Skeletal Radiol (2011) 40:831842

DOI 10.1007/s00256-010-0968-3

REVIEW ARTICLE

Clavicle and acromioclavicular joint injuries: a review

of imaging, treatment, and complications
Yulia Melenevsky & Corrie M. Yablon &
Arun Ramappa & Mary G. Hochman

Received: 15 December 2009 / Revised: 4 May 2010 / Accepted: 11 May 2010 / Published online: 6 June 2010
# ISS 2010

Abstract Fractures of the clavicle account for 2.65% of

all fractures. Clavicular fractures have traditionally been
treated conservatively, however, there has recently been
increased interest in surgical repair of displaced clavicular
fractures, with resultant lower rates of nonunion and
malunion. Treatment of acromioclavicular (AC) separation
has traditionally been conservative, with surgery reserved
for patients with chronic pain or significant dislocation and
acute soft tissue injury. It is important for the radiologist to
become familiar with the surgical techniques used to fixate
these fractures as well as the post-operative appearance and
potential complications.
Keywords Clavicle fractures .
Clavicle and acromioclavicular joint imaging .
Acromioclavicular reconstruction

Introduction
Fractures of the clavicle account for 2.65% of all fractures
[13]. Clavicular fractures have traditionally been treated
conservatively, with initial reported rates of nonunion as
low as 1% [4, 5]. However, recent literature has shown that
the outcome of nonoperative treatment is not as good as
previously thought. Nonunion of displaced clavicular
Y. Melenevsky : C. M. Yablon (*) : M. G. Hochman
Department of Radiology, Beth Israel Deaconess Medical Center,
Boston, MA, USA
e-mail: cyablon@bidmc.harvard.edu
A. Ramappa
Department of Orthopedic Surgery,
Beth Israel Deaconess Medical Center,
Boston, MA, USA

fractures can result in orthopedic, neurovascular, and

cosmetic complications [6]. Recent studies demonstrate
lower rates of nonunion with surgery compared to
nonoperative treatment [7]. Furthermore, patients nowadays
expect improved cosmetic outcomes and earlier resumption
of preoperative activity levels, leading surgeons to focus on
primary surgical repair of displaced clavicular fractures.
Treatment of acromioclavicular (AC) separation has also
traditionally tended to be conservative, however, there is a
role for surgery in patients with chronic pain, significant
dislocation, and acute soft tissue injury, or type III
separations in high performance athletes [8].
This article will focus on the more common clavicular
injuries, including midshaft clavicular fractures, distal
clavicular fractures, and AC separation. Each of these
injuries has its own classification system and rationale for
treatment. It is important for the radiologist to become
familiar with the techniques developed to fixate these
fractures. Some of the surgical anchors and fixation devices
are radiolucent on radiography, and thus the postsurgical
appearance can be subtly altered from the preoperative
appearance. In addition, there are multiple potential
postsurgical complications of which one needs to be
cognizant. It is important to understand the surgical
considerations when these injuries are corrected, as this
allows an appreciation for the expected postoperative
appearance and potential postoperative complications.

Imaging of clavicular fractures

Radiography is usually the first-line imaging modality used
to evaluate patients with uncomplicated clavicular and
acromioclavicular joint injury. Clavicular anterior-posterior
(AP) and apical oblique views (1525 cephalic tilt) are

832

Skeletal Radiol (2011) 40:831842

used to evaluate clavicular fractures. Computed tomography

(CT) is not routinely used for the evaluation of simple,
nondisplaced clavicle fractures. However, thin section CT has
become the standard of care to evaluate suspected subtle
medial clavicle fractures in younger patients with open physes
or for sternoclavicular dislocation [9]. Multidetector CT
(MDCT) with sagittal and coronal reformatted images or
three-dimensional volume renderings (3DVR) can be
extremely helpful for the preoperative evaluation of
suspected nonunion or displaced clavicle fractures. MDCT
can assess the degree of displacement of the fracture
fragments and the proximity of the fragments to adjacent
vessels and to the brachial plexus (Figs. 1, 2).
Magnetic resonance imaging (MRI), with its threedimensional imaging capability and superior soft tissue
contrast, can be extremely useful for imaging suspected
neurovascular complications, pseudoaneurysm formation,
impingement of fracture fragments on the brachial plexus
and adjacent vessels, and hematoma formation (Fig. 3).
MRI is also extremely helpful to delineate concomitant
ligamentous injury with distal clavicular fractures and aid in
further subtyping these injuries.

Classification of clavicle fractures

There are myriad classification schemes used to describe
clavicle fractures. Allman initially divided clavicle fractures
by anatomic location into thirds: type I involves the middle
third of the clavicle; type II, the distal clavicle; and type III,
the proximal clavicle [10]. Although in common use, the
Allman classification does not take into account the
presence of comminution or displacement of fracture
fragments. The Neer modification of the Allman classification further subdivides distal clavicle fractures (type II)
based on the integrity of the coracoclavicular (CC)
ligaments and the acromioclavicular (AC) joint. Craig
subsequently modified the Neer and Allman system, further
refining the classification to include medial fractures,
degree of comminution, displacement, and joint involvement [11]. The Allman classification, incorporating the
Neer modification, is commonly used. In 1998, Robinson
created the newer Edinburgh classification, and this system
is gaining popularity because of its useful prognostic
information as to fracture healing. This scheme subdivides
clavicular fractures on the basis of anatomical location,
comminution, and displacement of the fracture [12]. In
clinical practice, orthopedic surgeons and radiologists
usually place less emphasis on trying to classify the fracture
than on making the clinical determination of the location of
the clavicle fracture, the degree of comminution and
displacement, the relationship of the fracture to the AC
joint and CC ligaments, and the integrity of the ligaments.

