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Additional X-ray views increase decision to treat clavicular fractures surgically
Austin SL. J Should Elbow Surg. 2011. doi:10.1016/j.jse.2011.08.050
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Use of a novel four-view radiographic series that includes orthogonal viewing angles may make surgeons more likely to operatively treat clavicular fractures, according to this study from researchers in Philadelphia.
The authors also found surgeons who used the four-view radiographic series displayed improved intraobserver reliability, “suggesting improved visualization of anterior-posterior displacement.”
According to the study abstract, 50 consecutive patients presenting with acute midshaft clavicular fracture underwent radiographs. The traditional two-view series of radiographs was taken, as well as the four-view series (anterior-posterior, 20° cephalic tilt, 45° cephalic tilt and 45° caudal tilt). The authors then asked four blinded orthopedists to assess through radiographic evidence whether each case should be operatively or nonoperatively treated — first looking at the traditional two-view series and then, at a minimum of 1 week later, looking at the four-view series.
The procedure, the authors noted, was then repeated a minimum of 2 months later. Treatment modification as well as intraobserver and interobserver reliability were all assessed.
According to the study results, in 17 cases at least one surgeon changed their treatment decision between two- and four-view review. Thirteen cases saw treatment change from nonoperative to operative. The authors also reported greater intraobserver reliability for the four-view series when compared with the two-view series, with no reported differences in interobserver reliability.
The authors have shown that by increasing the number of radiographs to evaluate clavicle fractures, 4 orthopedic surgeons would operate more frequently than they would have with a traditional 2-view series.
Typically, with increased views and/or advanced imaging studies (i.e. CT scan, 3D CT scan) better understanding of the fracture pattern, displacement, comminution, and overall “personality” of the fracture is appreciated. The Canadian multicenter prospective study led by Mike McKee (1) has previously shown improved outcomes for patients treated with open reduction internal fixation for displaced midshaft clavicle fractures.
However, the more important question of course is would the outcome for these patients be different if operative treatment is pursued as opposed to non-operative treatment? If not, then the increased time, radiation exposure, and expense may not be justified. Further evaluation with a prospective study design would be prudent before wide adoption of this new X-ray series is incorporated into the armamentarium for evaluation of clavicle fractures.
— William N. Levine, MD
New York, NY
1. McKee MD et al (Canadian Orthopaedic Trauma Society). Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007 Jan;89(1):1-10.