Technique Spotlight: Arthoscopic-Assisted Reduction and Internal Fixation of Distal Clavicle Fractures

Indications

Clavicle fractures account for 2.6%–4% of all adult fractures, with 10%–30% of these occurring in the distal third of the clavicle. The stability and displacement of the fracture determine whether surgery is indicated as the coracoclavicular (CC) ligaments (conoid and trapezoid) can be affected in these injuries. ^, Essentially, fractures of the lateral third of the clavicle in adult patients where the coracoid no longer has structural continuity to the clavicle are considered for operative treatment. The Neer classification for distal clavicle fractures is most commonly used, with displaced type IIA, type IIB, and type V commonly considered relative indications for surgical intervention due to the functional disruption of the ligaments leading to an unstable fracture pattern with high nonunion rates. ^, For acute fractures that are unstable and/or displaced, multiple surgical options exist including dynamic compression plating, hook plating, acromioclavicular (AC) joint spanning fixation, transacromial fixation, tension band techniques, intramedullary screw fixation, CC screw, and CC ligament repair or reconstruction. Surgery is associated with both faster time to and higher rates of union with improved functional outcomes and less pain, particularly with overhead activities. However, it does come with the risk of symptomatic hardware, increased need for future procedures, and wound complication/infection. ^, The incidence of hardware removal can be as high as 100% for devices where this is routinely recommended (hook plate and AC spanning fixation) but even for devices where hardware removal is not routinely recommended and removal rates can be as high as 30%, and thus alternative surgical techniques have been sought. ^{, , ,}

Fracture stability, disruption of the CC ligaments, and pattern according to the Neer classification are considered. An unstable fracture is a relative indication for surgical treatment. For lower-demand patients, nonoperative treatment can be considered and certain patients may be willing to accept the risk of and even tolerate a nonunion. Many studies combine all Neer classification types, thus making interpretation of the results for unstable patterns more difficult. ^{, ,} For unstable fractures with disruption of the CC ligaments and insufficient distal bone for locking plate fixation screws, hook plates have traditionally been used, but with relatively high complication rates and recommendations for routine removal with a second procedure. ^{, , ,} In these cases, the authors prefer arthroscopic-assisted reduction and CC fixation to allow fracture reduction to near anatomic alignment and relative fracture stability for fracture healing in the acute setting (<2 weeks from time of injury). Treatment of these fractures in a subacute or delayed fashion has generated mixed outcomes due to the CC ligaments’ poor ability to heal and the need to provide autograft or allograft collagen to supplement this deficiency. The arthroscopic-assisted technique is minimally invasive, facilitates treatment of associated pathology, maintains fracture site biology, and typically avoids complications seen with plating or more bulky hardware including secondary hardware removal.