Fig. 1 A 20-year-old male who fell while snowboarding and

presented with a foreshortened limb. a Frontal radiograph demonstrates 6 cm overriding of the medial and lateral clavicle fracture
fragments. b Standard sagittal reformat of multidetector CT demonstrates a posteriorly displaced distal clavicle fracture fragment
impinging on the subclavian vessels (black arrow). c 3D volume
rendering (VR) MDCT demonstrates a markedly distracted, displaced
midshaft clavicle fracture with overriding of the fragments and a
posteriorly displaced fragment (white arrow) abutting the first rib. A
comminuted fracture fragment (black arrow) is wedged perpendicularly between the proximal and distal comminuted fracture fragment
and required surgical reduction. 3DVR most effectively demonstrates
this fracture configuration

Medial clavicular fractures

Medial clavicular fractures occur uncommonly and comprise 23% of all clavicle fractures [2]. Most medial
clavicle fractures are nondisplaced and do not involve the
sternoclavicular joint. These fractures are usually managed
nonoperatively. However, posterior fractures or dislocations
have the potential to displace into the superior mediastinum

Skeletal Radiol (2011) 40:831842

833

with resultant great vessel, airway, and neurologic injury.

Medial clavicular fractures may be radiographically occult,
and CT commonly helps to identify the fracture and
evaluate for neurovascular or airway compromise (Fig. 4).
If reduction is required, closed reduction is preferable to
open reduction, due to potential for implant migration.
Internal fixation methods including plates, interosseous
sutures, and Kirschner wires have been described [12].

Midshaft clavicular fractures

Fig. 2 A 28-year-old female hit by a snowplow who sustained near

total left forequarter amputation. a Frontal chest radiograph demonstrates a large soft tissue defect and markedly distracted comminuted
fractures of the clavicular midshaft and scapula. (Incidental note is
made of right mainstem bronchial intubation with associated left lung
atelectasis. The endotracheal tube was pulled back). b 3D VR MDCT
demonstrates the markedly comminuted midshaft clavicle and scapular
fractures. These images aided in the preoperative planning of
reconstruction of the clavicle and scapula with plate and screw fixation

Fig. 3 A 52-year-old male who sustained a displaced left midshaft

clavicle fracture after falling off a bicycle. He was managed
conservatively initially. Four months later he presented with decreased
strength and weakness in his left C8 and T1 distributions suggestive of
brachial plexus neuropathy. MR of the torso demonstrates callus with
hematoma formation (black arrow) at the left midshaft clavicle
fracture site causing impingement of the brachial plexus with
concomitant edema of the brachial plexus distal to the site of
impingement (white arrow)

Midshaft clavicular fractures account for 6982% of all

clavicular fractures and occur more frequently in children
and young adults [1, 2]. These injuries have been shown to
result from falls, a direct blow incurred in sports, or motor
vehicle accidents. Although midshaft clavicle fractures have
traditionally been treated nonoperatively with presumptive
good outcomes, it has now been shown that conservatively
treated displaced midshaft clavicular fractures can result in
nonunion rates as high as 15% [6, 13, 14]. This discrepancy
is explained in part by the inclusion of pediatric patients in
earlier studies, with pediatric patients having superior
outcomes to adults. Criteria for outcome assessment among
the studies differed, which affected the reported rates of
nonunion. There is also debate in the literature as to whether
displaced midshaft clavicle fractures should be treated
initially or after conservative treatment has failed [12, 15].

Fig. 4 a Frontal radiograph demonstrates sternoclavicular dislocation

with disruption of the sternoclavicular joint and proximal elevation of the
medial clavicle. b Axial CT centered on the sternoclavicular joints
demonstrates marked posterior displacement of the left clavicle with
respect to the sternum. There is mild impingement on the arch vessels and
brachiocephalic vein (arrow). The patient was managed conservatively.
(Images courtesy of Dr. Jim S. Wu, Boston, MA)

834

Skeletal Radiol (2011) 40:831842

Nonoperative management
Mid-shaft clavicular fractures, either nondisplaced or displaced, have commonly been treated conservatively with
closed reduction with a sling or a figure-of-eight brace [1,
2, 57, 13, 14]. It has traditionally been thought that
radiographic nonunion or malunion had little effect on
functional outcome [16]. However, recent studies have
shown a high nonunion and malunion rate if displaced
midshaft fractures are treated conservatively [6, 7, 13]. A
recent study examined patient-based outcomes after
clavicular fractures and demonstrated 31% of patients
reporting unsatisfactory results after nonoperative treatment
including weakness, numbness, paresthesias of the hand
and forearm with elevation of the limb, and droopy
shoulder [7, 14]. A meta-analysis of recent studies showed
a 15.1% rate of nonunion of displaced midshaft clavicular
fractures treated conservatively compared with 2.2% after
plate fixation [7, 15].
Operative management
Several types of fixation plates have been used in the
treatment of midshaft clavicle fractures. Dynamic compression plates are most commonly applied to the anterosuperior
surface of the clavicle with a minimum of three screws in the
proximal and distal fracture fragments. Care is taken to restore
the original length and rotation of the clavicle, as well as the
preoperative distance between the AC and sternoclavicular
joints. Precontoured anatomic plates are favored rather than
straight compression plates as the precontoured plates are
found to produce less soft tissue irritation [17]. Anteroinferior plating has also been described with good functional
and cosmetic results and reduced hardware-related skin
irritation [18, 19] (Fig. 5).
Intramedullary nailing or pinning is an alternative to
plating that has the potential benefit of less soft tissue
stripping at the fracture site, better cosmetic appearance
with a smaller skin incision, easier hardware removal,
and less weakness at the fracture site after hardware
removal. However, intramedullary nailing may provide
less rotational stability compared to plating. Several
other fixation methods have been described to repair
midshaft clavicle fractures, including Kirschner wires,
Knowles pins, Steinmann pins, elastic nails, and cancellous
screws [2025] (Fig. 6).

