Fractures of the Clavicle


Recent studies favor surgical management of displaced clavicle fractures. Displacement is measured using anterior-posterior (AP) X-rays. Since displacement can occur in all three dimensions, however, standard methods of evaluation can be difficult and inaccurate. This study was conducted to determine the X-ray angle that provides the most accurate assessment. Nine CT scans of acute displaced clavicle fractures were analyzed with AmiraDev imaging software. 3D measurements for degrees of shortening and fracture displacement of the fracture clavicle were taken. Using a segmentation and manipulation module, five digitally reconstructed radiographs (DRRs) mimicking AP X-rays were created for every CT, with each DDR differing slightly by projection angle. After comparison to the original CTs, all samples using an AP view with a 20° downward tilt yielded displacements closest to the 3D “gold standard” or true measurements. Therefore, it is suggested that using this projection would provide the most accurate indication of fracture displacement.

Fractures of the clavicle are relatively common [5], and occur mostly in young, active individuals [2]. In recent years, there has been a major change in the principles of management of these fractures. Traditionally, supported by historical publications, fractures of the clavicle have largely been managed non-operatively [6]. In 1997, Hill et al. [3] published a study indicating that fractures of the clavicle with displacement of greater than 2 cm gave poor results. This study indicated that fractures with greater than 2 cm of shortening had a 15% incidence of non-union. McKee and the Canadian Orthopaedic Trauma Society published a landmark paper in 2008 titled “Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures” [1]. This prospective randomized, multicenter clinical trial concluded that completely displaced clavicle fractures had superior patient centered outcomes with surgical management as opposed to non-operative closed treatment. McKee defined a displaced clavicle fracture as “no cortical contact between the main proximal and distal fragments” [1]. With these publications, there has been a major change in the approach to clavicle fracture management. Surgeons are moving much more readily to surgical treatment than in the past. The indication for surgical treatment has expanded to include displacement of the fracture fragments of greater than 2 cm. The COTS Study suggests, “completely displaced” [1] as the criteria for surgical management rather than a specific measurement distance as with Hill et al. [3]. Nonetheless, common practice seems to be based on the 2-cm displacement criteria. Currently, fracture displacement is measured using simple anterior-posterior or posterior-anterior two-dimensional X-rays of the clavicle [9]. Since displacement can occur in all three dimensions, evaluation of the amount of displacement through the use of plain radiographs can be difficult and inaccurate. Many factors can influence the degree of displacement seen on traditional plain X-rays. These include patient positioning, supine vs. upright, angle of the X-ray beam projection, rotation of the chest wall, and the support or lack thereof of the affected arm. The purpose of this investigation was to assess the influence of different radiographic projections on the accuracy of clinical fracture displacement measurements and to determine the best projections for accurate measurements.

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Managing Editor
Journal of Orthopedic and trauma.
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