The clavicle, commonly known as the collarbone, is a long, slender bone located at the base of the neck, connecting the sternum (breastbone) to the shoulder blade (scapula). The distal end of the clavicle is the part closest to the shoulder, where it joins with a part of the scapula called the acromion, forming the acromioclavicular (AC) joint. A distal clavicle fracture occurs when this specific part of the collarbone breaks. This type of fracture impacts the stability and function of the shoulder, often requiring careful medical attention.
Common Causes and Symptoms
Distal clavicle fractures frequently result from direct trauma to the shoulder, such as falling directly onto the side of the shoulder or outstretched arm. Sports activities like football, rugby, cycling, or snowboarding are common scenarios where these injuries occur. Vehicle accidents can also generate sufficient force to cause this type of fracture.
Upon experiencing a distal clavicle fracture, individuals feel immediate, sharp pain localized over the top of the shoulder. This pain is often intensified with any attempt to move the arm or shoulder. A noticeable bump or deformity may appear over the fracture site, sometimes accompanied by swelling and bruising around the affected area. Many people find it difficult or impossible to lift their arm away from their body due to the pain and instability, indicating a significant disruption to shoulder mechanics.
Medical Diagnosis and Classification
A doctor begins the diagnostic process with a physical examination of the injured shoulder. They will observe the shoulder for deformities, swelling, or bruising, and palpate the area to pinpoint pain and tenderness. The range of motion of the arm and shoulder will also be assessed, though this is often limited by pain in the presence of a fracture.
To confirm a distal clavicle fracture, X-rays are the primary diagnostic tool. Multiple views of the clavicle and shoulder are taken to visualize the fracture line, assess any bone displacement, and check the integrity of the AC joint. In cases where the fracture pattern is complex or there is concern about associated injuries to surrounding structures, a computed tomography (CT) scan may be utilized. A CT scan provides more detailed cross-sectional images, offering a clearer three-dimensional view of the bone fragments and their relationship to adjacent tissues.
Distal clavicle fractures are classified to guide treatment decisions, with the Neer classification system being a common standard. This system categorizes fractures based on the location of the fracture line relative to the coracoclavicular (CC) ligaments. Some fractures involve the bone breaking outside the attachment points of these ligaments, which remain stable because the ligaments are still intact. Other fractures occur between or medial to the CC ligaments, leading to instability because the main support structures are either torn or detached from the smaller bone fragment.
Treatment Approaches
Non-Surgical Treatment
Non-surgical treatment is generally favored for distal clavicle fractures that are considered stable, meaning the bone fragments are not significantly displaced and the supporting ligaments remain intact. The goal of this approach is to allow the bone to heal naturally while managing pain and protecting the shoulder. Patients are advised to wear an arm sling for several weeks, which helps to immobilize the shoulder and support the weight of the arm, reducing stress on the healing fracture site. The duration of sling use varies but ranges from three to six weeks, depending on the fracture’s stability and the patient’s comfort.
Ice packs applied to the shoulder can help reduce swelling and discomfort, especially in the initial days following the injury. Pain management is also addressed through over-the-counter or prescription pain relievers, allowing the individual to remain comfortable. Regular follow-up appointments with X-rays are scheduled to monitor the fracture’s healing progression and ensure alignment. While non-surgical treatment avoids the risks associated with surgery, it requires patient adherence to immobilization guidelines to achieve a successful outcome.
Surgical Treatment
Surgical intervention becomes a consideration for distal clavicle fractures that are unstable, significantly displaced, or involve severe tearing of the coracoclavicular ligaments. The objective of surgery is to realign the fractured bone fragments and stabilize them, restoring shoulder integrity. One common surgical technique involves open reduction and internal fixation (ORIF), where an incision is made to access the fracture, the bone fragments are realigned, and then secured with small metal plates and screws. These plates act as internal splints, holding the bone pieces in place while they mend.
Another surgical method involves the use of specialized suture-button devices. These devices are designed to reconstruct or augment the torn coracoclavicular ligaments, effectively pulling the displaced bone fragment back into position. The suture-button technique can be useful for fractures where ligamentous support is compromised, as it aims to restore the biomechanics of the AC joint.
Recovery and Physical Therapy
The recovery process for a distal clavicle fracture, with bone union often taking anywhere from six weeks to three months, or sometimes longer for complex cases, involves several stages. During the initial healing period, the arm sling remains an important component, protecting the fracture site from movement and external forces. Adherence to sling use is important to prevent re-displacement of the bone fragments and facilitate bone formation.
Physical therapy begins once early bone healing has occurred and the surgeon determines it is safe to start moving the shoulder. The initial phase focuses on gentle, passive range-of-motion exercises, where the therapist moves the patient’s arm without active muscle engagement from the patient. This helps prevent stiffness in the shoulder joint and surrounding tissues, which can develop after immobilization. Gradually, the program progresses to active range-of-motion exercises, where the patient actively moves their arm, rebuilding control and flexibility.
The final stage of physical therapy focuses on strengthening exercises, targeting the muscles around the shoulder, arm, and upper back. These exercises are designed to restore full strength, stability, and endurance to the shoulder girdle, allowing individuals to regain their pre-injury function for daily activities and sports.