Does altering projection of the fractured clavicle change treatment strategy?

Background: Shortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy. Methods: Thirty-six AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen–Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment. Results: On average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (P =.01). Conclusion: This study reveals the influence the projection of the midshaft clavicular fracture has on the surgeon's decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.