Treatment Of Clavicle Fractures Research Articles

Distribution and treatment of clavicular fractures in monotrauma and polytrauma patients.

BackgroundAlthough extensive research for the optimal treatment of clavicle fractures has been performed, comparative studies between monotrauma and polytrauma patients are lacking.ObjectiveTo compare fracture distribution and treatment in monotrauma and polytrauma patients with a clavicle fracture.MethodsSingle center retrospective cohort study. Fractures were classified by the Robinson classification. Monotrauma patients sustained only a clavicle fracture or a clavicle fracture plus a minor abrasion, hematoma, or superficial skin lesion leading to an Injury Severity Score (ISS) of 4 or 5 respectively. Polytrauma patients had an ISS ≥16 as a result of injury in 2 or more Abbreviated Injury Scale (AIS) regions.Results154 monotrauma and 155 polytrauma patients with a clavicle fracture were identified. Monotrauma patients had a higher incidence of Type IIB fractures (displaced midshaft) compared to polytrauma patients (P = 0.002). No difference was observed regarding Type I (medial) and Type III (lateral) fractures. In monotrauma patients, Type IIB fractures were treated operatively more frequently (P = 0.004). The initial treatment for Type I and Type III fractures did not differ between monotrauma and polytrauma patients.ConclusionsMonotrauma patients had a higher incidence of displaced midshaft clavicle fractures compared to polytrauma patients, and monotrauma patients with displaced midshaft clavicle fractures were treated operatively more frequently. No differences were found in the distribution and treatment of medial and lateral clavicle fractures.

Treatment of Midshaft Clavicular Fractures with Elastic Titanium Nails

Background:One of the modern techniques for the treatment of clavicle fracture (Fx) is elastic titanium intramedullary nailing. But, there are different opinions about this technique. We studied this technique in 12 patients with clavicle Fx and assessed its outcome.Objectives:We aimed to study the prognosis of midshaft clavicular Fx treated via minimally invasive stable elastic intramedullary nailing.Patients and Methods:We operated on 13 clavicle Fx in 12 patients from 2008 through 2012. We used a new technique called minimally invasive titanium elastic intramedullary nailing for operating patients with midshaft clavicular Fx.Results:Clinical union was achieved 3-5 weeks after the operation with no pain over Fx sites upon physical examination. Radiologic union appeared at 6 to 12 weeks .We did not encounter nonunion or infection, but one of the comminuted Fx united 1 cm shorter; however, it had a solid union with a good score. All but two patients had good scores.Conclusions:Although controversy exist regarding intramedullary nailing of clavicle Fx, our results using this technique for minimally comminuted midshaft clavicular Fx were very good.

Treatment of Clavicle Fractures in Athletes and Young Active Patients

Clavicle fractures are very common and nearly all clavicle fractures heal with simple conservative methods. Clavicle fractures are also rather frequent in athletes as well as the ordinary young, active people because of simple falls and accidents. In this review, current treatment modalities for clavicle fractures in athletes and young active patients are given briefly. Those suggestions may also be beneficial for a person seeking for a faster recovery.

Treatment of Clavicle Fractures in Athletes and Young Active Patients

Treatment of Clavicle Fractures in Athletes and Young Active Patients

The results of low profile locking anatomical plate application for the treatment of Edinburg type 2 clavicle diaphysis fractures

Although conservative measures are the general choice of treatment for clavicle fractures; surgery is advised for displaced and multifragmentary fractures. Open reduction and osteosynthesis with a plate-screw combination are used widely as surgical treatment options. In our study, there were 21 patients with Edinburgh Type IIB clavicle middiaphysal fractures treated surgically with locked anatomical clavicle plate. Among those 31 patients and 32 clavicle middiaphysal fractures, Seventeen clavicle fractures were right-side, and fifteen were left side. 24 of them were males, 7 of them were females and the mean age was 28 (15-62) years. The mean follow-up period was 12.3 (6-36) months and healing time 15.2 (12-20) weeks. 3 patients with Type IIB fracture had a healing time longer than 12 weeks. As the result of healing patients', mean constant score was 92 (85-98) and DASH score 9 (2-20). There has been a problem due to the implant detected in 3 (9%) patients. Successful functional and radiographic results can be achieved as a result of the surgical treatment of the clavicle middiaphysal fractures with locked anatomical plates.

Operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults: a systematic review

Intervention studies of clavicle fracture treatment are numerous, but only a few high quality studies prospectively compare operative and nonoperative treatment. The objective of this study was to review evidence from randomized controlled trials on operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults with focus on fracture healing, complications and functional outcome. An electronic search was performed of PubMed, Embase and Cochrane databases which revealed 559 articles. All articles published before October 18th 2012 and written in English, Danish or Swedish were eligible. Articles were excluded if they included children under the age of 16, did not include acute midshaft fractures, included concomitant fractures, did not meet the requirements of Level I evidence according to Centre for evidence based medicine 2009 guidelines, were systematic reviews or meta-analyses, or did not compare operative and nonoperative treatment. Articles were parsed for relevance by two reviewers independently regarding title, abstract, and full text. Extraction of data was done by both reviewers in collaboration and sorted according to the aims of the study. Complications were grouped according to additional surgery required. The quality of studies was assessed by both reviewers in unison using Critical Appraisal Skills Programme 2010 checklists. It seems like operative intervention leads to fewer nonunions at the cost of an increase in minor complications compared to nonoperative treatment. However, the effects of operation on functional outcome remains controversial. High quality evidence is currently sparse supporting either operative or nonoperative treatment on displaced midshaft clavicle fractures in adults.

VA-LCP anterior clavicle plate: The anatomically precontoured fixation system with angular stability for clavicle shaft

The aim of this investigation was to evaluate the introduction of the VA-LCP anterior clavicle plate in the treatment of clavicle fractures. From March 2011 to March 2013, 42 clavicle fractures were treated; 40 were middle-third and 2 lateral-third, and 13/42 (31 %) patients were treated due to painful nonunion. Patient age ranged from 16 to 81 years. Complications were screw placement through the AC-joint, one superficial wound infection and one neuropraxia of the nervus radialis with dropping hand. We had some difficulties prebending both lateral to low and lateral to high but without clinical consequences. In all cases, the fracture healed with full functionality. After 1 year, 4 patients underwent a removal of the hardware. The VA-LCP anterior plate showed good reliability and sufficient stability with both middle-third, lateral and nonunion fractures of the clavicle.

Biomechanical study of different internal fixators and fixation modes for middle 1/3 clavicle fractures

Objective To investigate the effect of different internal fixators and fixation modes on the biomechanical properties of the middle 1/3 clavicle fractures.Methods Twenty-four artificial clavicle samples were prepared and used to simulate middle 1/3 oblique fractures.According to the clinical operative procedures,fractures were fixed respectively with locking plates in superior position,locking plates in anteroinferior position,reconstruction plates in superior position,and reconstruction plates in anteroinferior position.Then,resistance strain gauges were placed on the broken ends of the bone,embedded in polymethylmethacrylate (PMMA) and placed on Instron-8874 servo-hydraulic mechanical testing machine to have compression test,torsion test,and three-point bending test.Results Bending stiffness of control group,anteroinferior locking plate group,anteroinferior reconstruction plate group,superior locking plate group and superior reconstruction plate group was (539.16 ±47.45) N/mm,(1 013.47 ± 121.62) N/mm,(701.06 ± 53.28) N/mm,(360.98 ± 35.37) N/mm and (336.07 ± 18.83) N/mm respectively,with statistical significance in pair comparison among the control,superior,and anterior groups (P ＜ 0.05).In three-point bending test,the deflection limit of these groups was (8.75 ± 0.53) mm,(16.07 ±1.22) mm,(13.08 ±0.52) mm,(15.84±0.48) mm and (12.23 ±0.41) mm respectively.Moreover,the deflection limit of locking plate group and reconstruction plate group showed significant difference (P ＜ 0.05) and both were higher than that in control group (P ＜ 0.05).In torsion test,the mean torsion stiffness of locking plate group and reconstruction plate group was (0.77 ±0.08) Nm/deg and (0.73 ±0.11) Nm/deg in internal rotation and was (0.72 ± 0.07) Nm/deg and (0.75 ± 0.08) Nm/deg in external rotation,without statistically significant difference between groups.Resistor strain value in internal fixation groups lowered when compared to that in control group (P ＜ 0.05) and particularly lower strain value was observed in anteroinferior locking plate group.Conclusions (1) Plate fixation is the preferred method for treatment of clavicle fractures in that the plate can bear large amount of stress,provide a solid support and facilitate early fracture healing.(2) Anteroinferior clavicle plating using a locking plate possesses good biomechanical properties and has advantages of easy operation,low risk,solid fixation,few complications and cosmetic improvement.The technique is worthy of clinical practice. Key words: Clavicle; fracture fixation, internal; Biomechanics

