Neer, Clin Orthop Relat Res 1968 - Fractures of the Distal Third of the Clavicle

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Fractures of the Distal Third of the Clavicle

Neer·Clin Orthop Relat Res·1968·561 citations·Case series

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Neer describes the pathologic anatomy and treatment of fractures lateral to the coracoid tubercle. He divides distal clavicle fractures into two types based on whether the coracoclavicular ligaments stay attached to the proximal fragment. The paper addresses why some of these fractures fail to unite and how to manage them.

Key Findings

Distal fractures make up only 10% of clavicle fractures but accounted for half of the nonunions in Neer's earlier closed-treatment series. This mismatch is what drove the whole investigation.
Type I fractures keep the coracoclavicular ligaments intact, so the fragments stay bound and stable. They occur about 3× more often than Type II and unite promptly with just a sling.
Type II fractures detach the CC ligaments from the medial fragment while the trapezoid stays on the distal piece. This leaves the proximal fragment unstable and pulled posteriorly by the trapezius, hidden on routine AP films.
Four displacing forces act on the Type II fracture:
- Weight of the arm
- Pectoralis and latissimus pull (overriding)
- Scapular rotation
- Trapezius pulling the shaft up and back
Closed treatment of Type II failed badly: no fracture united before 16 weeks and nonunion occurred in 4 of 12 patients. Adjacent tissue damage plus poor immobilization delayed healing.
Excising the outer segment backfired: only 1 of 4 patients did well and 2 of 4 needed further resection. Losing the distal fragment lets the shaft ride upward and become symptomatic.
Transacromial Kirschner wire fixation produced union at 6 weeks with a 6-day mean hospital stay, becoming Neer's procedure of choice for Type II lesions.

Board PearlDistal clavicle fractures are classified by coracoclavicular ligament integrity: Type I is stable and heals; Type II is unstable and prone to nonunion.

Fractures of the Distal Third of the Clavicle

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Fractures of the Distal Third of the Clavicle

Neer·Clin Orthop Relat Res·1968·561 citations·Case series

|

Neer describes the pathologic anatomy and treatment of fractures lateral to the coracoid tubercle. He divides distal clavicle fractures into two types based on whether the coracoclavicular ligaments stay attached to the proximal fragment. The paper addresses why some of these fractures fail to unite and how to manage them.

Key Findings

Distal fractures make up only 10% of clavicle fractures but accounted for half of the nonunions in Neer's earlier closed-treatment series. This mismatch is what drove the whole investigation.
Type I fractures keep the coracoclavicular ligaments intact, so the fragments stay bound and stable. They occur about 3× more often than Type II and unite promptly with just a sling.
Type II fractures detach the CC ligaments from the medial fragment while the trapezoid stays on the distal piece. This leaves the proximal fragment unstable and pulled posteriorly by the trapezius, hidden on routine AP films.
Four displacing forces act on the Type II fracture:
- Weight of the arm
- Pectoralis and latissimus pull (overriding)
- Scapular rotation
- Trapezius pulling the shaft up and back
Closed treatment of Type II failed badly: no fracture united before 16 weeks and nonunion occurred in 4 of 12 patients. Adjacent tissue damage plus poor immobilization delayed healing.
Excising the outer segment backfired: only 1 of 4 patients did well and 2 of 4 needed further resection. Losing the distal fragment lets the shaft ride upward and become symptomatic.
Transacromial Kirschner wire fixation produced union at 6 weeks with a 6-day mean hospital stay, becoming Neer's procedure of choice for Type II lesions.

Board PearlDistal clavicle fractures are classified by coracoclavicular ligament integrity: Type I is stable and heals; Type II is unstable and prone to nonunion.

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