Fig. 5 Midshaft clavicle fractures with different types of fixation

plates. a A 44-year-old male with displaced midshaft clavicle fracture
transfixed by anterior reconstruction plate. b A 23-year-old male with
anatomic reduction of midshaft fracture and fixation with a precontoured plate to the superior aspect of the clavicle. Three proximal and
four distal cortical screws transfix the proximal and distal fracture
fragments. Additionally, a lag screw transfixes the fracture fragments
in the antero-posterior direction

include shortening in the medial-lateral dimension with

inferior displacement of the distal fracture fragment. There
is commonly some clavicular length discrepancy between
the affected and normal side [6] (Fig. 7). Nonunion is
defined as the lack of radiographic healing with absence of
osseous bridging at the fracture site and clinical evidence of
pain and motion at the fracture site at 24 weeks [2]. There
are two types of nonunion: hypertrophic nonunion, where
there is sclerosis with abundant callus formation associated
with good blood supply, and atrophic nonunion, where
there is absence of callus and demineralization associated
with poor blood supply. Hypertrophic nonunion occurs
more frequently where there is abnormal motion at the
fracture site, either secondary to absence of fixation or to
inadequate fixation. Atrophic nonunion occurs more
frequently in the case of segmental fractures, where

Complications
Both nonoperative and operative management can result in
pain and tenderness at the fracture site, limited range of
motion, and malunion or nonunion of the fracture.
Radiographic characteristics of malunion in the clavicle

Fig. 6 A 21-year-old male with a midshaft clavicular fracture fixated

with a Hagie pin. Postoperative radiograph shows near anatomic
alignment of initially angulated fracture fragments

Skeletal Radiol (2011) 40:831842

Fig. 7 Malunion. a Initial radiograph at the time of injury

demonstrates a displaced midshaft clavicle fracture with overriding
of the fracture fragments and elevation of the proximal fracture
fragment. b Six months later after conservative management, there is
bulky callus formation with medial-lateral shortening of the clavicle, a
large residual step-off and deformity at the fracture site, with elevation
of the proximal fracture fragment

there is loss of bone apposition to promote healing

(Fig. 8). Subclavian vessel compression, thrombosis, and
pseudoaneurysm as well as brachial plexus injury can
occur secondary to posteriorly displaced fracture fragment
and hypertrophic callus formation at the fracture site after
conservative management [26] (Fig. 9).
Postoperative complications include hardware loosening,
with the possible consequence of subsequent migration,
hardware failure or breakage, wound dehiscence, and
infection (Fig. 10). Hardware-related irritation can necessitate removal of the hardware [6, 7, 20, 27]. Delayed union
and nonunion remain infrequent complications of surgical
management. Clavicle re-fracture following plate removal
has been described [27]. There have been reports of
occasional intramedullary nail migration [20]. Hardware
loosening can be manifested by radiolucency surrounding
the implant caused by abnormal motion (Fig. 11). Postoperative radiographs should always be evaluated for signs of
infection, manifesting as abnormal widening between bone
and hardware, erosion of bone, periosteal reaction, and soft
tissue swelling [27] (Fig. 12).

835

ligaments. Neer type I fractures occur between the

conoid and trapezoid ligaments; the CC ligaments remain
intact and the fracture is stable. Neer type II fractures
occur proximal to the CC ligaments, resulting in
displacement of the proximal fracture fragment. With
type IIa fractures, both CC ligaments remain attached;
with type IIB fractures one or both CC ligaments are
torn. Neer type III occur lateral to the CC ligaments but
extend into the AC joint [28]. The determination to
intervene operatively is made on the basis of whether the
fracture is stable or unstable, whether the CC ligaments
are torn, and whether the AC joint is involved. It has been
shown that type II distal clavicular fractures occurring
proximal to the CC ligaments heal with approximately a
30% rate of nonunion if treated conservatively [29].
Nonoperative management
Type I and III fractures are nondisplaced and stable.
These are treated conservatively with a sling. The type
III fracture may predispose to osteolysis and arthritis as
this injury involves the AC joint. The distal clavicle can
be resected once the fracture heals if the area remains
symptomatic [29].
Operative management
Surgical fixation of type II displaced distal clavicle
fractures has been advocated due to the reported high rate
of nonunion and delayed union after conservative management [12, 2830]. Surgical treatment, however, remains
somewhat controversial because the largest published series
have not reported significant symptoms or functional
limitation if these fractures are left untreated. This
discrepancy is explained in part by the fact that no large
prospective studies have been done. Comparison among the
studies is difficult because the published studies have had
differing initial treatments and differing reported outcomes
on the basis of reported radiographic union, patient

Distal clavicular fractures

Approximately 28% of clavicular fractures occur at the
distal aspect of the clavicle [2]. The mechanism ranges
from simple falls to trauma involving a direct blow to the
shoulder. The Neer modification of the Allman classification
has commonly been used to describe distal clavicular
fractures. The classification system categorizes fractures
based on their relationship to the coracoclavicular (CC)