Demographics of the injury pattern in severely injured patients with an associated clavicle fracture: a retrospective observational cohort study

BackgroundDespite an increasing interest in the treatment of clavicle fractures, this is still a not yet defined area in severely injured patients as most studies exclude these patients. Analyzing fracture type and evaluate accompanying injuries can provide valuable information in an early stage of trauma care.ObjectiveTo identify prevalence, fracture type and accompanying injuries of clavicle fractures in the severely injured patient.MethodsWe included all severely injured patients (ISS ≥ 16) with a clavicle fracture from January 2007 - December 2011. We prospectively collected data about demographics, injuries, trauma mechanism and mortality. Fractures were classified using the Robinson classification.ResultsA total of 1534 patients had an ISS ≥16, of which 164 (10.7%) patients had a clavicle fracture. Traffic related accidents were the main cause of injury (65%). Most fractures were midshaft fractures (66.5%) of which 56% were displaced. Seven patients were treated operatively. There was no significant difference in ISS between the three fracture types. 83% of the patients sustained additional injury to the head and neck; the most prevalent injuries were skull or skull base fractures (41.5%) and maxillofacial fractures (29%). Furthermore 77% of the patients had additional thoracic injury; the most prevalent injuries were rib fractures (59%) and a pneumothorax (38%). The mortality rate was 21.4%.ConclusionA clavicle fracture was present in more than 10% of the severely injured patients. Displaced midshaft clavicle fractures were the most common type of fracture. Additional injuries to the head and neck region occurred in 83% of the patients and thoracic injuries occurred in 77% of the patients.

Frequency and Complications after Operative Fixation of Clavicle Fractures

The purpose of this study was to analyze whether a recent trend in evidence supporting operative treatment of clavicle fractures is matched with an increase in operative fixation rates, as well as complication rates.

Surgical treatment of clavicular fractures in Finland – A register based study between 1987 and 2010

BackgroundClavicle fractures are among the most common upper extremity injuries. Traditionally most clavicle fractures have been treated non-surgically, but during recent decades the surgical treatment of clavicle fractures has increased. The purpose of this study was to assess the numbers and trends of surgically treated clavicle fractures in Finland between 1987 and 2010. MethodsThe study covered the entire adult (>18 years) population of Finland over the study period. Data on surgically treated clavicle fractures was collected from the Finnish National Hospital Discharge Register. We assessed the number and incidence of surgically treated clavicle fractures annually. ResultsA total of 7073 surgically treated clavicle fractures were identified in the register over the study period. Three-fourths of the surgically treated patients were men and one-fourth was women. The incidence of surgical treatment increased nearly ninefold from 1.3 per 100,000 person years in 1987 to 10.8 per 100,000 person years in 2010. The increase in the rate of surgical treatment was especially notable in men. ConclusionsA striking increase in incidence of surgically treated clavicle fractures was seen from 1987 to 2010. Although the actual incidence of clavicle fractures is not known, we assume that the proportion of patients receiving surgical treatment has increased markedly without high-quality evidence. Since recent reports have suggested similar functional results between operative and conservative treatment critical evaluation of the treatment policy of clavicle fractures is warranted.

