Distal Clavicle Fractures: Diagnosis, Treatment, and Complications
Distal Clavicle Fractures: Diagnosis, Treatment, and Complications
Distal Clavicle Fractures
Distal clavicle fractures are traumatic injuries caused by direct trauma to the shoulder and are most common in older or osteoporotic patients. Diagnosis is confirmed with standard shoulder radiographs and treatment may involve immobilization or surgery, depending on the displacement and stability of the distal clavicle.
Epidemiology
Incidence: Distal clavicle fractures account for 2.6-4% of all adult fractures.
Demographics: These fractures are more common in older or osteoporotic patients and less common in pediatric patients.
Figure 1: Anatomy of AC Joint and CC Ligaments (Source: Hutaif Orthopedic Center)
Etiology
Pathophysiology: Distal clavicle fractures usually occur after a direct compressive force is applied to the shoulder, such as after a fall or trauma. Factors such as fracture location, pattern, and the integrity of the coracoclavicular (CC) ligaments can impact the degree of displacement and stability of the fracture.
Associated conditions: Rare but possible associated conditions may include floating shoulder, scapulothoracic dissociation, rib fracture, pneumothorax, and neurovascular injury.
Anatomy
The acromioclavicular (AC) joint and coracoclavicular (CC) ligaments are important static and dynamic stabilizers of the shoulder. The AC joint is stabilized by the AC and CC ligaments, while the CC ligaments provide superior/inferior stability to the clavicle and involve the trapezoid (lateral) and conoid (medial) ligaments.
(View Anatomy Images)Classification
Distal clavicle fractures are classified using the Neer or AO classification systems based on factors such as fracture location, pattern, and stability.
(View Classification Images)Presentation
Symptoms of distal clavicle fractures include anterior shoulder pain, swelling, ecchymosis, tenderness to palpation, and AC joint deformity. Physical examination may reveal tenting of skin and weakness of external rotation with the arm in adduction, and a careful neurovascular exam should be performed.
Imaging
Standard shoulder radiographs, including an upright AP of bilateral shoulders, an axillary lateral, and a 15° cephalic tilt view (zanca view) are used to confirm the diagnosis of distal clavicle fractures. CT may be used to evaluate displacement, shortening, comminution, articular extension, and nonunion.
(View Imaging Images)Treatment
Treatment of distal clavicle fractures may involve nonoperative treatment with sling immobilization and ROM exercises or operative treatment such as open reduction internal fixation. The choice of treatment depends on the displacement and stability of the fracture, as determined by whether CC ligaments are intact.
Complications
Complications of distal clavicle fractures may include nonunion, infection, neurovascular injury, hardware prominence, AC joint arthritis, and adhesive capsulitis.
Distal Clavicle Fractures: Causes, Diagnosis, Treatment, and Complications
Distal clavicle fractures result from direct compressive force on the shoulder, and are commonly seen in older or osteoporotic patients after a fall or trauma. They account for 2.6-4% of all adult fractures, with 10-25% occurring in the distal third segment. Fracture location, pattern, and the integrity of the coracoclavicular (CC) ligaments impact the degree of displacement and stability of the fracture, with the AC joint and CC ligaments providing vital shoulder stabilization. Diagnosis is confirmed with radiographs, including a 15° cephalic tilt view. Depending on displacement and stability, treatment may involve immobilization or surgery, including open reduction internal fixation or coracoclavicular ligament reconstruction. Possible complications include nonunion, infection, neurovascular injury, hardware prominence, AC joint arthritis, and adhesive capsulitis.
Fracture of the Distal End of the Clavicle: An In-Depth Review
The management of distal clavicle fractures has always been a source of confusion for orthopedic surgeons. With a more active lifestyle, patients today expect better cosmetic and functional outcomes from treatment. Despite the vast amount of literature available on the management of this common fracture, there is still no consensus regarding the gold standard treatment. In this article, we review the literature on various conservative and surgical techniques for managing this fracture and their respective pros and cons.
Keywords:
Fracture clavicle, Distal end clavicle, Neer type 2
Introduction
Fracture of the distal end of the clavicle is a unique injury that poses a challenge for orthopedic surgeons. With so many treatment options and numerous recommendations available in the literature, there is no consensus regarding the gold standard treatment for this injury. The unstable nature of these fractures makes them prone to non-union, potentially impeding normal shoulder function. Therefore, these fractures must be viewed as special injuries, and a definitive line of management must be outlined. In this article, we review the existing literature, putting forward the pros and cons of various treatment modalities for this fracture.
Epidemiology
Fracture of the clavicle is one of the most commonly encountered injuries in the emergency department, accounting for 2.6-4% of total adult fractures. There is a bimodal age distribution with the first peak occurring in young active adult males less than thirty years of age and the second peak occurring in elderly females with osteoporotic bones. Although fractures of the shaft are the most common, lateral end fractures constitute 21–28% of all clavicle fractures. Of these, 10-52% are displaced fractures.
Classification
Various classification systems have been proposed, each with its advantages and disadvantages. The Craig and Neer classifications are most helpful for determining prognosis and management of distal end fractures. In Neer's classification, Type 1 is a fracture lateral to the coracoclavicular ligament attachment, with minimal displacement. Type 2 fractures are medial to the ligament attachment and are subdivided into 2A, where both the conoid and the trapezoid ligaments are attached to the distal fragment, and 2B, where the conoid is detached from the proximal fragment while the trapezoid attaches to the distal fragment. Type 5 involves an avulsion fracture, leaving behind an inferior cortical fragment attached to the coracoclavicular ligament. Among these types, Type 2 and 5 are unstable and have been the subject of controversy.
Clinical and Radiological Assessment
Clinical diagnosis of a distal clavicle fracture may be challenging, and it can be confused with AC joint dislocation, AC joint osteoarthritis, and rarely, septic arthritis. Radiographic studies are necessary, with the 15-degree cephalad anteroposterior view and stress radiograph providing additional information about the integrity of the coracoclavicular ligament. Neer's classification is based on the simple anteroposterior radiograph.
Treatment
Operative fixation is needed due to the unstable nature of distal clavicle fractures. Treatment with functional non-operative management is associated with a higher risk of non-union. There are many rigid and flexible fixation methods available, with no single definitive treatment recommended. Treatment options can be broadly divided into conservative management, rigid fixation (such as osteosynthesis with locking plate, hook plate fixation, fixation with distal radius locking plate, coracoclavicular screws, Knowles pin fixation), and flexible fixation (such as simple K-wire fixation, tension band wiring, suture anchors, vicryl tape, dacron arterial graft for coracoclavicular ligament reconstruction). Studies show that among the available techniques, while rigid fixation techniques produce good functional outcomes, they have higher major complication rates and need for re-surgery. Flexible fixation techniques, on the other hand, avoid implant-related secondary complications and need for implant removal. Further studies with higher levels of evidence are needed to establish the single definitive treatment for this fracture.
Conclusion
The unstable nature of distal clavicle fractures necessitates operative fixation. While flexible fixation techniques such as coracoclavicular screws and flexible coracoclavicular fixations showed fewer complications, rigid fixation techniques like hook plate, locking plate, and distal radius plates tended to produce more major complications and a definite need for implant removal. Rigid fixations therefore needed re-surgery for implant removal, which put the patient under the risk of general anesthesia. Further studies with higher levels of evidence are needed to establish the single definitive treatment for this special fracture.