Management of Distal Clavicle Fractures
Management of Distal Clavicle Fractures
Management of Distal Clavicle Fractures
Abstract
Rahul Banerjee, MD Most clavicle fractures heal without difficulty. However, radiographic
Brian Waterman, MD nonunion after distal clavicle fracture has been reported in 10% to
44% of patients. Type II distal clavicle fractures, which involve
Jeff Padalecki, MD
displacement, are associated with the highest incidence of
William Robertson, MD nonunion. Several studies have questioned the clinical relevance of
distal clavicle nonunion, however. Nonsurgical and surgical
management provide similar results. The decision whether to
operate may be influenced by the amount of fracture displacement
and the individual demands of the patient. Surgical options to
achieve bony union include transacromial wire fixation, a modified
Weaver-Dunn procedure, use of a tension band, screw fixation,
plating, and arthroscopy. Each technique has advantages and
disadvantages; insufficient evidence exists to demonstrate that any
one technique consistently provides the best results.
Clinical Evaluation
Most distal clavicle fractures are the
result of a fall onto the distal clavicle
Illustration of the Robinson classification of distal clavicle fractures (type 3). or a direct blow to it.1,16 Direct impact
Type A, cortical alignment fractures: 1, extra-articular; 2, intra-articular. Type occurs at the acromion, usually with
B, displaced fractures: 1, extra-articular; 2, intra-articular. (Redrawn with
permission from Robinson CM: Fractures of the clavicle in the adult:
the arm in an adducted position, and
Epidemiology and classification. J Bone Joint Surg Br 1998;80[3]:476-484.) force is transmitted through the AC
joint to the CC ligaments and the dis-
tal clavicle. Patients with distal clavicle
jury. In Neer type IIB fractures, the taphysis. Depending on the degree of fractures typically present with shoul-
conoid ligament is torn, but the trap- displacement, these patients are der pain. Associated injuries should be
ezoid is presumed to remain attached treated with closed or open reduc- ruled out, such as other injuries to the
to the distal fragment.12 This classifi- tion.14 In type V fracture, only a shoulder girdle, rib fracture, ipsilateral
cation was developed before wide- small inferior cortical fragment re- upper extremity injury, and injury to
spread use of MRI, and we are un- mains attached to the CC ligaments. the thorax or cervical spine. These are
aware of any study that has Type V fractures are functionally particularly likely to occur in conjunc-
confirmed the integrity of the trape- similar to type II injuries in that nei- tion with high-energy mechanisms.
zoid and conoid ligaments in type ther the proximal nor the distal frag- Physical examination findings in-
IIA and IIB injuries. Although in type ment is connected to the coracoid clude swelling, ecchymosis, and ten-
II fractures, fracture displacement process via the CC ligaments. Al- derness over the distal clavicle, as
may be obvious, the exact location though the ligaments may remain at- well as painful active and passive
of the fracture and the integrity of tached to a free-floating bony frag- range of motion (ROM) of the
the CC ligaments may be difficult to ment, the stability of the distal and shoulder. Fracture displacement may
judge on plain radiographs. proximal fracture fragments is com- cause the proximal fragment to tent
Type IV and V fractures were sub- promised. Although the Craig modi- the skin, with an appearance similar
sequently added to the classifica- fication of the Neer classification to that of AC joint separation (Fig-
tion.11 Type IV fractures are rare; system is widely used, no study has ure 3). Paresthesias resulting from
they involve disruption of the perios- assessed the validity of this classifica- swelling or injury to the supraclavic-
teal sleeve in the pediatric popula- tion through inter- and intraobserver ular nerves are common. Neurologic
tion.13,14 These fractures are injuries reliability. examination of the shoulder and up-
to the growth plate in which the Robinson15 proposed an alternative per extremity should be performed
epiphysis and physis typically main- classification for all clavicle fractures and documented. Suprascapular
tain their relationship to the shoulder based on fracture location, displace- nerve injury after distal clavicle frac-
joint, resulting in apparent superior ment, and intra-articular involve- ture has been described.17 Weakness
displacement of the clavicular me- ment (Figure 2). Distal clavicle frac- on external rotation with the arm in
Figure 3
A, Clinical photograph of a displaced left distal clavicle fracture in a 21-year-old woman who fell onto her left shoulder.