Fig. 8 A 52-year-old male with atrophic nonunion of a displaced

comminuted midshaft clavicle fracture after conservative treatment,
8 months after the initial injury. Frontal radiograph demonstrates
nonunion of the midshaft fracture with wide distraction of the fracture
fragments, elevation of the proximal fracture fragment, eburnation of
the fracture ends, without evidence of callus or osseous bridging

836

Skeletal Radiol (2011) 40:831842

Fig. 9 A 47-year-old male who

developed a pseudoaneurysm of
the subclavian artery secondary
to a midshaft clavicle fracture
that was initially treated conservatively. a Displaced midshaft
clavicular fracture with overriding fracture fragments. b MR
angiogram demonstrates a large
pseudoaneurysm (white arrow)
arising from the right subclavian
artery. The patient presented
18 months after the initial injury
with a pulsatile mass and a right
ulnar nerve palsy. c Digital
subtraction angiographic spot
view confirms the presence of a
right subclavian artery pseudoaneurysm (black arrow)

satisfaction, and patients functional expectations following

surgery [28, 29]. The decision to intervene surgically
remains to be made on the basis of the patients age,
preoperative function, and postoperative expectations.
Many surgical fixation techniques have been described
including clavicular plates, hook plates, Kirschner (K)
wires, coracoclavicular screws, coracoclavicular ligament
reconstruction, Knowles pin fixation, tension band wiring,
and transacromial K-wiring. These methods require open
dissection and the removal of hardware before the patient
can resume mobilization [29, 3136]. Clavicular plates
have been developed that use either bicortical screws in the
distal fracture fragment or locking screw technology [37]
(Fig. 13). Plate fixation may be augmented by cerclage
wiring (Fig. 14). The clavicular hook plate system is
designed to fixate fractures with distal fragments that are
too small to be fixated with the two or three bicortical
screws. The plate is affixed to the superior aspect of the

Fig. 10 An 18-year-old male with midshaft clavicle fracture with a

bent plate. a Immediate postoperative radiograph obtained post plate
fixation of a comminuted midshaft clavicular fracture with a
reconstruction plate and cortical screws. b Radiograph obtained at
the 2 week follow-up visit demonstrates interval apical deformity of
the plate with apex deformity of the fracture. The large butterfly
fracture fragment is inferiorly displaced. The skin was visibly tented.
One week after this radiograph was obtained, the patient presented
with wound dehiscence

Fig. 11 Nonunion in a 40-year-old male with a right midshaft

clavicular fracture fixated with a 3 mm Rockwood pin. Despite
extensive callus formation, the fracture line remains visible with
pseudarthrosis, hypertrophic callus formation, and nonunion. There is
extensive lucency around the pin indicating loosening and motion at
the fracture site. Clinically there were no signs of infection in this
patient

Skeletal Radiol (2011) 40:831842

Fig. 12 Osteomyelitis in a 52-year-old male with midshaft clavicular

fracture with plate fixation. The proximal fracture fragment is
superiorly displaced with respect to the distal fragment. The fracture
remains ununited and there is fragmentation and erosive change at the
fracture site, particularly at the proximal aspect of the distal clavicle
fragment. The lateral aspect of the plate has become dislodged from
the distal fracture fragment, and the two lateral screws have backed
out of the bone. There is lucency subjacent to the screws and the
cortex is eroded (arrow), consistent with osteomyelitis. The patient
presented with pain, deformity, and discharge from a sinus tract;
cultures grew Staphylococus aureus

clavicle, and the hook passes below the acromion into a

tunnel created in the subacromial space behind the
acromioclavicular joint. There is the potential for hook
migration into the acromion, and hardware removal is
recommended within 6 months after surgery [35] (Fig. 15).
K-wire fixation was initially used by Neer, but this
technique has fallen out of favor due to wire breakage and
migration [28, 33]. Use of coracoclavicular screws can be
less invasive and has been associated with high healing rates,
but a second procedure for removal is required as range of
motion can be limited, and hardware failure and migration
remain a potential concern [31, 32]. Reconstruction of the

837

Fig. 14 A 42-year-old female with distal clavicular fracture. In

addition to the superior plate and screws, a cerclage wire has been
placed about the distal fragments of this comminuted fracture

coracoclavicular ligaments to create a coracoclavicular sling

about the coracoid and clavicle can be performed with
Dacron or Mersiline tape, polydioxanone sutures, wire, or
cable [29, 37, 38].
Complications
Complications of surgical treatment of distal clavicular
fractures are similar to those of midshaft clavicle fractures,
including hardware-related complications, loosening and
infection, delayed union and nonunion. Unique complications with the hook plate include hook migration,
loosening, and osteolysis around the hook, warranting
hardware removal [34, 35] (Fig. 16). Fractures may occur
medial to the hook plate if the plate is removed too soon
[33]. K-wire migration, breakage, and infection have been
seen occasionally [33]. The CC reconstruction can fail;
either the graft material can rupture or the hardware can
break (Fig. 17). Osteoarthritis of the acromioclavicular
joint remains a persistent potential complication of
fractures of the distal clavicle if the fracture involved the
AC joint at the time of initial injury.

