Clinical diagnosis of clavicle fractures: a pilot study

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.

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.

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.

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.