B, Preoperative AP radiograph demonstrating fracture displacement with no residual cortical contact between the bone
ends. The patient was treated with a distal radius 2.4-mm locking plate and simultaneous coracoclavicular stabilization
using suture. C, AP radiograph obtained 3 months postoperatively demonstrating fracture healing.
adduction and disproportionate re- tal clavicle fractures are typically series used the Neer definition of
ports of pain could be indicative of nondisplaced and heal without diffi- nonunion. Rokito et al7 reported
suprascapular nerve injury. Careful culty with nonsurgical management. nonunion in 7 of 16 patients treated
examination of the remainder of the In contrast, type II fractures are of- nonsurgically for type II distal clavi-
upper extremity, as well as the cervi- ten displaced and may have a higher cle fractures.
cal spine and the thorax, is essential. rate of nonunion.4 Reported rates Risk factors for nonunion include
of nonunion following nonsurgical displacement, that is, no residual cor-
management of type II distal clavi- tical contact between the bone ends,
Radiographic Evaluation
cle fractures range from 28% to and advancing patient age.19 Robin-
Radiographic evaluation should in- 44%1,4,5,7,11,19-21 (Table 1). Most stud- son et al19 noted that both of these
clude true AP and axillary lateral ies define distal clavicle fracture non- factors are independently predictive
views of the shoulder. A Zanca view union based on Neer’s original series. of nonunion.
of the AC joint, which is obtained in Neer defined delayed nonunion as Because some patients remain
10° to 15° cephalic tilt, is also help- “lack of bone bridging for more than asymptomatic, the clinical impor-
ful in evaluating for intra-articular 12 months after injury.”4 This defini- tance of distal clavicle nonunion has
involvement.18 A radiograph show- tion has been used in subsequent been questioned. In the study by
ing the bilateral clavicles and includ- studies on distal clavicle fracture. Deafenbaugh et al,21 none of the
ing the AC joint is useful in assessing Deafenbaugh et al21 reported 3 three reported distal clavicle non-
fracture displacement. These radio- nonunions in a series of 10 Neer type unions was symptomatic. Other
graphs can provide an overall assess- II distal clavicle fractures. Nordqvist studies involving clinical assessment
ment of fracture pattern, location, et al20 reported a 28% nonunion rate of patients with distal clavicular non-
and displacement. (5 of 18). In their review of 43 type unions have indicated that 20% to
II distal clavicle fractures, Edwards 34% were symptomatic and eventu-
Management et al22 noted that up to 75% of pa- ally required surgical fixation.1,20
tients treated nonsurgically devel- Closer evaluation of studies that
Distal clavicle fractures may be man- oped a delayed union or nonunion. included outcomes scores in their
aged nonsurgically or surgically. Of the 20 patients treated nonsurgi- analyses further clarifies the impact
Most nondisplaced distal clavicle cally, 6 (30%) developed nonunion of distal clavicle nonunion. In the
fractures are managed nonsurgically. (ie, lack of bony bridging after 12 small series by Rokito et al,7 7 of the
For example, Neer type I and III dis- months). The authors of these three 16 patients treated nonsurgically de-
Table 1
Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures
No. of Pts With Neer No. of Pts Followed
Study Level of Evidence Total No. of Pts Type II Fracture to End of Study
N/A = not applicable, NR = not reported, ORIF = open reduction and internal fixation, Pts = patients
a
In the nonsurgical group, no fracture was “united by callus prior to 16 weeks after injury.”
b
In the surgical group, “[h]eavy labor was resumed at the third month.”
c
Only 38 patients were reviewed clinically and radiographically. The authors state, “[T]he remaining 5 had adequate case notes and
radiographs.”
d
Only 18 of the 23 patients with Neer type II distal clavicle fractures were evaluated radiographically at final follow-up.
