Most distal clavicle fractures will heal successfully and uneventfully with nonoperative management. Initial management typically requires temporary immobilization for comfort followed by gradual increase in activity.
Operative fixation is indicated for selected cases of displaced distal clavicle fractures in high demand patients. Plate fixation is a preferred technique if distal clavicular bone purchase is adequate.
Precontoured anatomic plates with locking capabilities facilitate and optimize fixation in the distal fragment.
While hook plate fixation is an option for those fractures with inadequate distal screw purchase, the high rate of plate irritation and subsequent need of removal of hook plates makes anatomic plate fixation preferred if technically feasible.
Pitfall: The typical mode of failure of distal clavicle fixation is pullout of the distal fixation with redisplacement of the shaft. It is mandatory for the operating surgeon to obtain sufficient distal fixation consistent with the expected compliance and healing potential of the patient such that union will occur prior to potential hardware failure. If, in the opinion of the operating surgeon, this is not obtainable with conventional plate fixation, convert to hook plate fixation.
Following reflection of the deltoid, the distal clavicle fracture site is identified and cleared of any hematoma or debris.
Pitfall: it is important to preserve the integrity of the acromioclavicular joint capsule, as this contributes to stability of the small distal clavicular fragment.
A sterile 18 gauge needle is used to identify the acromioclavicular joint. This allows the surgeon to determine accurately the size and integrity of the distal clavicular fragment. Assessment is then performed to determine whether conventional plate fixation is possible, or if hook plate fixation is required.
Reduction can be performed using fracture clamps on the proximal and distal fragments, with downward and anterior pressure on the proximal fragment and superiorly directed force on the shoulder girdle and attached distal fragment.
Alternatively, a ball spiked pusher may be utilized to align the fragments.
Following accurate reduction, temporary fixation with a K-wire directed from anterior to posterior can be performed.
Alternatively (and preferentially) if fracture configuration permits, a lag screw can be placed at this point.
An anatomical precontoured plate for the distal clavicle is chosen for fixation. Advantages of these plates include the insertion of multiple (locked or unlocked) screws in the distal fragment to maximize fixation. Use the guide jigs to help you determine the predetermined pattern of locking screws which may also increase fixation strength.
While fixation is typically weakest in the distal fragment, it is important to assure proximal fixation with at least 3 bicortical screws in the shaft fragment.
Placement and temporary securement of the plate
The plate is then positioned on the distal clavicle and temporarily fixed with either K-wires drilled through preset holes in the plate or with a reduction clamp.
Pitfall: It is important to avoid screw penetration into the acromioclavicular joint. If there is any doubt an intraoperative radiograph can confirm plate position.
Alternative 1: Application in compression mode
If fracture pattern is amenable to compression, the plate can be applied in compression mode. To do this, screws are placed in the distal fragment to secure the plate to the distal fragment. Typically, cancellous screws are used in the distal fragment.
If desired threaded drill sleeves can be used to insert locking screws in a preset pattern in the distal fragment.
Then, a compression screw is inserted in the shaft of the plate to compress the fracture site.
Alternative 2: Application in neutralization mode with lag screw through plate
Alternatively, if fracture configuration permits, a lag screw can be inserted across the fracture site through the plate. Following this step, remaining screws in the plate may be inserted.
Pearl: Additional stability
Redisplacement of the shaft fragment can be further prevented by the insertion of a coracoclavicular screw inserted through the plate and then into the coracoid. One must aim for the posterior base portion of the coracoid. Due to the intrinsic motion between the clavicle and the coracoid this screw will eventually loosen or break, but will provide 6-8 weeks of added fixation before failure. The placement of this screw is at the surgeon's discretion when added stability is deemed necessary.
5. Check of osteosynthesis
At the conclusion of fixation, the fracture site, plate and screws are carefully checked to ascertain accurate reduction, correct plate placement, and avoidance of any intra-articular screw placement. If any doubt remains regarding these findings, an intraoperative radiograph should be taken for confirmation.
Two days post-surgery the main surgical dressing may be removed and showers are permitted and a light dry dressing may be applied. Soaking in baths, hot tubs and swimming pools are not permitted until minimum two weeks after surgery when the wound is completely healed and the sutures and staples have been removed.
Plate removal from the clavicle is not routinely required or recommended. Symptomatic prominence and impingement of the clavicle plate can occur. After the fracture has completely healed, removal of the implant may be a consideration.
Athletes who return to contact sports should only have the plate removed if absolutely necessary and if so, done at the end of the season to allow maximal healing prior to return to sport.
Many patients who request hardware removal from local symptomatology 6-12 months after implantation find that symptoms diminish significantly by 2 years postoperatively and defer hardware removal indefinitely.
The patient should sleep wearing the sling on his/her back or on the non-injured side.
When sleeping on the side, a pillow can be placed across the chest to support the injured side.
When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm.
It may be more comfortable sleeping in a sitting or semi reclined position.
A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while bathing. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.
Loose fitting clothing and button-up shirts are ideal. The affected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.
Sling support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture shows early evidence of healing radiographically.
Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function. The phases of nonoperative treatment are thus:
Passive/assisted range of motion
Active range of motion
Progressive resistance exercises
Usually immobilization is maintained for 1-2 weeks for comfort and wound healing purposes. The use of the sling is gradually decreased at this point.
This is followed by gentle range of motion exercises.
Non-weight-bearing of the affected upper limb is continued for approximately for 6 weeks or until radiographic and clinical evidence of progressive healing.
Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending on the injury and patient symptoms.
Phase I: Day one after surgery
After clavicular surgery, it is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended:
Straightening and flexion of the elbow
Open and closure of the hand
Squeezing of a soft ball
Bending of the wrist forward, backwards and in a circular motion
Movement of an open hand from side to side
Squeezing the shoulder blades together, while shoulders remain relaxed
Phase II: Two to six weeks after surgery
Pendular exercises can be started when pain starts to subside.
Gradual progression to passive and assisted range of motion exercises are started as tolerated. Scapular stabilization must be observed to restore normal kinetics to shoulder motion.
Activated assisted range of motion exercises are started with:
Flexion with arms on table
Flexion with ball on wall
Sub-maximal isometric exercises with:
External rotation (1)
Note: Timing and progression of exercises are ultimately directed by the operating surgeon as factors such as bone quality, type of fracture and fixation may vary in individuals.
Phase III: Six to twelve weeks after surgery
Pending clinical and radiographic review by the operating surgeon, weight-bearing may now be permitted and gradual resisted/strengthening exercises can begin.
Return to full activities and/or contact sports is permitted once the fracture is united and the extremity has regained full strength. Typically this takes around 6 months post injury. It may be sooner or later depending on the patient factors, progress of fracture healing and response to rehabilitation.
If there has been no progress on serial radiographs of fracture healing, at 3 months, then delayed or impaired healing may be present. If the fracture has not united after 9 months surgical intervention should be considered.