title: Additional x-ray views increase decision to treat clavicular fractures surgically.
abstract: 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.
authors.affiliation: The Rothman Institute, Philadelphia, PA 19107, USA.
authors.forename: Luke S
authors.initials: LS
authors.lastname: Austin
authors.forename: Michael J
authors.initials: MJ
authors.lastname: O'Brien
authors.forename: Benjamin
authors.initials: B
authors.lastname: Zmistowski
authors.forename: Eric T
authors.initials: ET
authors.lastname: Ricchetti
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Kraeutler
authors.forename: Ashish
authors.initials: A
authors.lastname: Joshi
authors.forename: John M
authors.initials: JM
authors.lastname: Fenlin
mesh_terms: D000328:Adult; D000368:Aged; D002968:Clavicle / Q000000981:diagnostic imaging / Q000293:injuries*; D003657:Decision Making; D005260:Female; D005592:Fracture Fixation / Q000379:methods*; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D011859:Radiography; D015203:Reproducibility of Results