e
86 of the original 101 patients were available for follow-up, but the authors do not specify how many of these were Neer type II clavicle
fractures.
f
This rate is based on all 86 lateral or distal clavicle fractures; the authors do not specify Neer classification.
g
84 lateral end clavicle fractures were followed for 24 weeks. Although 42 fractures were displaced, the number of Neer type II fractures was
not reported.
h
The authors report a 25.4% nonunion rate for displaced lateral end clavicle fractures but an overall nonunion rate of 11.5% (ie, displaced
and nondisplaced).
veloped nonunion, but there was no tal clavicle fractures reflects that of management of closed displaced type
difference in mean Constant or Neer’s original series. (2) Fracture II distal clavicle fracture must be ap-
American Shoulder and Elbow Sur- displacement, as seen in most Neer proached on a case-by-case basis.
geons (ASES) scores between those type II fractures, is associated with
treated nonsurgically and those the development of nonunion. (3) Nonsurgical
treated surgically. In the case series Radiographic nonunion does not al-
Most distal clavicle fractures are
by Robinson and Cairns,1 there was ways correlate with symptomatic
managed nonsurgically. Sling immo-
no significant difference in the Con- nonunion. (4) Patients who develop
bilization for 2 weeks is instituted
stant score or the Medical Outcomes symptomatic nonunion may or may
for comfort, and shoulder motion is
Study 36-Item Short Form score be- not require additional surgery.
initiated as soon as the initial pain
tween any of the three groups stud- Surgical management of distal
ied: patients treated nonsurgically, clavicle fractures is indicated for improves. Repeat radiographs are
patients who developed a nonunion, open fractures, skin compromise, obtained at 6-week follow-up to
and patients who underwent delayed and associated vascular injury re- monitor for fracture displacement
surgical treatment after the develop- quiring surgery. Because of the high and evidence of healing. These pa-
ment of a nonunion. rate of nonunion, Neer4 and tients typically recover fully without
Based on these data, several con- others2,3,6,23-45 have advocated pri- sequelae. Type I and type III frac-
clusions may be reached regarding mary surgical management of distal tures are at risk of delayed-onset
nonunion after distal clavicle frac- clavicle fracture. However, because symptomatic AC arthrosis,5 which
ture: (1) The reported rate of radio- radiographic nonunion does not cor- can be managed with distal clavicle
graphic nonunion of all types of dis- relate with symptomatic nonunion, resection, if necessary. Nondisplaced
Table 1 (continued)
Reported Rates of Nonunion Following Nonsurgical Management of Type II Distal Clavicle Fractures
No. of Symptomatic
Management Average Follow-up Outcome Nonunions
N/A = not applicable, NR = not reported, ORIF = open reduction and internal fixation, Pts = patients
a
In the nonsurgical group, no fracture was “united by callus prior to 16 weeks after injury.”
b
In the surgical group, “[h]eavy labor was resumed at the third month.”
c
Only 38 patients were reviewed clinically and radiographically. The authors state, “[T]he remaining 5 had adequate case notes and
radiographs.”
d
Only 18 of the 23 patients with Neer type II distal clavicle fractures were evaluated radiographically at final follow-up.
e
86 of the original 101 patients were available for follow-up, but the authors do not specify how many of these were Neer type II clavicle
fractures.
f
This rate is based on all 86 lateral or distal clavicle fractures; the authors do not specify Neer classification.
g
84 lateral end clavicle fractures were followed for 24 weeks. Although 42 fractures were displaced, the number of Neer type II fractures was
not reported.
h
The authors report a 25.4% nonunion rate for displaced lateral end clavicle fractures but an overall nonunion rate of 11.5% (ie, displaced
and nondisplaced).
