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Current concepts in distal clavicle fractures: an evidence-based update
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Du-Han Kim, Hyuk-Joon Sohn, Byung-Chan Choi, Chul-Hyun Cho
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Received June 24, 2026 Accepted July 20, 2026 Published online August 14, 2026
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DOI: https://doi.org/10.12671/jmt.2026.00241
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 Abstract
- Distal clavicle fractures (DCFs) account for 10%–30% of all clavicle fractures and remain difficult to manage because fracture stability depends heavily on coracoclavicular ligament integrity, plain radiographic classification has limited reliability, and distal fragment size varies substantially, complicating fixation planning. This review provides an evidence-based update on the anatomy, classification, imaging, and management of DCFs, incorporating recent literature, including population-specific cadaveric data and three-dimensional fracture mapping. The conoid and trapezoid ligaments have distinct osseous footprints that influence fracture stability in both the Neer/Craig and Cho classification systems; however, interobserver reliability remains only fair-to-moderate for both systems, particularly when conoid ligament integrity must be inferred. Three-dimensional computed tomography mapping has shown that posterior displacement and angulation are nearly universal but often underrecognized on standard radiographs, supporting selective computed tomography use when radiographs do not adequately characterize fracture morphology, comminution, or multiplanar displacement. Magnetic resonance imaging should be reserved for cases in which ligament integrity remains diagnostically ambiguous. Stable fractures generally have excellent outcomes with conservative treatment using a simple arm sling. For unstable fractures, operative and conservative treatment yield similar 1-year functional outcomes despite different union rates (96% vs. 63%), with conservative treatment carrying a nonunion risk of approximately one-third and operative treatment carrying a technique-dependent reoperation burden, ranging from planned implant removal in most hook plate cases to less than 10% with coracoclavicular stabilization constructs. When surgery is indicated, technique selection should be guided by fracture morphology and surgeon experience: anatomic locking plate fixation with or without coracoclavicular augmentation for Neer IIA/Cho IIA fractures, dedicated coracoclavicular stabilization for Neer IIB fractures (Cho IIB/IIC), and hook plate fixation as a salvage construct for Neer V/Cho IID fractures. Management should integrate classification, imaging findings, union risk, reoperation risk, expected recovery, and patient-specific factors through shared decision-making.
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