Fractures of the clavicle are relatively common, occurring mostly in younger patients and have historically been managed non-operatively. Recent studies have shown an advantage to surgical reduction and stabilisation of clavicle fractures with significant displacement. Currently, fracture displacement is measured using simple anterior-posterior two-dimensional x-rays of the clavicle. Since displacement can occur in all three-dimensions, however, evaluation of the amount displacement can be difficult and inaccurate. The purpose of this study was to determine the view that provides the most accurate assessment.

Nine CT scans of acute displaced clavicle fractures were analysed with AmiraDEV5.2.2 Imaging software. Measurements for degrees of shortening and fracture displacement of the fracture clavicle were taken. Using a segmentation and manipulation module (ITK toolkit), five digitally reconstructed radiographs (DRRs) mimicking antero-posterior x-rays were created for every CT, with each differing by projection angle (ranging from 20° upwards tilt to 20° downwards tilt). Measurements were taken on each DRR using landmarks of entire clavicle length, distance from vertebrae to fracture (medial fragment length), distance from fracture to acromium (lateral fragment length), and horizontal shortening, and then compared to the true measurement obtained from the original CT.

For all 9 samples, after comparing the measurements of clavicle fracture displacement in each 2D image, we found that an AP view with a 20° downward tilt yielded displacement measurements closest to the 3D (“gold standard”) measurements. The results agree with previous data collected from cadaveric specimens using physical X-ray film images. DDRs enable creation of multiple standard AP radiographs from which accurate tilt can be measured. The large deviation in measurements on different DRR projections motivates consideration of standardising X-ray projections. A uniform procedure would allow one to correctly evaluate the displacement of clavicular fractures if fracture displacement information is to be utilized in motivating surgical decision-making.