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

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.