Acromioclavicular joint separation

Approximately 9% of shoulder girdle injuries involve damage
to the acromioclavicular joint [16]. The mechanism of most

Fig. 13 A 28-year-old male with comminuted distal clavicular

fracture. a Preoperative radiograph demonstrates an intact AC joint
and disrupted coracoclavicular ligaments with marked retraction of the
proximal fracture fragment. b Postoperative radiograph demonstrates
near anatomic alignment of the fracture fragments with plate and
screw fixation and restoration of the CC distance

Fig. 15 Radiograph of the right shoulder demonstrates an AO hook

plate transfixing a healed distal clavicle fracture. The plate is affixed
to the superior margin of the clavicle and the hook passes beneath the
acromion

838

Fig. 16 A 25-year-old male with distal clavicular fracture with hook

plate fixation. AP image demonstrates a hook plate with cortical
screws and a screw transfixing the proximal and distal fracture
fragments. There is focal lucency around the hook within the
acromion (black arrow) denoting loosening of the hook plate

AC separations is trauma, caused either by a direct blow to

the top of the shoulder with the arm in the adducted position
or by a fall on an outstretched hand; these injuries tend to
occur in younger, more physically active patients [8].
Classification of acromioclavicular joint separation
Tossy originally classified AC separations into three types:
in type I the AC ligaments are sprained; in type II the AC
ligaments are torn but the CC ligaments remain intact; in
type III both AC and CC ligaments are torn [39]. The Tossy
classification was expanded by Rockwood to include three
additional types of injuries; this classification is now
commonly used to describe acromioclavicular joint separation [40]. Type IV injury occurs when the clavicle is
dislocated posteriorly. Type V AC injury is an exaggerated
type III injury where the AC and CC ligaments are torn and
deltotrapezial fascia are also torn, causing the scapula to
droop inferiorly. Type VI AC injury occurs when the
clavicle dislocates inferiorly to the coracoid.

Skeletal Radiol (2011) 40:831842

controversial and are falling into disfavor because they are

uncomfortable for the patient and frequently add no new
information to the clinical examination [41].
There has been growing interest in using MRI to
delineate AC and CC ligamentous disruption and the
degree of concomitant soft tissue injury with AC joint
separations [42, 43]. MRI can be very useful in classifying
the types of AC joint injury preferentially to radiography as
the coracoclavicular ligaments can be directly visualized on
MRI, whereas their integrity is only inferred on radiography. MRI is also useful to characterize postoperative
changes and to distinguish degenerative changes from acute
injury. A specialized coronal plane of imaging parallel to
the anterior acromion has been described [43] (Fig. 18).
Initial management
Type I and II AC separations are treated conservatively [8,
44]. Type IV through VI AC separations are treated
operatively due to the significant morbidity associated with
joint dislocation and severe soft tissue injury [8, 4549].
Initial treatment of acute type III AC separations is usually
conservative although some authors do advocate surgery
for acute injuries in high performance throwing athletes.
Patients with persistent pain or disability after conservative
treatment for type III separations may be candidates for
surgery [8, 46, 50].
Operative management
As of March 2010, there have been at least 17 published
techniques for repairing the AC joint. These involve
various methods for stabilization of the AC joint, distal

Imaging of acromioclavicular joint separation

In patients with suspected acromioclavicular injuries,
simultaneous bilateral AP views are obtained providing a
reference for the normal AC and CC distances in the
uninjured shoulder. Lateral and axial views are beneficial in
the diagnosis of posterior dislocation of the clavicle.
Bilateral Zanca views (the beam is directed 10 cephalad
toward the AC joint) and cross-arm adduction AP views
can also be performed. It is generally accepted that
acromioclavicular joint distances greater than 67 mm and
coracoclavicular distances greater than 1113 mm are
pathologic. Weighted views of the AC joint may unmask
the difference between type II and III injuries. Traditionally,
these have been performed by comparing views of the AC
joint performed with and without a 10 pound weight affixed
to the patients ipsilateral wrist. However these views are

Fig. 17 a A 34-year-old female with distal clavicle fracture nonunion

repaired with cortical screw through the distal fracture fragments and a
Dall-Miles cable about the coracoid process and the distal clavicle. b
The same patient presented 1 year later with pain. Frontal radiograph
demonstrates a fractured cable indicating loss of the CC reconstruction

Skeletal Radiol (2011) 40:831842

839

Fig. 18 Normal MR coracoclavicular ligamentous anatomy

and common types of AC joint
injury. a PD coronal image
demonstrates intact conoid
(white arrow) and trapezoid
(black arrow) ligaments. b
Radiograph of type II AC joint
separation demonstrates intact
AC and CC intervals. c PD
coronal MR of a type II AC
joint separation with abnormal
signal, fluid, and edema at the
AC joint (white arrow) without
widening of the AC joint. d
Radiograph of type III AC joint
separation demonstrates disrupted AC and CC ligaments with
elevation of the clavicle. e PD
coronal MR shows a type III AC
separation with disruption of the
AC joint, fluid, and edema and
elevation of the clavicle (black
arrow). f T2FS MR shows a
type V AC separation, with
disruption of the CC ligaments
(small white arrow), widening
of the AC joint, fluid, and
edema. In addition, the clavicle
is displaced superiorly into the
trapezius (large white arrow)
with resultant partial tear of the
trapezius

clavicle resection, CA ligament transfer, and CC ligament

reconstruction [8]. It is beyond the scope of this paper to
describe all of these techniques, but we will describe those
more commonly used.