type II fractures may also be man- tions, including nonunion, AC decrease complications.24-26
aged nonsurgically. However, the arthrosis, and Kirschner wire (K- CC ligament repair or reconstruc-
likelihood of subsequent displace- wire) migration. Although Eskola tion without supplemental fixation
ment and possible nonunion should et al46 reported good or satisfactory has been reported.6,27 Webber and
be recognized, discussed with the pa- outcomes in 22 of 23 patients, 26% Haines6 described CC ligament re-
tient, and monitored with repeat ra- experienced a complication or non- construction using a Dacron graft in
diographs at 6 weeks. union following transacromial wir- 11 patients. All fractures united by
ing. Late migration of the wires into an average of 43.5 days postopera-
Surgical the cervical spine, trachea, vascular tively. At a mean follow-up of 4.6
A variety of methods of surgical structures, lung, and abdomen has years, the average Constant score
management of distal clavicle frac- been reported.47-49 Modifications was 98.9.
tures has been proposed, including have led to a reduction in unsatisfac- The modified Weaver-Dunn proce-
transacromial wire fixation, a modi- tory results and complications asso- dure is primarily used for AC dislo-
fied Weaver-Dunn procedure, use ciated with transacromial wire fixa- cation, but it also has been advo-
of a tension band, CC screw fixa- tion. Good results have been cated for the management of distal
tion, plate fixation, and arthro- reported with the use of a transacro- clavicle fractures.50 This procedure is
scopic treatment. Neer4 recom- mial Knowles pin rather than usually reserved for cases in which
mended transacromial wire fixation K-wires.23,24 Transacromial fixation the distal clavicle fragment can be
of distal clavicle fractures. This com- supplemented with CC ligament easily excised and the coracoacro-
monly used technique has been asso- repair or reconstruction has also mial ligament can be transferred
ciated with a high rate of complica- been shown to improve results and to the distal end of the proximal
Figure 4
A, AP radiograph of the right shoulder in a 56-year-old woman who sustained a closed distal clavicle fracture after a
fall. B, The patient was initially treated nonsurgically and developed painful nonunion. She then underwent fixation with
a 2.7-mm plate, which allowed placement of three screws into the distal fragment. The fixation was augmented with
coracoclavicular stabilization using Mersilene tape. AP radiograph (C) and postoperative photographs (D through G)
obtained 3 months postoperatively demonstrating healing and return to preinjury level of function.
clavicle fragment. to the coracoid process. Successful clavicle fragment. All eight patients
K-wire fixation with a supplemen- healing of the distal clavicle has been who were available for follow-up
tary tension band wire has also been reported in several small case achieved bony union. The mean
suggested for fixation of type II dis- series.22,32-34 This technique has also Constant score was 96.
tal clavicle fractures.51 In this been performed using a cannulated If the distal fragment is too small
method, K-wires are placed on the screw.35 More recently, Fazal et al36 to hold screws, a plate that hooks
superior aspect of the clavicle, avoid- reported a 100% union rate using under the acromion may be used
ing the AC joint. The tension band is this technique in 30 patients. A sec- (Figure 5). Kashii et al38 reported on
placed around the wires. In one se- ond procedure is required to remove 34 patients with distal clavicle frac-
ries, 11 of 12 patients achieved pain- the screw following union. tures treated with an AC hook plate.
less union with this approach.52 Oth- Small and mini-fragment locking Although all patients achieved bony
ers have reported similar success plates may be used to stabilize distal union, the hook caused acromial
rates with modified tension band clavicle fractures (Figures 3 and 4). fracture in one patient and rotator
techniques using suture.28-30 Symp- These plates allow fixation of the cuff tear in another. Good union
tomatic hardware is a potential com- distal clavicle fragment without rates with the hook plate were re-
plication, particularly when tension crossing the AC joint. Kalamaras ported in two other studies, but
band wiring is used.31 et al37 used a distal radius locking asymptomatic osteolysis of the acro-
In CC screw fixation, open reduc- plate on nine patients with distal mion and migration of the hook into
tion and internal fixation of the dis- clavicle fracture. The 2.4-mm lock- the acromion were frequently en-
tal clavicle fragment is performed by ing screws in the distal portion of the countered.39,40 With the hook plate, a
temporarily fixing the distal clavicle plate were used to capture the distal second procedure is required for
fixation is supplemented by a dorsal 16, 20, 22-30, 32-40, 43, 44, and 52 13. Katznelson A, Nerubay J, Oliver S:
Dynamic fixation of the avulsed clavicle.
suture tension band placed through are level IV studies. Reference 10 is J Trauma 1976;16(10):841-844.
the incision, as described by Levy.30 level V expert opinion.
