The collarbone, or clavicle, is an S-shaped bone that connects the arm to the trunk of the body, allowing for a wide range of shoulder movement. A distal clavicle fracture specifically affects the lateral third of the bone, the section closest to the shoulder joint. This area is heavily influenced by surrounding ligaments, which makes these breaks distinct from the more common fractures that occur in the middle of the collarbone.
Understanding the Distal Clavicle Fracture
The distal end of the clavicle articulates with the acromion to form the acromioclavicular (AC) joint. Stability is maintained by the strong coracoclavicular (CC) ligaments, which consist of the conoid and trapezoid ligaments. These ligaments anchor the clavicle to the coracoid process on the scapula. Distal clavicle fractures typically occur when a person falls directly onto the shoulder or sustains a forceful impact.
The severity of the injury is directly related to the integrity of these stabilizing CC ligaments. Clinicians use the Neer classification system to categorize fractures based on the fracture line’s relationship to the ligaments. Stable fractures (Type I and Type III) occur with the CC ligaments intact or lateral to the fracture line. Unstable fractures (Type II and Type V) involve a fracture medial to the ligaments or their disruption, often resulting in the bone being pulled upward by muscle forces, leading to significant displacement.
Identifying the Injury
A distal clavicle fracture is usually accompanied by immediate, intense pain in the outer shoulder and collarbone area. Patients often experience swelling and bruising around the injured site, along with an inability to lift the arm. If the fracture fragments are displaced, a visible bump or deformity may appear on the top of the shoulder.
Diagnosis begins with a physical examination to assess the pain, range of motion, and any potential deformity. Standard X-rays confirm the fracture and determine its precise location and degree of displacement. Specialized views, such as a cephalic-tilt or Zanca view, help visualize the AC joint and the fracture pattern more clearly. For complex surgical planning or when ligament integrity is questionable, advanced imaging like a CT scan or MRI may be used.
Treatment Pathways: Non-Surgical and Surgical Approaches
Treatment is dictated by the stability of the broken bone segments, corresponding to the fracture’s Neer classification. Stable, non-displaced fractures (Type I and Type III) are managed non-surgically. This approach involves immobilizing the arm in a sling for four to six weeks to allow the bone to heal naturally.
Non-operative management includes rest and pain medication during the initial healing phase. This conservative method is effective for stable fractures because intact ligaments hold the bone fragments in place. Even some displaced Type II fractures may be treated non-surgically, particularly in older or less active individuals.
Unstable fractures, such as Neer Type II, are significantly displaced due to CC ligament disruption and have a high non-union rate (28% to 44%) without intervention. For these unstable patterns, surgery is recommended to reduce and stabilize the fracture fragments.
Common surgical techniques involve open reduction and internal fixation (ORIF), where the bone is realigned and secured using hardware. This fixation may include precontoured locking plates and screws placed directly onto the bone. Alternatively, techniques may focus on stabilizing the CC ligaments, often using high-strength sutures or button devices to pull the clavicle back into its correct anatomical position.
What to Expect During Healing
The initial healing phase involves wearing a sling for immobilization, which can last two to six weeks depending on fracture stability and whether surgery was performed. During this period, the patient should keep the elbow, wrist, and hand moving to prevent stiffness. The focus during the first few weeks is on pain management and protecting the fracture site to ensure bony union can begin.
Physical therapy (PT) is a necessary component of recovery and typically begins gently after the initial immobilization period, around two to four weeks post-injury or post-surgery. Early PT focuses on restoring passive and active-assisted range of motion to the shoulder. This includes exercises like pendulum swings and gradually increasing overhead elevation to prevent stiffness.
As healing progresses (usually six to twelve weeks), the rehabilitation program shifts to strengthening the surrounding musculature, particularly the rotator cuff and periscapular muscles. Most patients can return to light daily activities around six weeks. More strenuous work or non-contact sports typically resume after three to four months, provided there is radiographic evidence of fracture healing. Full return to contact sports may require a four- to six-month timeline, based on complete functional recovery and physician clearance.