Fig. 19 A 19-year-old male with acromioclavicular joint dislocation

treated with a hook plate. Postoperative radiograph shows nearanatomic reduction of the AC joint and normalization of coracoclavicular distance achieved with an AO hook plate. A CC reconstruction
was performed with tibialis allograft, passed beneath the coracoid
process and secured in a clavicular tunnel (black arrow)

Initially, primary AC joint fixation was performed using

K-wires, however this is no longer commonly done owing
to known complications of K-wire migration described
above. Currently, AC joint repair involves reducing the AC
joint and reconstructing the coracoclavicular ligament.
Many of these techniques are similar to the methods
employed in distal clavicle fracture repair. Hook plate

Fig. 20 A 48-year-old male with AC joint reconstruction. Postoperative radiograph of bilateral AC joints shows the normal right AC
joint and the postoperative left AC joint with evidence of distal
clavicle resection and normalization of the coracoclavicular distance.
Parallel tunnels in the distal clavicle are created to reproduce conoid
and trapezoid ligaments. A tibialis graft has been passed underneath
the base of the coracoid process and secured in the clavicular tunnels

840

Skeletal Radiol (2011) 40:831842

Fig. 21 A 38-year-old male

with infected AC joint reconstruction. a PD coronal MR
demonstrates a fractured screw
in the clavicular tunnel (white
arrow) with abnormal signal in
the coracoid process and distal
clavicle. b T1FS postcontrast
coronal MR shows attenuation
of the CC graft (white arrow)
with a large amount of
enhancement consistent with
infection. Cultures subsequently
grew Mycobacterium fortuitum

fixation of the AC joint is becoming more commonplace,

either alone or in combination with ligament reconstruction
[51, 52]. As with distal clavicle repair, hook plates cannot
be left in permanently and must be removed after initial
healing (Fig. 19).
The classic Weaver-Dunn technique deserves special
mention as this method involved the resection of the distal
aspect of the clavicle and the transfer of the acromial end of
the coracoacromial (CA) ligament to the medullary
cavity of the distal aspect of the clavicle [53]. It is no
longer commonly performed. The modified Weaver-Dunn
technique involves stabilizing the clavicle to the coracoid
during ligament healing with preservation of the AC joint,
thereby reducing the risk of symptomatic arthritis. However, the CA ligament is sacrificed in the procedure. This
may predispose to anterosuperior instability if the patient
should suffer a rotator cuff tear in the future, because the
stabilizing force of the coracoacromial ligament is lost
[54, 55].
At our institution the CA ligament is spared. The CC
ligament is reconstructed using a hamstring tendon
autograft or an allograft. Parallel tunnels in the distal

Fig. 22 A 55-year-old male with post-AC joint reconstruction who

experienced repeated falls and presented with pain. The radiograph
demonstrates evidence of prior modified Weaver Dunn procedure,
with distal clavicular resection, and parallel radiolucent tunnels in the
distal clavicle for graft attachment sites. There has been loss of
anatomical reduction with proximal retraction of the clavicle, lack of
alignment of the distal clavicle and acromion, and widening of the
coracoclavicular interval

clavicle are created to reproduce the conoid and

trapezoid ligament attachments. The tendon graft is
passed underneath the base of the coracoid process and
secured in the clavicular tunnels. Studies have found
these constructs to be biomechanically superior to CA
ligament transfer [56, 57] (Fig. 20). Postoperatively it is
normal to see a widened AC interval consistent with the
distal clavicular resection; however, the plane of the clavicle
is nearly aligned with the acromion process.
The newest technique to have been developed is the
TightRope system, which secures the coracoid to the
clavicle by means of a double metallic button with
FiberWire suture. This method does not require tendon
graft to be incorporated into clavicular tunnels [8].
Alternatively, a variety of fixation devices can be used to
achieve coracoclavicular stabilization, including coracoclavicular screws, suture loops, and synthetic loops between
the coracoid process and clavicle. These devices may be
combined with ligament reconstruction techniques [5861].
Patients with persistent pain and arthritis following low
grade injury (type I or II AC separations with intact
coracoclavicular ligaments) may benefit from open or
arthroscopic distal clavicular resection without ligamentous
reconstruction (Mumford procedure) [52].

Fig. 23 Postoperative radiograph obtained approximately 1 year after

coracoclavicular ligament reconstruction demonstrates heterotopic
ossification of the reconstructed coracoclavicular ligament graft. In
addition, there is loss of reduction, with disruption of the normal AC
interval. The patient was asymptomatic

Skeletal Radiol (2011) 40:831842

Complications
Wound infection and dehiscence are occasionally seen
postoperatively as are hardware migration and failure
(Fig. 21). Complete or partial loss of the surgical
reduction is encountered more commonly (Fig. 22).
Fracture of the clavicle and coracoid process can also be
seen and heterotopic ossification can occur about the
tendon graft site [8] (Fig. 23). Patients may eventually
develop osteoarthritis of the AC joint or distal clavicle
osteolysis whether they receive conservative or surgical
treatment.

Summary
Nonoperative treatment of displaced midshaft and distal
clavicular fractures can result in nonunion or malunion,
patient dissatisfaction, and potential orthopedic, neurologic, and cosmetic complications. These factors have
compelled surgeons to examine surgical repair of midshaft and distal clavicular fractures, in an effort to restore
preoperative baseline function and improve cosmesis.
While surgical treatment of type III AC separation
remains controversial, surgical fixation occurs regularly
in active, highly functioning patients and in some
athletes. Familiarity with the multiple surgical techniques
employed in treating midshaft and distal clavicular
fractures as well as AC separations allows improved
postoperative assessment by the radiologist. Knowledge
of potential postoperative complications may facilitate
timely intervention by the surgeon and improve patient
care and postsurgical outcomes.