14. Ogden JA: Distal clavicular physeal
Surgeons who are trained in shoulder References printed in bold type indi- injury. Clin Orthop Relat Res 1984;
arthroscopy may perform the proce- cate those published within the past (188):68-73.
dure arthroscopically. 5 years. 15. Robinson CM: Fractures of the clavicle
Postoperatively, the patient is in the adult: Epidemiology and
1. Robinson CM, Cairns DA: Primary classification. J Bone Joint Surg Br 1998;
placed in a sling for 6 weeks. Supine nonoperative treatment of displaced 80(3):476-484.
passive and active-assisted ROM ex- lateral fractures of the clavicle. J Bone
Joint Surg Am 2004;86(4):778-782. 16. Stanley D, Trowbridge EA, Norris SH:
ercises are begun immediately. Active The mechanism of clavicular fracture: A
ROM is started at 6 weeks, with 2. Hessmann M, Kirchner R, Baumgaertel clinical and biomechanical analysis.
F, Gehling H, Gotzen L: Treatment of J Bone Joint Surg Br 1988;70(3):461-
progression to strengthening exer- unstable distal clavicular fractures with 464.
cises 6 to 12 weeks postoperatively. and without lesions of the acromio-
clavicular joint. Injury 1996;27(1):47- 17. Huang KC, Tu YK, Huang TJ, Hsu RW:
Patients are typically restricted from Suprascapular neuropathy complicating
52.
engaging in heavy labor and sports a Neer type I distal clavicular fracture: A
3. Herrmann S, Schmidmaier G, Greiner S: case report. J Orthop Trauma 2005;
for 12 weeks.
Stabilisation of vertical unstable distal 19(5):343-345.
clavicular fractures (Neer 2b) using
locking T-plates and suture anchors. 18. Zanca P: Shoulder pain: Involvement of
the acromioclavicular joint: Analysis of
Summary Injury 2009;40(3):236-239.
1,000 cases. Am J Roentgenol Radium
4. Neer CS II: Fracture of the distal clavicle Ther Nucl Med 1971;112(3):493-506.
Most distal clavicle fractures may be with detachment of the coracoclavicular
ligaments in adults. J Trauma 1963;3:99- 19. Robinson CM, Court-Brown CM,
managed nonsurgically. Type II distal McQueen MM, Wakefield AE:
110.
clavicle fractures are associated with Estimating the risk of nonunion
5. Neer CS II: Fractures of the distal third following nonoperative treatment of a
radiographic nonunion in up to 44% of the clavicle. Clin Orthop Relat Res clavicular fracture. J Bone Joint Surg Am
of cases. Fracture displacement is as- 1968;58:43-50. 2004;86(7):1359-1365.
sociated with a higher risk of non- 6. Webber MC, Haines JF: The treatment 20. Nordqvist A, Petersson C, Redlund-
union. However, the clinical rele- of lateral clavicle fractures. Injury 2000; Johnell I: The natural course of lateral
31(3):175-179. clavicle fracture: 15 (11-21) year
vance of this nonunion may be follow-up of 110 cases. Acta Orthop
minimal, and initial nonsurgical 7. Rokito AS, Zuckerman JD, Shaari JM, Scand 1993;64(1):87-91.
Eisenberg DP, Cuomo F, Gallagher MA:
management may be warranted. Al- A comparison of nonoperative and 21. Deafenbaugh MK, Dugdale TW, Staeheli
though surgical management of distal operative treatment of type II distal JW, Nielsen R: Nonoperative treatment
clavicle fractures. Bull Hosp Jt Dis 2002- of Neer type II distal clavicle fractures: A
clavicle fractures has been described, 2003;61(1-2):32-39. prospective study. Contemp Orthop
current evidence suggests equivalent 1990;20(4):405-413.
