Page 50 - ISAKOS 2021 Newsletter Volume 1

CURRENT CONCEPTS
Management of Distal Clavicular Fractures
Introduction
Prashant Meshram, MS, DNB
Johns Hopkins University, Lutherville, Maryland, UNITED STATES
Edward G. McFarland, MD
Johns Hopkins at Green Springs, Lutherville, Maryland, UNITED STATES
Uma Srikumaran, MD
Johns Hopkins, Columbia, Maryland, UNITED STATES
Stephen C. Weber, MD
The Johns Hopkins School of Medicine, San Diego, California, UNITED STATES
01 Modified Neer classification for distal clavicular fractures. (Reprinted with permission from: Banerjee R, Waterman B, Padalecki J, Robertson W. Management of distal clavicle fractures. J Am Acad Orthop Surg. 2011;19[7]:392-401.)
In both Type-I and Type-III fractures, the distal fragment is nondisplaced as the fracture is located distal to the CC ligaments; as such, these fractures typically heal with nonoperative treatment. In Type-II and Type-V fractures, the main controversy is related to the type of treatment (nonoperative versus operative). The main impetus for this controversy is the observation that nonoperative treatment of Type-II and Type-V fractures is associated with a nonunion rate of 33% (Fig. 2), whereas operative treatment is associated with a nonunion rate of only 6.7%1,2. Despite this difference, most studies have shown no significant difference in functional scores between patients managed nonoperatively and those managed operatively1,2. As a result, some surgeons advocate early operative intervention, whereas others note that, over time, patients who receive nonoperative treatment function just as well as those who receive operative intervention. In addition, among surgeons who recommend operative treatment, there is no agreement with regard to which surgical technique is most effective1-4. The aim of the current review is to summarize the advantages and disadvantages of various surgical techniques recommended in the literature for Type-II and Type-V distal clavicular fractures.
While the clavicle is one of the most commonly fractured bones in the body, fractures of the distal part of the clavicle account for 2.6% to 4%1 of all adult fractures and 10% to 30%2 of all clavicular fractures. Distal clavicular fractures have a bimodal age distribution, with a first peak in active young adults and a second peak, usually due to falls, in elderly people. The most common classification system is the Neer system, in which Type-I is a nondisplaced fracture, Type-II is a fracture with disruption of the coracoclavicular (CC) ligaments, and Type-III is an intra-articular fracture (Fig. 1). Later additions to this system include Type-IV fractures, which are rare and in the pediatric population involve disruption of the periosteal sleeve, with the epiphysis and physis mostly maintaining their relationship to the shoulder joint. Type-V fractures involve avulsion of the CC ligaments along with a fragment of bone from the inferior portion of the clavicular shaft, with subsequent superior displacement of the distal part of the clavicle.
48 ISAKOS NEWSLETTER 2021: VOLUME I