References
1. Nordqvist A, Petersson CJ, Redlund-Johnell I. Mid-clavicle
fractures in adults: end result study after conservative treatment.
J Orthop Trauma. 1998;12:5726.
2. Robinson CM. Fractures of the clavicle in the adult. Epidemiology
and classification. J Bone Joint Surg Br. 1998;80:47684.
3. Neer CS 2nd. Fractures of the clavicle. Philadelphia: Lippincott;
1984.
4. Neer CS 2nd. Nonunion of the clavicle. J Am Med Assoc.
1960;172:100611.
5. Rowe CR. An atlas of anatomy and treatment of midclavicular
fractures. Clin Orthop Relat Res. 1968;58:2942.
6. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of
the clavicle. J Bone Joint Surg Am. 2003;85-A:7907.
7. Canadian Orthopedic Trauma Society. Nonoperative treatment
compared with plate fixation of displaced midshaft clavicular
fractures. A multicenter, randomized clinical trial. J Bone Joint
Surg Am. 2007;89:110.
8. Rios CG, Mazzocca AD. Acromioclavicular joint problems in
athletes and new methods of management. Clin Sports Med.
2008;27:76388.

841
9. McCulloch P, Henley BM, Linnau KF. Radiographic clues for
high-energy trauma: three cases of sternoclavicular dislocation.
AJR Am J Roentgenol. 2001;176:1534.
10. Allman Jr FL. Fractures and ligamentous injuries of the clavicle
and its articulation. J Bone Joint Surg Am. 1967;49:77484.
11. Craig EV. Fractures of the clavicle. In: Rockwood CA, Matsen
FA, Harryman DT, editors. The shoulder. Philadelphia: WB
Saunders; 1990. p. 373.
12. Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the
clavicle. J Bone Joint Surg Am. 2009;91:44760.
13. McKee MD, Pedersen EM, Jones C, et al. Deficits following
nonoperative treatment of displaced midshaft clavicular fractures.
J Bone Joint Surg Am. 2006;88:3540.
14. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced
middle-third fractures of the clavicle gives poor results. J Bone
Joint Surg Br. 1997;79:5379.
15. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD.
Treatment of acute midshaft clavicle fractures: systematic review
of 2144 fractures: on behalf of the Evidence-Based Orthopaedic
Trauma Working Group. J Orthop Trauma. 2005;19:5047.
16. Crenshaw A. Fractures of the shoulder girdle, arm and forearm.
St. Louis: Mosby; 1992.
17. Altamimi SA, McKee MD. Nonoperative treatment compared
with plate fixation of displaced midshaft clavicular fractures.
Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2 Pt
1):18.
18. Chen CE, Juhn RJ, Ko JY. Anterior-inferior plating of middlethird fractures of the clavicle. Arch Orthop Trauma Surg.
2010;130(4):50711
19. Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R.
Anterior-inferior plate fixation of middle-third fractures and
nonunions of the clavicle. J Orthop Trauma. 2006;20:6806.
20. Lee YS, Huang HL, Lo TY, Hsieh YF, Huang CR. Surgical
treatment of midclavicular fractures: a prospective comparison of
Knowles pinning and plate fixation. Int Orthop. 2008;32:5415.
21. Ngarmukos C, Parkpian V, Patradul A. Fixation of fractures of the
midshaft of the clavicle with Kirschner wires. Results in 108
patients. J Bone Joint Surg Br. 1998;80:1068.
22. Capicotto PN, Heiple KG, Wilbur JH. Midshaft clavicle nonunions
treated with intramedullary Steinman pin fixation and onlay bone
graft. J Orthop Trauma. 1994;8:8893.
23. Boehme D, Curtis Jr RJ, DeHaan JT, Kay SP, Young DC,
Rockwood Jr CA. The treatment of nonunion fractures of the
midshaft of the clavicle with an intramedullary Hagie pin and
autogenous bone graft. Instr Course Lect. 1993;42:28390.
24. Connolly JF. Non-union of fractures of the mid-shaft of the clavicle.
Treatment with a modified Hagie intramedullary pin and autogenous
bone-grafting. J Bone Joint Surg Am. 1992;74:14301.
25. Jubel A, Andemahr J, Bergmann H, Prokop A, Rehm KE. Elastic
stable intramedullary nailing of midclavicular fractures in athletes.
Br J Sports Med. 2003;37:4803. discussion 484.
26. Howard FM, Shafer SJ. Injuries to the clavicle with neurovascular
complications. A study of fourteen cases. J Bone Joint Surg Am.
1965;47:133546.
27. Bostman O, Manninen M, Pihlajamaki H. Complications of plate
fixation in fresh displaced midclavicular fractures. J Trauma.
1997;43:77883.
28. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin
Orthop Relat Res. 1968;58:4350.
29. Anderson K. Evaluation and treatment of distal clavicle fractures.
Clin Sports Med. 2003;22:31926. vii.
30. Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal
clavicle: a case for fixation. Injury. 1992;23:446.
31. Ballmer FT, Gerber C. Screw fixation for unstable fractures of the
distal clavicle. A report of five cases. J Bone Joint Surg Br.
1991;73:2914.

