Archives of Orthopaedic and Trauma Surgery

, Volume 137, Issue 5, pp 651–662 | Cite as

Comparative analysis of locking plate versus hook plate osteosynthesis of Neer type IIB lateral clavicle fractures

  • Benjamin Erdle
  • Kaywan Izadpanah
  • Martin Jaeger
  • Patrizia Jensen
  • Lukas Konstantinidis
  • Jörn Zwingmann
  • Norbert P. Südkamp
  • Dirk Maier
Trauma Surgery



Controversy exists on optimal operative treatment of vertically unstable Neer IIB lateral clavicle fractures. Aim of this study was to analyse and compare clinical and radiological results and complications of locking plate osteosynthesis (LPO) versus hook plate osteosynthesis (HPO) with acromioclavicular joint (ACJ) stabilization. The hypothesis was, that HPO would recreate coracoclavicular stability more effectively and potentially lead to a superior outcome.


This retrospective, observational cohort study included 32 patients (19 HPO, 13 LPO) with a mean age of 44.1 ± 14.2 years at surgery. The mean follow-up period was 54.2 months (range 25.2–111.4 months). Besides standard radiography, bilateral coracoclavicular distances were assessed by means of preoperative and follow-up stress radiographs after implant removal. Clinical outcome measures included the Constant score (CS), the Oxford shoulder score (OSS), the subjective shoulder value (SSV) and the Taft score (TS).


Bone union occurred in all but one patient and proved to occur delayed in five patients (15.6%). Radiographical healing required a mean of 4.2 ± 4.0 months irrespective of the type of osteosynthesis. At follow-up, mean coracoclavicular distance was increased by 34% (±36) without significant differences between both groups. HPO patients obtained a significantly lower TS (HPO: 9.5 ± 1.5 points, LPO: 11.1 ± 1.3 points; p = 0.005). Other mean score values did not differ (CS: 90.1 ± 7.4 points, OSS: 43.2 ± 9.2 points, SSV: 91.1 ± 14.7%). Sixteen patients (50.0%) experienced complications. Overall prevalence of complications was significantly higher in the HPO group (p = 0.014).


Both HPO and LPO were equally effective in relation to restoration of vertical stability, overall functional outcome and fracture consolidation in treatment of Neer IIB fractures. Contrary to our hypothesis, HPO was not associated with superior recreation of the coracoclavicular distance. Considerable drawbacks of HPO were an inferior ACJ-specific outcome (Taft-Score) and a higher overall complication rate.

Level of evidence IV.


Distal clavicle fracture Neer type IIB Coracoclavicular distance Locking plate Clavicular hook plate Acromioclavicular joint 


Compliance with ethical standards

Conflict of interest

None of the above authors declare to have received any source of support in the form of grants, equipment, or other items. The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Institutional Review Board (IRB) or Ethical Committee approval

Ethical Committee, Albert-Ludwigs-University Freiburg, Engelberger Strasse 21, 79106 Freiburg; Study number 397/15.


