This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.
There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.
Conclusion
Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.