842
32. Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth
method for unstable fractures of the distal clavicle. Int Orthop.
1998;22:3668.
33. Flinkkila T, Ristiniemi J, Hyvonen P, Hamalainen M. Surgical
treatment of unstable fractures of the distal clavicle: a comparative
study of Kirschner wire and clavicular hook plate fixation. Acta
Orthop Scand. 2002;73:503.
34. Flinkkila T, Ristiniemi J, Lakovaara M, Hyvonen P, Leppilahti J.
Hook-plate fixation of unstable lateral clavicle fractures: a report
on 63 patients. Acta Orthop. 2006;77:6449.
35. Muramatsu K, Shigetomi M, Matsunaga T, Murata Y, Taguchi T.
Use of the AO hook-plate for treatment of unstable fractures of the
distal clavicle. Arch Orthop Trauma Surg. 2007;127:1914.
36. Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY.
Treatment of distal clavicle fracture using Kirschner wires and
tension-band wires. J Trauma. 2001;51:5225.
37. Hessmann M, Kirchner R, Baumgaertel F, Gehling H, Gotzen L.
Treatment of unstable distal clavicular fractures with and without
lesions of the acromioclavicular joint. Injury. 1996;27:4752.
38. Levy O. Simple, minimally invasive surgical technique for
treatment of type 2 fractures of the distal clavicle. J Shoulder
Elbow Surg. 2003;12:248.
39. Tossy JD, Mead NC, Sigmond HM. Acromioclavicular separations:
useful and practical classification for treatment. Clin Orthop Relat
Res. 1963;28:1119.
40. Rockwood CA Jr, Williams GR, Young CD. Injuries to the
acromioclavicular joint. In: Rockwood CA Jr et al. Fractures in
adults. Philadelphia: Lippincott; 1996. pp. 1341431.
41. Bossart PJ, Joyce SM, Manaster BJ, Packer SM. Lack of efficacy
of weighted radiographs in diagnosing acute acromioclavicular
separation. Ann Emerg Med. 1988;17:204.
42. Antonio GE, Cho JH, Chung CB, Trudell DJ, Resnick D. MR
imaging appearance and classification of acromioclavicular joint
injury. AJR Am J Roentgenol. 2003;180:110310.
43. Alyas F, Curtis M, Speed C, Saifuddin A, Connell D. MR imaging
appearances of acromioclavicular joint dislocation. Radiographics.
2008;28:463. quiz 619.
44. Galpin RD, Hawkins RJ, Grainger RW. A comparative analysis
of operative versus nonoperative treatment of grade III
acromioclavicular separations. Clin Orthop Relat Res 1985;
(193)150155.
45. Nicholas SJ, Lee SJ, Mullaney MJ, Tyler TF, McHugh MP.
Clinical outcomes of coracoclavicular ligament reconstructions
using tendon grafts. Am J Sports Med. 2007;35:19127.
46. Bishop JY, Kaeding C. Treatment of the acute traumatic
acromioclavicular separation. Sports Med Arthrosc. 2006;
14:23745.
47. Beim GM. Acromioclavicular joint injuries. J Athl Train.
2000;35:2617.

Skeletal Radiol (2011) 40:831842

48. Jerosch J, Filler T, Peuker E, Greig M, Siewering U. Which
stabilization technique corrects anatomy best in patients with ACseparation? An experimental study. Knee Surg Sports Traumatol
Arthrosc. 1999;7:36572.
49. Monig SP, Burger C, Helling HJ, Prokop A, Rehm KE. Treatment
of complete acromioclavicular dislocation: present indications and
surgical technique with biodegradable cords. Int J Sports Med.
1999;20:5602.
50. Farber AJ, Cascio BM, Wilckens JH. Type III acromioclavicular
separation: rationale for anatomical reconstruction. Am J Orthop.
2008;37:34955.
51. Faraj AA, Ketzer B. Use of a hook-plate in the management of
acromioclavicular injuries. Report of ten cases. Acta Orthop Belg.
2001;67:44851.
52. Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ.
Acromioclavicular joint injuries: diagnosis and management. J
Am Acad Orthop Surg. 2009;17:20719.
53. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries,
especially complete acromioclavicular separation. J Bone Joint
Surg Am. 1972;54:118794.
54. Jiang C, Wang M, Rong G. Proximally based conjoined tendon
transfer for coracoclavicular reconstruction in the treatment of
acromioclavicular dislocation. J Bone Joint Surg Am. 2007;
89:240812.
55. Rokito AS, Oh YH, Zuckerman JD. Modified Weaver-Dunn
procedure for acromioclavicular joint dislocations. Orthopedics.
2004;27:218.
56. Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski
ML, Arciero RA. A biomechanical evaluation of an anatomical
coracoclavicular ligament reconstruction. Am J Sports Med.
2006;34:23646.
57. Lee SJ, Nicholas SJ, Akizuki KH, McHugh MP, Kremenic IJ,
Ben-Avi S. Reconstruction of the coracoclavicular ligaments with
tendon grafts: a comparative biomechanical study. Am J Sports
Med. 2003;31:64855.
58. Tienen TG, Oyen JF, Eggen PJ. A modified technique of
reconstruction for complete acromioclavicular dislocation: a
prospective study. Am J Sports Med. 2003;31:6559.
59. Kumar S, Sethi A, Jain AK. Surgical treatment of complete
acromioclavicular dislocation using the coracoacromial ligament
and coracoclavicular fixation: report of a technique in 14 patients.
J Orthop Trauma. 1995;9:50710.
60. Hessmann M, Gotzen L, Gehling H, Richter A. Reconstruction of
complete acromioclavicular separations (Tossy III) using PDSbanding as augmentation: experience in 64 cases. Acta Chir Belg.
1995;95:14751.
61. Goldberg JA, Viglione W, Cumming WJ, Waddell FS, Ruz PA.
Review of coracoclavicular ligament reconstruction using Dacron
graft material. Aust N Z J Surg. 1987;57:4415.