8. Fukuda K, Craig EV, An KN, Cofield
outcomes between surgical and nonsur- RH, Chao EY: Biomechanical study of 22. Edwards DJ, Kavanagh TG, Flannery
gical management. Additionally, no the ligamentous system of the MC: Fractures of the distal clavicle: A
acromioclavicular joint. J Bone Joint case for fixation. Injury 1992;23(1):44-
single surgical technique has been Surg Am 1986;68(3):434-440. 46.
shown to be superior to the others. A
9. Renfree KJ, Riley MK, Wheeler D, Hentz 23. Fann CY, Chiu FY, Chuang TY, Chen
prospective randomized study compar- JG, Wright TW: Ligamentous anatomy CM, Chen TH: Transacromial Knowles
ing surgical and nonsurgical manage- of the distal clavicle. J Shoulder Elbow pin in the treatment of Neer type 2 distal
Surg 2003;12(4):355-359. clavicle fractures: A prospective
ment of type II distal clavicle fractures evaluation of 32 cases. J Trauma 2004;
is necessary to better determine the op- 10. Bearden JM, Hughston JC, Whatley GS: 56(5):1102-1105.
Acromioclavicular dislocation: Method
timal treatment. of treatment. J Sports Med 1973;1(4):5- 24. Wang SJ, Wong CS: Extra-articular
17. knowles pin fixation for unstable distal
clavicle fractures. J Trauma 2008;64(6):
11. Neer C II: Fractures and dislocations of 1522-1527.
References the shoulder, in Rockwood CA Jr, Green
DP, eds: Fractures in Adults. Philadel- 25. Bezer M, Aydin N, Guven O: The
phia, PA, J.B. Lippincott, 1984, pp 711- treatment of distal clavicle fractures with
Evidence-based Medicine: Levels of 712. coracoclavicular ligament disruption: A
evidence are listed in the table of report of 10 cases. J Orthop Trauma
12. Craig EV: Fractures of the clavicle, in 2005;19(8):524-528.
contents. In this article, reference 19 is Rockwood CA Jr, Green DP, Bucholz
a level I study. Reference 21 is a level II RW, Heckman JD, eds: Rockwood and 26. Chen CH, Chen WJ, Shih CH: Surgical
Green’s Fractures in Adults, ed 4. treatment for distal clavicle fracture with
study. References 31 and 45 are level Philadelphia, PA, Lippincott-Raven, coracoclavicular ligament disruption.
III studies. References 1-7, 13, 14, 1996, pp 1109-1193. J Trauma 2002;52(1):72-78.
27. Goldberg JA, Bruce WJ, Sonnabend DH, screw fixation technique. J Trauma Arthroscopic treatment of distal clavicle
Walsh WR: Type 2 fractures of the distal 2006;60(6):1358-1361. fractures: A technical note. Knee Surg
clavicle: A new surgical technique. Sports Traumatol Arthrosc 2008;16(9):
J Shoulder Elbow Surg 1997;6(4):380- 36. Fazal MA, Saksena J, Haddad FS: 884-886.
382. Temporary coracoclavicular screw
fixation for displaced distal clavicle 45. Flinkkilä T, Ristiniemi J, Hyvönen P,
28. Mall JW, Jacobi CA, Philipp AW, Peter fractures. J Orthop Surg (Hong Kong) Hämäläinen M: Surgical treatment of
FJ: Surgical treatment of fractures of the 2007;15(1):9-11. unstable fractures of the distal clavicle: A
distal clavicle with polydioxanone suture comparative study of Kirschner wire and
tension band wiring: An alternative 37. Kalamaras M, Cutbush K, Robinson M:
clavicular hook plate fixation. Acta
osteosynthesis. J Orthop Sci 2002;7(5): A method for internal fixation of
Orthop Scand 2002;73(1):50-53.
