Archives of Orthopaedic and Trauma Surgery

, Volume 131, Issue 4, pp 525–533 | Cite as

Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures

  • Joo Han Oh
  • Sae Hoon KimEmail author
  • Jung Ha Lee
  • Seung Han Shin
  • Hyun Sik Gong
Trauma Surgery


The Neer type II distal clavicle fracture is notorious for its high nonunion rate, and surgical treatment is usually recommended. We reviewed articles from January 1990 to September 2009, and among them, 425 cases from 21 studies were included. According to the 425 cases in the literature, sixty patients were treated nonsurgically and 365 surgically. From 365 patients who were treated surgically, 105 were identified as receiving the coracoclavicular stabilization, 162 hook plate, 42 intramedullary fixation, 16 interfragmentary fixation, and 40 K-wire plus tension band wiring. The nonsurgical treatment resulted in 20 (33.3%) nonunions and 4 (6.7%) other complications. The surgical treatment resulted in 6 (1.6%) nonunions, 81 (22.2%) complications other than nonunion. The nonunion rate was significantly high with nonsurgical treatment (p < 0.001), and the complication rate was statistically high with surgery (p = 0.002). With surgical treatment, the nonunion rate was not significantly different among the modalities (p = 0.391). The complication rate was significantly higher in cases of the hook plate (40.7%) and the K-wire plus tension band wiring (20.0%) than those of the coracoclavicular stabilization (4.8%), the intramedullary (2.4%) and the interfragmentary fixation (6.3%). For the nonsurgical treatment, the functional outcomes were generally acceptable despite the high nonunion rate. The nonsurgical treatment could be considered as the first line treatment after sufficient counsel with the patient. The nonunion rate is high, however, the functional outcome is acceptable in most of the cases with nonunion. If the surgical treatment is considered, the intramedullary screw fixation, CC stabilization and interfragmentary fixation would be preferred because of their low complication rate.


Distal clavicle fracture Nonunion Complication Functional result 


Conflict of interest

There is no conflict of interest among the authors.


  1. 1.
    Nordqvist A, Petersson C (1994) The incidence of fractures of the clavicle. Clin Orthop Relat Res 300:127–132PubMedGoogle Scholar
  2. 2.
    Postacchini F, Gumina S, De Santis P, Albo F (2002) Epidemiology of clavicle fractures. J Shoulder Elbow Surg 11(5):452–456PubMedCrossRefGoogle Scholar
  3. 3.
    Craig E (1998) Fractures of the clavicle. In: Rockwood CA Jr, (ed) The shoulder. W.B. Saunders, Philadelphia, pp 428–482Google Scholar
  4. 4.
    Neer C (1984) Fractures in adults. J B Lippincott Company, PhiladelphiaGoogle Scholar
  5. 5.
    Meda PV, Machani B, Sinopidis C, Braithwaite I, Brownson P, Frostick SP (2006) Clavicular hook plate for lateral end fractures: a prospective study. Injury 37(3):277–283PubMedCrossRefGoogle Scholar
  6. 6.
    Neer CS II (1968) Fractures of the distal third of the clavicle. Clin Orthop Relat Res 58:43–50PubMedGoogle Scholar
  7. 7.
    Neer CS II (1963) Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma 3:99–110PubMedCrossRefGoogle Scholar
  8. 8.
    Heppenstall RB (1975) Fractures and dislocations of the distal clavicle. Orthop Clin North Am 6(2):477–486PubMedGoogle Scholar
  9. 9.
    Edwards DJ, Kavanagh TG, Flannery MC (1992) Fractures of the distal clavicle: a case for fixation. Injury 23(1):44–46PubMedCrossRefGoogle Scholar
  10. 10.
    Eskola A, Vainionpaa S, Patiala H, Rokkanen P (1987) Outcome of operative treatment in fresh lateral clavicular fracture. Ann Chir Gynaecol 76(3):167–169PubMedGoogle Scholar
  11. 11.
    Herscovici D Jr, Sanders R, DiPasquale T, Gregory P (1995) Injuries of the shoulder girdle. Clin Orthop Relat Res 318:54–60Google Scholar
  12. 12.
    Hessmann M, Kirchner R, Baumgaertel F, Gehling H, Gotzen L (1996) Treatment of unstable distal clavicular fractures with and without lesions of the acromioclavicular joint. Injury 27(1):47–52PubMedCrossRefGoogle Scholar
  13. 13.
    Neviaser RJ (1987) Injuries to the clavicle and acromioclavicular joint. Orthop Clin North Am 18(3):433–438PubMedGoogle Scholar
  14. 14.
    Poigenfurst J, Rappold G, Fischer W (1992) Plating of fresh clavicular fractures: results of 122 operations. Injury 23(4):237–241PubMedCrossRefGoogle Scholar
  15. 15.
    Post M (1989) Current concepts in the treatment of fractures of the clavicle. Clin Orthop Relat Res 245:89–101Google Scholar
  16. 16.
    Zenni EJ Jr, Krieg JK, Rosen MJ (1981) Open reduction and internal fixation of clavicular fractures. J Bone Joint Surg Am 63(1):147–151PubMedGoogle Scholar
  17. 17.
    Neer CS II (1960) Nonunion of the clavicle. J Am Med Assoc 172:1006–1011PubMedGoogle Scholar
  18. 18.
    Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA (2002) A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis 61(1–2):32–39PubMedGoogle Scholar
  19. 19.
    Deafenbaugh MK, Dugdale TW, Staeheli JW, Nielsen R (1990) Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study. Contemp Orthop 20(4):405–413PubMedGoogle Scholar
  20. 20.
    Webber MC, Haines JF (2000) The treatment of lateral clavicle fractures. Injury 31(3):175–179PubMedCrossRefGoogle Scholar
  21. 21.
    Tambe AD, Motkur P, Qamar A, Drew S, Turner SM (2006) Fractures of the distal third of the clavicle treated by hook plating. Int Orthop 30(1):7–10PubMedCrossRefGoogle Scholar
  22. 22.
    Robinson CM, Cairns DA (2004) Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 86-A(4):778–782Google Scholar
  23. 23.
    Flinkkila T, Ristiniemi J, Hyvonen P, Hamalainen M (2002) Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand 73(1):50–53PubMedCrossRefGoogle Scholar
  24. 24.
    Levy O (2003) Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg 12(1):24–28PubMedCrossRefGoogle Scholar
  25. 25.
    Flinkkila T, Ristiniemi J, Lakovaara M, Hyvonen P, Leppilahti J (2006) Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients. Acta Orthop 77(4):644–649PubMedCrossRefGoogle Scholar
  26. 26.
    Kona J, Bosse MJ, Staeheli JW, Rosseau RL (1990) Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 4(2):115–120PubMedCrossRefGoogle Scholar
  27. 27.
    Jackson WF, Bayne G, Gregg-Smith SJ (2006) Fractures of the lateral third of the clavicle: an anatomic approach to treatment. J Trauma 61(1):222–225PubMedCrossRefGoogle Scholar
  28. 28.
    Wang SJ, Wong CS (2008) Extra-articular knowles pin fixation for unstable distal clavicle fractures. J Trauma 64(6):1522–1527PubMedCrossRefGoogle Scholar
  29. 29.
    Shin SJ, Roh KJ, Kim JO, Sohn HS (2009) Treatment of unstable distal clavicle fractures using two suture anchors and suture tension bands. InjuryGoogle Scholar
  30. 30.
    Goldberg JA, Bruce WJ, Sonnabend DH, Walsh WR (1997) Type 2 fractures of the distal clavicle: a new surgical technique. J Shoulder Elbow Surg 6(4):380–382PubMedCrossRefGoogle Scholar
  31. 31.
    Chen CH, Chen WJ, Shih CH (2002) Surgical treatment for distal clavicle fracture with coracoclavicular ligament disruption. J Trauma 52(1):72–78PubMedCrossRefGoogle Scholar
  32. 32.
    Bezer M, Aydin N, Guven O (2005) The treatment of distal clavicle fractures with coracoclavicular ligament disruption: a report of 10 cases. J Orthop Trauma 19(8):524–528PubMedCrossRefGoogle Scholar
  33. 33.
    Herrmann S, Schmidmaier G, Greiner S (2009) Stabilisation of vertical unstable distal clavicular fractures (Neer 2b) using locking T-plates and suture anchors. Injury 40(3):236–239PubMedCrossRefGoogle Scholar
  34. 34.
    Yamaguchi H, Arakawa H, Kobayashi M (1998) Results of the Bosworth method for unstable fractures of the distal clavicle. Int Orthop 22(6):366–368PubMedCrossRefGoogle Scholar
  35. 35.
    Jin CZ, Kim HK, Min BH (2006) Surgical treatment for distal clavicle fracture associated with coracoclavicular ligament rupture using a cannulated screw fixation technique. J Trauma 60(6):1358–1361PubMedCrossRefGoogle Scholar
  36. 36.
    Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY (2001) Treatment of distal clavicle fracture using Kirschner wires and tension-band wires. J Trauma 51(3):522–525PubMedCrossRefGoogle Scholar
  37. 37.
    Nordqvist A, Petersson C, Redlund-Johnell I (1993) The natural course of lateral clavicle fracture. 15 (11–21) year follow-up of 110 cases. Acta Orthop Scand 64(1):87–91Google Scholar
  38. 38.
    Haidar SG, Krishnan KM, Deshmukh SC (2006) Hook plate fixation for type II fractures of the lateral end of the clavicle. J Shoulder Elbow Surg 15(4):419–423PubMedCrossRefGoogle Scholar
  39. 39.
    Kalamaras M, Cutbush K, Robinson M (2008) A method for internal fixation of unstable distal clavicle fractures: early observations using a new technique. J Shoulder Elbow Surg 17(1):60–62PubMedCrossRefGoogle Scholar
  40. 40.
    Lee YS, Lau MJ, Tseng YC, Chen WC, Kao HY, Wei JD (2008) Comparison of the efficacy of hook plate versus tension band wire in the treatment of unstable fractures of the distal clavicle. Int OrthopGoogle Scholar
  41. 41.
    Ballmer FT, Gerber C (1991) Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. J Bone Joint Surg Br 73(2):291–294Google Scholar
  42. 42.
    Fazal MA, Saksena J, Haddad FS (2007) Temporary coracoclavicular screw fixation for displaced distal clavicle fractures. J Orthop Surg (Hong Kong) 15(1):9–11Google Scholar
  43. 43.
    Macheras G, Kateros KT, Savvidou OD, Sofianos J, Fawzy EA, Papagelopoulos PJ (2005) Coracoclavicular screw fixation for unstable distal clavicle fractures. Orthopedics 28(7):693–696PubMedGoogle Scholar
  44. 44.
    Mall JW, Jacobi CA, Philipp AW, Peter FJ (2002) Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: an alternative osteosynthesis. J Orthop Sci 7(5):535–537PubMedCrossRefGoogle Scholar
  45. 45.
    Kashii M, Inui H, Yamamoto K (2006) Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res 447:158–164PubMedCrossRefGoogle Scholar
  46. 46.
    Mizue F, Shirai Y, Ito H (2000) Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. J Nippon Med Sch 67(1):32–34PubMedCrossRefGoogle Scholar
  47. 47.
    Muramatsu K, Shigetomi M, Matsunaga T, Murata Y, Taguchi T (2007) Use of the AO hook-plate for treatment of unstable fractures of the distal clavicle. Arch Orthop Trauma Surg 127(3):191–194PubMedCrossRefGoogle Scholar
  48. 48.
    Renger RJ, Roukema GR, Reurings JC, Raams PM, Font J, Verleisdonk EJ (2009) The clavicle hook plate for Neer type II lateral clavicle fractures. J Orthop Trauma 23(8):570–574PubMedCrossRefGoogle Scholar
  49. 49.
    Fann CY, Chiu FY, Chuang TY, Chen CM, Chen TH (2004) Transacromial Knowles pin in the treatment of Neer type 2 distal clavicle fracturesA prospective evaluation of 32 cases. J Trauma 56(5):1102–1105; discussion 1105–1106Google Scholar
  50. 50.
    Scadden JE, Richards R (2005) Intramedullary fixation of Neer type 2 fractures of the distal clavicle with an AO/ASIF screw. Injury 36(10):1172–1175PubMedCrossRefGoogle Scholar
  51. 51.
    Badhe SP, Lawrence TM, Clark DI (2007) Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures. Arch Orthop Trauma Surg 127(1):25–28PubMedCrossRefGoogle Scholar
  52. 52.
    Haidar SG, Singh Shergill G (2007) Re: clavicular hook plate for lateral end fractures: a prospective study. Injury 38(2):252–253PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Joo Han Oh
    • 1
  • Sae Hoon Kim
    • 1
    Email author
  • Jung Ha Lee
    • 1
  • Seung Han Shin
    • 1
  • Hyun Sik Gong
    • 1
  1. 1.Department of Orthopedic SurgerySeoul National University College of Medicine, Seoul National University HospitalSeoulKorea

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