Epidemiology
Elderly population
Less common in younger population
Lateral 1/3 Neer Classification
Type I
Fracture lateral to the CC ligaments
- does not extend into the ACJ
- non displaced
- most common 4:1
Type II
2A
- medial to CC ligaments
- CCL ligaments attached to lateral fragment
- medial fragment displaced superiorly
- highest rate of non union
2B
- between conoid and trapezoid
- conoid disrupted
- trapezoid remains attached to the lateral fragment
- more stable
Type III
Involves articular surface ACJ
- ligaments intact
- may present as late degenerative change
Type IV
- skeletally immature patient
- paediatric sleeve fracture
- ligaments attached to periosteum
- displacement of proximal fragment
Non Operative Management
Robinson JBJS Am 2004
- cohort of 100 displaced Type II fractures
- 20% asymptomatic non-union
- 14% of cohort required surgery
- recommended non operative treatment in middle aged / elderly
Operative Management
Operative Indications
- Compound / skin compromise
- displaced fracture in young people
- non union
Options
1. Dorsal plate / locking wrist plate
Case 1
The lateral clavice fracture has been cleaned and reduced
- held with K wire across ACJ
- high strength suture around clavicle and coracoid
- locking plate applied, reinforced with IM screw, and high strength tape around coracoid
- advantage: no need to remove hook plate
2. Hook Plate
Halder et al J Should Elbow Surg 2006
- 22 patients treated with hook plate
- very limited ROM (90o flexion) until plates removed at 3-4 months
- 1 disengaged from acromion (should have used acromial screws)
- 1 disengaged from clavicle (should have used 6 not 4 hole plate)
- 1 clavicular fracture at end of plate
- 1 non union, 1 delayed union
- 1 infection
- most complications in patients > 60
3. Endobutton
Robinson et al JBJS Br 2010
- 16 patients under 60 with displaced type 2
- all treated under 3 weeks
- endobutton in coracoid, clavicle reduced, endobutton clavicle
- 1 symptomatic non union
Non Union
Options
1. Bone graft / ORIF
2. Excise
- open
- arthroscopic