Hostname: page-component-cd9895bd7-lnqnp Total loading time: 0 Render date: 2024-12-27T14:55:16.096Z Has data issue: false hasContentIssue false
  • English
  • Français

Prospective evaluation of clinical assessment in the diagnosis and treatment of clavicle fracture: Are radiographs really necessary?

Published online by Cambridge University Press:  21 May 2015

Michael Shuster ,
Riyad B. Abu-Laban ,
Jeff Boyd ,
Charles Gauthier ,
Sandra Mergler ,
Lance Shepherd  and
Chris Turner
Michael Shuster*
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
Riyad B. Abu-Laban
Affiliation:
the Department of Emergency Medicine and the Centre for Clinical Epidemiology and Evaluation, Vancouver General Hospital, Division of Emergency Medicine, University of British Columbia, Vancouver, BC
Jeff Boyd
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
Charles Gauthier
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
Sandra Mergler
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
Lance Shepherd
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
Chris Turner
Affiliation:
Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alta.
*
Mineral Springs Hospital, Box 1050, Banff AB T1L 1H7; fax 403 762-4193, michael.shuster@telus.net

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Introduction:

Current recommended treatment for middle-third clavicle fractures is limited to the use of ice, analgesics, a sling, and rest. Radiography for these fractures would be superfluous if physicians could accurately identify them by clinical examination alone. The primary purpose of this study was to determine whether emergency physicians can accurately diagnose clavicle fractures, and whether they can differentiate middle-third fractures from medial- or lateral-third fractures by clinical assessment alone.

Methods:

We enrolled a convenience sample of patients who presented to our rural emergency department with possible clavicle fracture between Nov. 1, 2001, and Apr. 30, 2002. Prior to viewing radiographs, physicians scored their clinical certainty of diagnosis on a 10-cm visual analogue scale. When certain of fracture, physicians determined the location of the fracture, the nature of the fracture and their hypothetical comfort in treating the injury without radiography.

Results:

In 51 of 77 enrolled patients (66%; 95% confidence interval [CI], 54.6%–76.6%), treating physicians were certain of the diagnosis of clavicle fracture prior to radiography. In these 51 cases, radiography revealed a fracture in 50 cases (98.0%; 95%CI, 89.6%–99.9%). The physicians were 100% accurate for 4 fractures clinically identified as lateral-third fractures (95% CI, 39.7%–100%) and for 41 fractures identified as middle-third fractures (95% CI, 91.4%–100%). They were correct on only 1 of 5 injuries (20%; 95% CI: 1%–72%) they clinically identified as medial-third fractures. Despite high clinical accuracy with middle-third fractures, they stated in 27 of 42 cases (64%; 95%CI, 48.0%–78.5%) that they would have been uncomfortable treating the patient without a radiograph.

Conclusions:

This study provides evidence that experienced emergency physicians are highly accurate when they are clinically certain of clavicle fracture. Further, when emergency physicians do clinically diagnose clavicle fracture, they can accurately identify the patient subgroup that will be responsive to conservative treatment. Routine radiography of obvious middle-third clavicle fractures does not appear to improve diagnostic accuracy or treatment decisions.

Keywords

fractureclavicleradiographinjuries
Type
EM Advances • Innovations en MU
Information
Canadian Journal of Emergency Medicine , Volume 5 , Issue 5 , September 2003 , pp. 309 - 313
Copyright
Copyright © Canadian Association of Emergency Physicians 2003

References

1.Stiell, IG, Greenberg, GH, McKnight, RD, Nair, RC, McDowell, I, Reardon, M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269:1127–32.CrossRefGoogle ScholarPubMed
2.Stiell, IG, Greenberg, GH, Wells, GA, McDowell, I, Cwinn, AA, Smith, NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996;275:611–5.CrossRefGoogle ScholarPubMed
3.Stiell, IG, Wells, GA, Vandemheen, K, Laupacis, A, Brison, R, Eisenhauer, MA, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. CMAJ 1997;156:1537–44.Google ScholarPubMed
4.Shuster, M, Abu-Laban, RB, Boyd, J. Prereduction radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med 1999;17:653–8.CrossRefGoogle ScholarPubMed
5.Shuster, M, Abu-Laban, RB, Boyd, J, Gauthier, C, Shepherd, L, Turner, C. Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in the clinically obvious anterior shoulder dislocation. Can J Emerg Med 2002;4(4):257–62.CrossRefGoogle ScholarPubMed
6.Marx, JA, Hockberger, RS, Walls, RM, editors. Rosen’s Emergency medicine: concepts and clinical practice, 5th ed. Chicago: Mosby-Year Book, Inc; 2002. p. 581–4.Google Scholar
7.Jeys, LM, Cribb, G, Toms, AD, Hay, SM. Mountain biking injuries in rural England. Br J Sports Med 2001;35:197–9.Google Scholar
8.Kocher, MS, Feagin, JA Jr. Shoulder injuries during alpine skiing. Am J Sports Med 1996;24:665–9.CrossRefGoogle ScholarPubMed
9.Orenstein, JB. Injuries and small-wheel skates. Ann Emerg Med 1996;27:204–9.Google Scholar
10.Landine, J, McGraw R, Pickett, W. Clinical diagnosis of clavicle fractures: a pilot study. Can J Emerg Med 2001;3(2):95–8.CrossRefGoogle ScholarPubMed
11.Anderson, K, Jensen, PO, Lauritzen, J. Treatment of clavicular fractures: figure-of-eight bandage vs. a simple sling. Acta Orthop Scand 1987;57:71–4.CrossRefGoogle Scholar
12.McCandless, DN, Mowbray, M. Treatment of displaced fractures of the clavicle. sling vs. figure-of-eight bandage. Practitioner 1979;223:266–7.Google Scholar
13.Stanley, D, Norris, SH. Recovery following fractures of the clavicle treated conservatively. Injury 1988;19:162–4.CrossRefGoogle ScholarPubMed
14.Oroko, PK, Buchan, M, Winkler, A, Kelly, IG. Does shortening matter after clavicular fractures? Bull Hosp Jt Dis 1999;58:6–8.Google ScholarPubMed
15.Nordqvist, A, Redlund-Johnell, I, von Scheele, A, Petersson, CJ. Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients. Acta Orthop Scand 1997;68:349–51.CrossRefGoogle ScholarPubMed
16.Rockwood, CG. Fractures of the clavicle. In: Craig, EV, editor. Rockwood & Green’s Fractures in adults, 4th ed, Philadelphia: Lippincott-Raven; 1996. p. 1109–61.Google Scholar