Fractures of the distal-third of the clavicle which are nondisplaced, minimally displaced, or extra-articular have shown high union rates and good functional outcomes with nonsurgical treatment [16]. These fractures are typically defined as type I distal clavicle fractures according to the classification system by Neer [42], occurring distal to the coracoclavicular (CC) ligaments and without extension into the acromioclavicular joint. This fracture pattern is inherently stable due to the integrity of the CC ligaments and quick functional recovery is commonly seen. Even if a nonunion develops after a type I injury, they are seldom symptomatic. In the infrequent cases when painful nonunion does develop, distal clavicle excision is typically curative. The immobilization method, rehabilitation, and conservative treatment modalities for these injuries are similar or identical to those for midshaft clavicle fractures.

Controversy does exist, however, in whether nonoperative or operative treatment is the optimal choice for management of displaced type II and type III distal clavicle injuries. Type II distal clavicle fractures occur medial to the coracoclavicular ligaments and similar to an earlier study done by Neer [42], displaced type II fractures treated nonsurgically have demonstrated a nonunion rate of 33.3% in a recent large systematic review [43]. Despite the high nonunion rate, multiple studies have shown that nonoperative treatment does not lead to a significant difference in functional scores compared to those treated surgically [44–47]. In addition, the complication rate associated with surgical management far exceeds that of nonoperative treatment for these fractures [43]. Nonoperative treatment of type III fractures which extend into the acromioclavicular articulation may result in later development of symptomatic joint degeneration and if symptomatic arthrosis occurs, delayed surgical management in the form of distal clavicle excision may be indicated.

In small prospective study by Deafenbaugh et al. [44], ten patients were treated nonoperatively for a displaced Neer type II distal clavicle fracture . At an average follow-up of 14.3 months, seven out of ten fractures healed while three went on to develop nonunion. Of the seven patients with healed fractures, six (86%) reported a satisfactory outcome. None of the patients with nonunion desired later surgery although they did report at least occasional discomfort. At final follow-up, eight out of ten (80%) patients had returned to full activity. In a larger, long-term study by Nordqvist et al. [46], a total of 110 patients with various types of distal clavicle fractures were treated nonoperatively and followed for an average of 15 years after their injury. Outcomes were rated as fair in 15 patients who reported moderate pain and dysfunction; however, no patients reported severe shoulder disability or pain. The nonunion rate in their study was 9% and included more type II fractures but 80% of patients with a nonunion were asymptomatic. Their conclusions were that nonoperative treatment provides satisfactory results and operative management in many cases is likely unnecessary. Finally in a study by Rokito et al. [47], the authors retrospectively compared patients having either undergone nonsurgical management or open reduction and CC stabilization for a type II distal clavicle fracture. Despite early healing in the operative group and 44% of patients developing a nonunion in the nonoperative group, they found no significant differences in UCLA, Constant, or ASES scores between the two cohorts. Nonunion had no effect on functional outcome or strength leading the authors to conclude that type II fractures could be successfully treated nonoperatively.

Nonsurgical management has been proven to be successful for all types of distal clavicle fractures and could be supported in nearly all cases with the obvious exceptions being open injuries or skin compromise from excessive displacement. Despite this, the ultimate decision on ideal management is still based on multiple factors, most important of which are the patient’s specific demands and activity level as well as acceptance of potential cosmetic deformity. If surgery is to be performed, the timing and acceptance of this decision is critical as delayed surgery has been shown to have markedly increased complication rates compared to acute management (36% vs. 7%) [48].

The indications for surgical management of distal clavicle fractures are based largely on the stability of fracture fragments, patient age, and patient activity level. Absolute indications include open fractures or soft-tissue compromise, floating shoulder, or multiple trauma. Excessive displacement of the lateral clavicle, as seen in type II injuries with CC ligament disruption, has been shown to lead to nonunion in approximately one-third of cases [5, 42]. Multiple fixation methods have been described including Kirschner wire fixation, coracoclavicular screws, pre-contoured plates or hook-plate fixation, and suture or sling techniques to reconstruct the CC ligaments. Surgical management has shown to significantly reduce the incidence of nonunion and multiple techniques have provided good long-term outcomes. However, the benefits over nonsurgical treatment are inconclusive [44, 46, 47] and complications vary significantly depending on the chosen technique with some having fallen out of favor due to unacceptably high complication rates.

Medial-third fractures of the clavicle are exceedingly rare, representing only 2–3% of all clavicle fractures [3–5, 56, 57]. They are routinely nondisplaced or minimally displaced and rarely extend to involve the sternoclavicular joint. Nonoperative treatment is the gold standard for medial-third fractures unless displacement is great enough that an open injury occurs or skin or neurovascular compromise is present. Sling or figure-of-eight bracing for comfort is initiated until pain allows for progression of activities, typically 2–6 weeks.

Surgical indications for displaced medial clavicle fractures include skin tenting, open fracture, multiple trauma, “floating shoulder” injuries, and mediastinal neurovascular compromise. Plate fixation and transosseous sutures or wires have been described for treatment of these fractures [49, 58]. Kirschner wire fixation has been abandoned due to reported breakage and wire migration [59]. One of the largest studies reporting on the operative outcomes of medial clavicle fractures evaluated 24 patients after undergoing plate or transosseous suture fixation for an acute displaced medial clavicle injury [60]. At an average follow-up of 12 months, all patients obtained excellent outcomes assessed by the DASH score and all fractures united. There were no reported limitations in shoulder motion and all patients returned to preinjury levels of activity. No complications were reported.

Medial clavicle fractures are typically treated surgically only by necessity and nonoperative management is the predominant treatment of choice. The proximity of neurovascular structures to the medial clavicle make accurate diagnosis and evaluation for displacement critical. Advanced imaging such as computed tomography is indicated if there is suspicion for posterior displacement [61].

Clavicle fractures are common injuries that present treatment dilemmas depending on the particular fracture characteristics as well as patient’s preinjury function and demands with the involved extremity. Recent literature has shown that surgical management for displaced injuries of the middle-third clavicle may improve patient’s long-term pain and functional outcomes. As surgical intervention has become more prevalent, care must be taken in selecting the appropriate patients to provide maximal outcome benefits and reducing the incidence of complications. Hardware prominence and irritation are concerns for all fixation methods at any location on the clavicle due to it subcutaneous position with minimal soft-tissue coverage but low-profile implants and surgical approach may help to minimize patient complaints. Distal clavicle fractures are prone to nonunion with nonoperative treatment. However, while surgical intervention lowers this incidence, it does not appear to improve long-term outcomes and complication rates are unacceptably high with certain methods. Medial clavicle fractures are rare and as they are typically minimally displaced, are predominantly treated nonoperatively. Discussion and patient education prior to treatment is essential to achieve optimal outcomes and mitigate complications in clavicle fracture management.