Shoulder
Additional x-ray views increase decision to treat clavicular fractures surgically

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Background

The trauma series for clavicular fractures includes anterior-posterior and 20° cephalic tilt radiographs. Management of clavicular fractures either nonoperatively or operatively is dependent on radiographs. We hypothesized that the interobserver and intraobserver reliability of the treatment decision would be improved with a novel 4-view radiographic series over the standard 2-view radiographic trauma series.

Methods

Four-view radiographic analysis was performed and consisted of anterior-posterior, 20° cephalic tilt, 45° cephalic tilt, and 45° caudal tilt. Radiographs were collected for 50 consecutive patients presenting with acute midshaft clavicular fractures. Four blinded orthopedists were asked to judge whether each case should be treated either operatively or nonoperatively based on the standard 2-view series and then the 4-view series a minimum of 1 week later. This procedure was repeated a minimum of 2 months later. The incidence of surgeon treatment modification was analyzed along with interobserver and intraobserver reliability of both series.

Results

In 17 cases, at least 1 surgeon changed the treatment decision between 2- and 4-view review. In 13 cases (26%), the treatment was changed from nonoperative to operative. Significantly greater intraobserver reliability was observed for the 4- versus 2-view series (R = 0.76 and R = 0.64, respectively), with no difference in interobserver reliability (intraclass correlation coefficient of 0.88 and 0.87, respectively).

Conclusions

With the use of a novel 4-view radiographic series that includes orthogonal viewing angles, surgeons are more likely to treat clavicular fractures operatively and their intraobserver reliability is improved, suggesting improved visualization of anterior-posterior displacement.

Section snippets

Methods

Standard radiographic studies of the clavicle at our institution include 4 views (AP, 20° cephalad, 45° cephalad, and 45° caudad) (Fig. 1). Radiographs, including all 4 views, were collected for 50 consecutive patients with confirmed acute midshaft fractures of the clavicle. The image groupings were de-identified and assigned a study identification number. The image files were separated into two folders, one including standard 2-view images (AP and 20° cephalad)1 and one including all 4 images.

Results

The ICC for interobserver reliability of treatment decisions for the 2-view analysis was 0.87 (95% confidence interval [CI], 0.80-0.92). Table I provides the κ values for direct comparison of reviewers. From this analysis, we found that all κ values were greater than or equal to 0.50 and the highest agreement was observed between the shoulder and elbow fellow and fellowship-trained surgeon. The second review provided a lower ICC for interobserver reliability (0.65; 95% CI, 0.53-0.76). The

Discussion

The decision to treat closed midshaft clavicular fractures either operatively or nonoperatively is heavily dependent on radiographic fracture displacement.1, 2 However, the traditional trauma series for clavicular fractures includes only an AP radiograph and a single cephalic or caudal tilt radiograph.3, 4, 5 This may be partially because of the cost of additional views. Regardless, it is our opinion that the degree of fracture displacement cannot be adequately determined on these 2 views

Conclusions

The standard 2-view clavicular radiographic trauma series underestimates AP displacement. With the use of a novel 4-view radiographic series (standard 2 views plus orthogonal views), surgeons are more likely to treat clavicular fractures operatively and their intraobserver reliability is improved.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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The Thomas Jefferson University Institutional Review Board granted approval for this study (control No. 09R.229).

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