A distal clavicle fracture is a break in the outer third of the collarbone, near the acromioclavicular joint. Distal clavicle fractures are less common than mid-shaft fractures but more likely to require surgical treatment because the nearby ligament attachments often determine whether the fracture is stable. The specific fracture pattern, not just the location, drives the treatment decision.
What Is a Distal Clavicle Fracture?
The distal clavicle is the outer portion of the collarbone where it meets the acromion at the AC joint. Two ligament complexes stabilize this region. The acromioclavicular ligaments run between the clavicle and the acromion directly. The coracoclavicular ligaments (the conoid and trapezoid) run from the clavicle down to the coracoid process of the scapula and provide vertical stability.
Distal clavicle fractures are classified by their relationship to these ligaments:
- Type I: fracture lateral to the coracoclavicular ligaments, which remain attached to both fragments (stable)
- Type II: fracture medial to the coracoclavicular ligaments, with the medial fragment destabilized and displaced (unstable)
- Type III: fracture through the AC joint surface itself, which can predispose to post-traumatic AC arthritis
Type II fractures have higher nonunion rates with non-surgical treatment because the coracoclavicular ligaments pull the medial fragment upward away from the distal fragment, preventing healing contact.
Causes and Risk Factors
- Direct fall onto the point of the shoulder
- Contact sport collisions
- Cycling and motor vehicle accidents
- High-energy trauma to the shoulder girdle
Symptoms
- Pain localized to the end of the collarbone and the top of the shoulder
- Swelling and visible deformity in unstable fracture patterns
- Tenderness directly over the distal clavicle
- Pain with overhead motion and cross-body reaching
- Pain on palpation distinguishes this from a pure AC separation, though the two injuries can coexist
Diagnosis
Dr. Chudik’s evaluation includes the mechanism of injury, examination of the clavicle and AC joint, and documentation of any associated injuries. X-rays of both shoulders are obtained to classify the fracture type and detect any AC joint disruption. Stress or weighted views are occasionally added to clarify stability. CT is reserved for complex intra-articular patterns when surgical planning requires detailed bone detail.
Treatment
Non-surgical treatment is appropriate for Type I fractures and for Type III fractures without significant displacement. It involves sling use for two to four weeks, pain control, and progressive range of motion. Union is generally reliable in these stable patterns.
Surgical treatment is recommended for Type II fractures in active patients because of the high nonunion rate with non-surgical management, and for Type III fractures with significant AC joint involvement. Dr. Chudik’s surgical options include:
- Open reduction and internal fixation with a hook plate or distal clavicle plate
- Coracoclavicular fixation using suture or button constructs when the bone stock is insufficient for standard plating
- Distal clavicle excision for Type III fractures with AC joint damage
- Combined fixation and reconstruction techniques for complex patterns
Recovery and Outcomes
Non-surgical recovery typically includes two to four weeks of sling use, progressive motion from two weeks, and return to daily activity by six to eight weeks. Contact sport return depends on radiographic union, usually at 10 to 12 weeks.
After surgical fixation, a sling is used for two to four weeks, active motion begins early, and progressive strengthening follows at six to eight weeks. Return to contact sport is typically 12 to 16 weeks. Hardware removal is common after union because of prominence at the end of the clavicle. Post-traumatic AC arthritis can develop after Type III fractures and may require later treatment.
When to See Dr. Chudik
Schedule an evaluation after any fall on the shoulder that produces pain at the top or outer collarbone, a visible step-off deformity, or pain with shoulder motion. Call 630-324-0402 or request an appointment online.