535-537. unstable distal clavicle fractures: Early
observations using a new technique. 46. Eskola A, Vainionpää S, Pätiälä H,
29. Badhe SP, Lawrence TM, Clark DI: J Shoulder Elbow Surg 2008;17(1):60-
Tension band suturing for the treatment Rokkanen P: Outcome of operative
62. treatment in fresh lateral clavicular
of displaced type 2 lateral end clavicle
fractures. Arch Orthop Trauma Surg 38. Kashii M, Inui H, Yamamoto K: Surgical fracture. Ann Chir Gynaecol 1987;76(3):
2007;127(1):25-28. treatment of distal clavicle fractures 167-169.
using the clavicular hook plate. Clin
30. Levy O: Simple, minimally invasive 47. Regel JP, Pospiech J, Aalders TA,
Orthop Relat Res 2006;447:158-164.
surgical technique for treatment of type Ruchholtz S: Intraspinal migration of a
2 fractures of the distal clavicle. 39. Tambe AD, Motkur P, Qamar A, Drew Kirschner wire 3 months after clavicular
J Shoulder Elbow Surg 2003;12(1):24- S, Turner SM: Fractures of the distal fracture fixation. Neurosurg Rev 2002;
28. third of the clavicle treated by hook 25(1-2):110-112.
plating. Int Orthop 2006;30(1):7-10.
31. Lee YS, Lau MJ, Tseng YC, Chen WC, 48. Tsai CH, Hsu HC, Huan CY, Chen HT,
Kao HY, Wei JD: Comparison of the 40. Muramatsu K, Shigetomi M, Matsunaga Fong YC: Late migration of threaded
efficacy of hook plate versus tension T, Murata Y, Taguchi T: Use of the AO wire (schanz screw) from right distal
band wire in the treatment of unstable hook-plate for treatment of unstable clavicle to the cervical spine. J Chin Med
fractures of the distal clavicle. Int fractures of the distal clavicle. Arch Assoc 2009;72(1):48-51.
Orthop 2009;33(5):1401-1405. Orthop Trauma Surg 2007;127(3):191-
194. 49. Lyons FA, Rockwood CA Jr: Migration
32. Ballmer FT, Gerber C: Coracoclavicular
of pins used in operations on the
screw fixation for unstable fractures of 41. Nourissat G, Kakuda C, Dumontier C,
shoulder. J Bone Joint Surg Am 1990;
the distal clavicle: A report of five cases. Sautet A, Doursounian L: Arthroscopic
72(8):1262-1267.
J Bone Joint Surg Br 1991;73(2):291- stabilization of Neer type 2 fracture of
294. the distal part of the clavicle. 50. Anderson K: Evaluation and treatment
Arthroscopy 2007;23(6):674.e1-4. of distal clavicle fractures. Clin Sports
33. Yamaguchi H, Arakawa H, Kobayashi
M: Results of the Bosworth method for 42. Baumgarten KM: Arthroscopic fixation Med 2003;22(2):319-326, vii.
unstable fractures of the distal clavicle. of a type II-variant, unstable distal
51. Heim U, Pfeiffer KM: Internal Fixation
Int Orthop 1998;22(6):366-368. clavicle fracture. Orthopedics 2008;
of Small Fractures: Technique
31(12):pii:orthosupersite.com/
34. Macheras G, Kateros KT, Savvidou OD, Recommended by the AO-ASIF Group,
view.asp?rID=32937.
Sofianos J, Fawzy EA, Papagelopoulos ed 3. New York, NY, Springer-Verlag,
PJ: Coracoclavicular screw fixation for 43. Checchia SL, Doneux PS, Miyazaki AN, 1987.
unstable distal clavicle fractures. Fregoneze M, Silva LA: Treatment of
Orthopedics 2005;28(7):693-696. distal clavicle fractures using an 52. Kao FC, Chao EK, Chen CH, Yu SW,
arthroscopic technique. J Shoulder Chen CY, Yen CY: Treatment of distal
35. Jin CZ, Kim HK, Min BH: Surgical Elbow Surg 2008;17(3):395-398. clavicle fracture using Kirschner wires
treatment for distal clavicle fracture and tension-band wires. J Trauma 2001;
associated with coracoclavicular 44. Pujol N, Philippeau JM, Richou J, 51(3):522-525.
ligament rupture using a cannulated Lespagnol F, Graveleau N, Hardy P: