Clinical diagnosis of clavicle fractures: a pilot study

Abstract

Objective: Clavicle fractures are commonly encountered in the emergency department (ED). Our objective was to determine whether emergency physicians can clinically predict the presence and location of a clavicle fracture prior to obtaining x-rays. Methods: Over a 16-month period we prospectively studied ED patients who had injuries compatible with a clavicle fracture. Following clinical examination and prior to obtaining radiographs, ED physicians or senior emergency medicine (EM) residents were asked to predict whether the clavicle was fractured and, if fractured, the location of the fracture. Clinical predictions were later compared to the radiologist's report. Results: Between April 1999 and August 2000, 184 patients with possible clavicle fracture were seen and 106 (58%) were enrolled. Of these, 94 had an acute fracture, and all 94 fractures were predicted on clinical grounds prior to x-ray. In 6 cases, physicians predicted a fracture but the radiograph was negative. In 6 additional cases, physicians were clinically unsure and the radiograph was negative. Physicians correctly predicted fracture location in 83 of 94 cases (88%; 95% confidence interval [CI], 82%-95%). In the 64 cases where physicians predicted a middle third fracture, they were 100% accurate (95% CI, 95%-100%). Errors made by physicians were conservative; that is, they occasionally predicted fractures in patients with only soft tissue injury, but they did not "miss" existing fractures. Conclusions:The results of this pilot study suggest that ED physicians can clinically predict the presence and location of clavicle fractures with a high degree of accuracy. It may be that x-rays are not always necessary in patients suspected of having a clavicle fracture. Future studies should define the indications for diagnostic radiography in patients with suspected clavicle fractures. RÉSUMÉObjectif : On rencontre souvent des fractures de la clavicule à l'urgence. Notre objectif était de déterminer si les médecins d'urgence pouvaient prédire au moyen de l'examen clinique la présence et la localisation d'une fracture de la clavicule avant d'avoir les résultats des radiographies. Méthodes : Au cours d'une période de 16 mois, nous avons effectué une étude prospective des cas de patients reçus à l'urgence pour une blessure compatible avec une fracture de la clavicule. Après l'examen clinique et avant d'obtenir les radiographies, on demanda aux médecins d'urgence ou aux résidents sénior en médecine d'urgence (MU) de prédire la présence de fracture de la clavicule et dans l'affirmative, de déterminer l'emplacement de la fracture. Les prédictions cliniques furent ensuite comparées au rapport du radiologiste. Résultats : Entre avril 1999 et août 2000, cent quatre-vingt-quatre patients présentant une fracture possible de la clavicule furent examinés et 106 d'entre eux furent inclus dans l'étude (58 %). Parmi ces patients, 94 présentaient une fracture aiguë. Chacune d'entre elles fut prédite à l'examen clinique avant les radiographies. Dans six cas, les médecins prédi...

Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric Emergency Department

“…The question of whether any clavicle imaging is needed at all in cases of high (or low) clinical suspicion has been raised in light of imaging’s associated costs and minimal effect on diagnosis, treatment, and outcomes 25,26 . While our results show clinical suspicion to be reasonably accurate, its PPVs and NPVs were improved in all cases with the addition of US results.…”

Conservative Management of Paediatric Clavicle Fractures

“…Our radiographic follow-up in this study was a mean of five weeks, but we do recognise that only 23% of our patients had fracture union confirmed by radiographs. Some studies have suggested that radiographs are not required at all in the assessment of clavicle fractures [31, 32], but we feel that an initial radiograph to confirm and classify the injury is appropriate even where the fracture is obvious clinically.…”

Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study

“…Clavicle fractures are frequently seen in the emergency department (ED), accounting for approximately 15% of all paediatric fractures. 1 2 The standard of care is to obtain a radiograph for suspected clavicle fractures prior to treatment. First-line treatment in most children is conservative management with broad arm sling (BAS).…”

“… 2–4 Past studies have shown that ED clinicians are able to accurately diagnose clavicle fractures from clinical examination alone. 1–4 Requesting radiographs may be a habit of emergency practice, as it has not been determined if radiographs add valuable information to clinicians’ assessment and influence their management. 1 4–6 …”

“… 1–4 Requesting radiographs may be a habit of emergency practice, as it has not been determined if radiographs add valuable information to clinicians’ assessment and influence their management. 1 4–6 …”