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Updated: Sep 6 2023

Clavicle Fractures - Distal

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  • 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
          • usually occurs after a direct compressive force is applied to the shoulder, i.e. after a fall or trauma
      • pathoanatomy
        • fracture displacement corresponds to
          • fracture location (e.g. extra-articular vs. intra-articular)
          • fracture pattern (e.g. simple vs. comminuted)
          • integrity of the coracoclavicular ligments
            • conoid (medial) and trapezoid (lateral) provide primary resistance to superior displacement of the lateral clavicle
          • age (e.g. pediatric patients usually have an intact periosteal sleeve)
        • deforming forces include
    • Associated conditions
      • rare but may include
        • floating shoulder
        • scapulothoracic dissociation
          • should be considered with significantly distracted or widened fractures
        • rib fracture
        • pneumothorax
        • neurovascular injury
  • Anatomy
    • Acromioclavicular joint anatomy
    • AC joint stability
      • static stabilizers
        • acromioclavicular (AC) ligament
          • provides anterior/posterior stability
          • inserts 6 mm from distal end of clavicle
          • components
            • superior
            • inferior
            • anterior
            • posterior
          • superior ligament is strongest, followed by posterior
        • coracoclavicular (CC) ligaments (trapezoid and conoid)
          • provides superior/inferior stability
          • components
            • trapezoid ligament (lateral)
              • inserts 2 - 3 cm from distal end of clavicle
              • attaches to the trapezoid tubercle, which is anterolateral to the conoid tubercle
            • conoid ligament (medial)
              • inserts 4-4.5 cm from distal end of clavicle in the posterior border
              • attaches to the conoid tubercle, which is posteromedial to the trapezoid tubercle
              • most important for vertical stability
        • 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
          • can see weakness of external rotation with the arm in adduction
  • Imaging
    • Radiographs
      • recommended views
        • upright AP of bilateral shoulders
        • axillary lateral
        • 15° cephalic tilt (zanca view)
          • helps to determine superior/inferior displacement
          • may consider having the patient hold 5-10 lbs of weight in the affected hand
    • 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
          • stable fractures (Neer Type I, III, IV)
          • pediatric distal clavicle fractures (skeletally immature)
    • Operative
      • open reduction internal fixation
        • indications
          • absolute
            • open or impending open fractures
            • subclavian artery or vein injury
            • floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement)
            • symptomatic nonunion
          • relative
            • unstable fracture patterns (Neer Type IIA, IIB, V)
            • brachial plexus injury (questionable because 66% have spontaneous return)
            • closed head injury
            • seizure disorder
            • polytrauma patient
  • Techniques
    • Sling Immobilization
      • technique
        • immobilize using sling or figure-of-eight brace
          • prospective studies have not shown a difference in functional or cosmetic outcomes between sling and figure-of-eight braces
        • 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%)
          • risk factors
            • Neer group II (up to 56%)
              • disrupted CC ligaments
            • advanced age
            • female gender
        • poorer cosmesis
    • Open Reduction Internal Fixation
      • techniques
        • limited contact dynamic compression plate
          • position
            • beach chair vs. supine
          • approach
            • superior approach to AC joint
            • temporary fixation with k wires
          • instrumentation
            • locking plates
            • precontoured anatomic plates
          • technique
            • need larger distal fragment for multiple locking screws
            • > 3-4 bicortical screws into medial fragment to reduce the risk of screw pull-out
        • hook plate
          • position
            • beach chair vs. supine
          • approach
            • superior approach to AC joint
            • temporary fixation with k wires
          • instrumentation
            • hook plates vary in hook depth and number of holes
            • proper hook depth ensures the AC joint is not over- or under-reduced
          • technique
            • hook plates are generally used when there is insufficent bone in the distal fragment for conventional clavicle plate fixation
            • hook should be placed posterior to AC joint and positioned as far lateral as possible to avoid hook escape
            • > 3-4 bicortical screws should be placed into the proximal (medial) fragment to reduce the risk of screw pull-out
            • requires a second procedure for hook plate removal
        • other options
          • AC joint spanning fixation
            • usually used as an alternative to hook plates
          • transacromial fixation
          • tension band wire
          • intramedullary screw fixation
          • coracoclavicular ligament repair/reconstruction
          • modified Weaver-Dunn procedure
            • primarily used for AC dislocations
            • can also be used for distal clavicle fractures with an easily excisable fragment and transferable CA ligament
      • 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
          • sling for 7-10 days followed by active motion
        • late
          • strengthening at ~6 weeks when pain-free motion and radiographic evidence of union
          • full activity including sports at ~3 months
          • hardware removal considered usually after 3 months
  • Complications
    • Nonoperative treatment
      • nonunion (~15%)
        • risk factors
          • comminution
          • displacement
          • Z deformity
          • female
          • older
          • smoker
          • distal third clavicle > middle third clavicle
        • treatment
          • if asymptomatic, no treatment necessary
          • if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
      • AC joint arthritis
        • risk factors
          • Neer Type I and III
        • treatment
          • distal clavicle resection
    • 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
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