  1. 1.
    Andersen JR, Willis MP, Nelson R, Mighell MA (2011) Precontoured superior locked plating of distal clavicle fractures: a new strategy. Clin Orthop Relat Res 469(12):3344–3350. doi: 10.1007/s11999-011-2009-5 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Beirer M, Siebenlist S, Cronlein M, Postl L, Huber-Wagner S, Biberthaler P, Kirchhoff C (2014) Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study. BMC Musculoskelet Disord 15:380. doi: 10.1186/1471-2474-15-380 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Beirer M, Zyskowski M, Cronlein M, Pforringer D, Schmitt-Sody M, Sandmann G, Huber-Wagner S, Biberthaler P, Kirchhoff C (2015) Concomitant intra-articular glenohumeral injuries in displaced fractures of the lateral clavicle. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3875-2 Google Scholar
  4. 4.
    Boehm D (2002) Scores. In: Gohlke F, Hedtmann A (eds) Schulter: Das Standardwerk für Klinik und Praxis. Thieme, Stuttgart, pp 98–104Google Scholar
  5. 5.
    Constant CR, Murley AH (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res (214):160–164Google Scholar
  6. 6.
    Craig E (1990) Fractures of the clavicle. In: Rockwood CA, Matsen FA (eds) The shoulder. WB Saunders, Philadelphia, pp 367–412Google Scholar
  7. 7.
    Dawson J, Fitzpatrick R, Carr A (1996) Questionnaire on the perceptions of patients about shoulder surgery. J Bone Jt Surg Br 78(4):593–600Google Scholar
  8. 8.
    Fleming MA, Dachs R, Maqungo S, du Plessis JP, Vrettos BC, Roche SJ (2015) Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates. J Shoulder Elbow Surg 24(5):700–704. doi: 10.1016/j.jse.2014.09.024 CrossRefPubMedGoogle Scholar
  9. 9.
    Gilbart MK, Gerber C (2007) Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 16(6):717–721. doi: 10.1016/j.jse.2007.02.123 CrossRefPubMedGoogle Scholar
  10. 10.
    Good DW, Lui DF, Leonard M, Morris S, McElwain JP (2012) Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study. J Shoulder Elbow Surg 21(8):1045–1048. doi: 10.1016/j.jse.2011.07.020 CrossRefPubMedGoogle Scholar
  11. 11.
    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):419–423. doi: 10.1016/j.jse.2005.11.012 CrossRefPubMedGoogle Scholar
  12. 12.
    Hohmann E, Hansen T, Tetsworth K (2012) Treatment of Neer type II fractures of the lateral clavicle using distal radius locking plates combined with TightRope augmentation of the coraco-clavicular ligaments. Arch Orthop Trauma Surg 132(10):1415–1421. doi: 10.1007/s00402-012-1570-z CrossRefPubMedGoogle Scholar
  13. 13.
    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):60–62. doi: 10.1016/j.jse.2007.04.012 CrossRefPubMedGoogle Scholar
  14. 14.
    Kashii M, Inui H, Yamamoto K (2006) Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res 447:158–164. doi: 10.1097/01.blo.0000203469.66055.6a CrossRefPubMedGoogle Scholar
  15. 15.
    Klein SM, Badman BL, Keating CJ, Devinney DS, Frankle MA, Mighell MA (2010) Results of surgical treatment for unstable distal clavicular fractures. J Shoulder Elbow Surg 19(7):1049–1055. doi: 10.1016/j.jse.2009.11.056 CrossRefPubMedGoogle Scholar
  16. 16.
    Kraus N, Stein V, Gerhardt C, Scheibel M (2015) Arthroscopically assisted stabilization of displaced lateral clavicle fractures with coracoclavicular instability. Arch Orthop Trauma Surg 135(9):1283–1290. doi: 10.1007/s00402-015-2271-1 CrossRefPubMedGoogle Scholar
  17. 17.
    Largo RD, Rudin MA, Hotz TK, Valderrabano V, Kach KK (2011) Anatomic reconstruction of unstable lateral clavicular fractures. J Trauma 71(5):1348–1351. doi: 10.1097/TA.0b013e3182095dd1 CrossRefPubMedGoogle Scholar
  18. 18.
    Lee SK, Lee JW, Song DG, Choy WS (2013) Precontoured locking plate fixation for displaced lateral clavicle fractures. Orthopedics 36(6):801–807. doi: 10.3928/01477447-20130523-28 CrossRefPubMedGoogle Scholar
  19. 19.
    Loriaut P, Moreau PE, Dallaudiere B, Pelissier A, Vu HD, Massin P, Boyer P (2015) Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device. Knee Surg Sports Traumatol Arthrosc 23(5):1429–1433. doi: 10.1007/s00167-013-2772-9 CrossRefPubMedGoogle Scholar
  20. 20.
    Martetschlager F, Kraus TM, Schiele CS, Sandmann G, Siebenlist S, Braun KF, Stockle U, Freude T, Neumaier M (2013) Treatment for unstable distal clavicle fractures (Neer 2) with locking T-plate and additional PDS cerclage. Knee Surg Sports Traumatol Arthrosc 21(5):1189–1194. doi: 10.1007/s00167-012-2089-0 CrossRefPubMedGoogle Scholar
  21. 21.
    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):277–283. doi: 10.1016/j.injury.2005.10.017 CrossRefPubMedGoogle Scholar
  22. 22.
    Motta P, Bruno L, Maderni A, Tosco P, Mariotti U (2014) Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope. J Shoulder Elbow Surg 23(3):e47–e52. doi: 10.1016/j.jse.2013.05.016 CrossRefPubMedGoogle Scholar
  23. 23.
    Oh JH, Kim SH, Lee JH, Shin SH, Gong HS (2011) Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg 131(4):525–533. doi: 10.1007/s00402-010-1196-y CrossRefPubMedGoogle Scholar
  24. 24.
    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):570–574. doi: 10.1097/BOT.0b013e318193d878 CrossRefPubMedGoogle Scholar
  25. 25.
    Schliemann B, Rosslenbroich SB, Schneider KN, Petersen W, Raschke MJ, Weimann A (2013) Surgical treatment of vertically unstable lateral clavicle fractures (Neer 2b) with locked plate fixation and coracoclavicular ligament reconstruction. Arch Orthop Trauma Surg 133(7):935–939. doi: 10.1007/s00402-013-1737-2 CrossRefPubMedGoogle Scholar
  26. 26.
    Schwarting T, Lechler P, Bockmann B, Debus F, Ziring E, Frink M (2015) The benefit of arthroscopically assisted therapy for concomitant glenohumeral injuries in patients with unstable lateral clavicle fractures. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3909-9 PubMedGoogle Scholar
  27. 27.
    Shin SJ, Ko YW, Lee J, Park MG (2015) Use of plate fixation without coracoclavicular ligament augmentation for unstable distal clavicle fractures. J Shoulder Elbow Surg. doi: 10.1016/j.jse.2015.10.016 Google Scholar
  28. 28.
    Stegeman SA, Nacak H, Huvenaars KH, Stijnen T, Krijnen P, Schipper IB (2013) Surgical treatment of Neer type-II fractures of the distal clavicle: a meta-analysis. Acta Orthop 84(2):184–190. doi: 10.3109/17453674.2013.786637 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Taft TN, Wilson FC, Oglesby JW (1987) Dislocation of the acromioclavicular joint. An end-result study. J Bone Jt Surg Am 69(7):1045–1051CrossRefGoogle Scholar
  30. 30.
    Tiren D, van Bemmel AJ, Swank DJ, van der Linden FM (2012) Hook plate fixation of acute displaced lateral clavicle fractures: mid-term results and a brief literature overview. J Orthop Surg Res 7:2. doi: 10.1186/1749-799X-7-2 CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Tiren D, Vroemen JP (2013) Superior clavicle plate with lateral extension for displaced lateral clavicle fractures: a prospective study. J Orthop Traumatol 14(2):115–120. doi: 10.1007/s10195-013-0228-0 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Zhang C, Huang J, Luo Y, Sun H (2014) Comparison of the efficacy of a distal clavicular locking plate versus a clavicular hook plate in the treatment of unstable distal clavicle fractures and a systematic literature review. Int Orthop 38(7):1461–1468. doi: 10.1007/s00264-014-2340-z CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Benjamin Erdle
    • 1
  • Kaywan Izadpanah
    • 1
  • Martin Jaeger
    • 1
  • Patrizia Jensen
    • 1
  • Lukas Konstantinidis
    • 1
  • Jörn Zwingmann
    • 1
  • Norbert P. Südkamp
    • 1
  • Dirk Maier
    • 1
  1. 1.Department of Orthopaedics and Trauma SurgeryMedical Centre/Faculty of Medicine - Albert-Ludwigs-University of FreiburgFreiburgGermany

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