ligament intact (2) fracture occurs lateral to CC ligaments - Conoid ligament torn - Trapezoid ligament torn Significant medial clavicle displacement Unstable - Up to 30-45% nonunion rate with nonoperative management Operative Type III Intra-articular fracture occurring lateral to CC ligaments and extending into AC joint Conoid and trapezoid ligaments remain intact Minimal displacement Stable - Patients may develop post-traumatic AC arthritis Nonoperative Type IV Physeal fracture that occurs in the skeletally immature Conoid and trapezoid ligaments remain intact Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum (clavicle pulls out of periosteal sleeve) Stable Nonoperative Type V Comminuted fracture pattern Conoid and trapezoid ligaments remain intact Significant medial clavicle displacement Usually unstable Operative AO Classification Type A = nondisplaced + intact CC ligaments A1 = extra-articular A2 = intra-articular Nonoperative Type B = displaced + intact CC ligaments B1 = extra-articular B2 = comminuted Nonoperative vs. Operative Type C = displaced + torn CC ligaments C1 = extra-articular C2 = intra-articular Operative Presentation Symptoms anterior shoulder pain Physical exam swelling, ecchymosis, tenderness to palpation AC joint deformity may have tenting of skin (impending open fracture) perform careful neurovascular exam suprascapular nerve is at risk of injury login to view 1 more bullet Imaging Radiographs recommended views upright AP of bilateral shoulders axillary lateral 15° cephalic tilt (zanca view) login to view 2 more bullets CT views coronal, saggital, axial 3D reconstruction views findings may help evaluate displacement, shortening, comminution, articular extension, and nonunion Differential Clavicle shaft fractures Pediatric medial clavicle physeal injury Pediatric distal clavicle physeal injury Acromioclavicular separation Treatment Nonoperative sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks indications login to view 2 more bullets Operative open reduction internal fixation indications login to view 11 more bullets Techniques Sling Immobilization technique immobilize using sling or figure-of-eight brace login to view 1 more bullet no attempt at reduction should be made begin gentle range of motion exercises after 2-4 weeks strengthening exercises begin at 6-10 weeks outcomes nonunion (~15%) login to view 5 more bullets poorer cosmesis Open Reduction Internal Fixation techniques limited contact dynamic compression plate login to view 11 more bullets hook plate login to view 13 more bullets other options login to view 9 more bullets advantages higher union rates faster time to union improved functional outcome/less pain with overhead activity decreased symptomatic malunion rate improved cosmetic satisfaction disadvantages increased risk of need for future procedures (e.g, removal of hook plate) symptomatic hardware infection postoperative rehabilitation early login to view 1 more bullet late login to view 3 more bullets Complications Nonoperative treatment nonunion (~15%) risk factors login to view 7 more bullets treatment login to view 2 more bullets AC joint arthritis risk factors login to view 1 more bullet treatment login to view 1 more bullet Operative treatment hardware prominence ~30% of patient request plate removal superior plates associated with increased irritation hardware removal most common with hook plates neurovascular injury (3%) superior plates associated with increased risk of subclavian artery or vein penetration subclavian thrombosis nonunion (1-5%) infection (~4.8%) mechanical failure (~1.4%) pneumothorax adhesive capsulitis 4% in surgical group develop adhesive capsulitis requiring surgical intervention