Surgical fixation of displaced clavicle fracture in adolescents: a review of literature

The literature available on patient-orientated outcomes of operative management for clavicle fractures in adolescents is fairly limited. Open surgical treatment of displaced midshaft fractures of the clavicle continues to be a topic of controversy. Traditional treatment of clavicle fractures has been via non-operative methods in both children and adults. Management in adolescent patients remains controversial, and rightly so, as the traditional experience from non-operative methods has been regarded as satisfactory, while the literature on the more recent approach towards fixing some of these fractures is evolving. We present a review of relevant literature.

Complications of operative treatment of clavicle fractures in a Level I Trauma Center

Traditionally, the belief is that the clavicle heals readily and with nonoperative treatment. Since evidence suggests that many clavicles benefit from operative care, the aim of this study was to find the incidence of complications after operative treatment of clavicle fractures. This retrospective study includes 56 patients (41 male and 15 female) who were treated operatively for clavicle fractures between 2010 and 2012. The indications were displacement more than 20mm, comminution, tenting of the skin, floating shoulder, and open fractures. Seventy-five percent of the fractures occurred in the midshaft and 25% in the lateral third of the clavicle. There were no fractures of the medial third. The midshaft fractures were either plated with 3.5mm reconstruction plates or anatomical locking plates. For internal fixation of the lateral fractures, we used acromioclavicular hook plates. The mean follow-up period was 4.6months (range 1.0-28.0). Three patients did not participate in the follow-up. There were 12 patients with complications (21%). Five of them required reoperations. Two patients were reoperated due to clavicle nonunions, two patients due to traumatic refracture of the plated clavicle, and one because of pain caused by the plate. Four cases developed superficial infections, and there was one patient with a deep tissue infection. None of the patients showed signs of neurovascular impairment postoperatively. None of the patients complained about decreased range of motion or loss of muscle strength postoperatively. Plating of clavicle fractures is a procedure that results in lower rates of malunion, nonunion, and functional impairment compared with nonoperative treatment. Nonetheless, one case in ten has a complicated course. Attention to technique and careful follow-up may prevent these problems.

Functional and Radiographic Outcomes of Nonoperative Treatment of Displaced Adolescent Clavicle Fractures

Studies of adult patients suggest that nonoperative treatment of clavicle fractures may result in functional disability, but this has not been demonstrated in adolescents. The purpose of this study was to determine the functional outcomes after nonoperative treatment of displaced, shortened, midshaft clavicle fractures in adolescents. Adolescents ten to eighteen years of age with an isolated, completely displaced, shortened, midshaft clavicle fracture sustained between 2009 and 2011 were recruited for this study. Injury and final radiographs were assessed for displacement, shortening, and clavicle length. Maximal and endurance strength testing was performed with the Baltimore Therapeutic Equipment (BTE) machine, with use of the uninjured shoulder as an internal control. Shoulder range of motion and clavicle length were assessed clinically, and patient-oriented outcomes were obtained. Sixteen patients (four of whom were female) with an average age (and standard deviation) of 14.2 ± 2 years and a mean duration of follow-up of 2 ± 1 years were included in the study. Fifteen patients were right-hand dominant and one was ambidextrous, and thirteen of the fractures occurred in the nondominant limb. Compared with the uninjured limb, no differences were noted in range of motion or strength except for an 8% decrease in maximal shoulder external rotation strength (p = 0.04) and a 11% loss of shoulder abduction endurance strength (p = 0.04). Radiographs demonstrated a 100% union rate but significant shortening compared with the uninjured clavicle (p ≤ 0.001). SANE (Single Assessment Numeric Evaluation), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), and Constant scores were similar between sides. Fifteen of the sixteen patients were satisfied with the appearance of the clavicle, and all returned to full activity, including the preinjury (or a higher) level of sports participation. Regardless of patient age, sports participation, and final clavicle shortening, no differences in pain, strength, shoulder range of motion, or subjective outcome scores were found between the injured and uninjured limbs of adolescents treated nonoperatively for a displaced, shortened, midshaft clavicle fracture.

Minimally invasive treatment of clavicle fracture with a hollow screw

Objective To evaluate the clinical effect of minimally invasive treatment of clavicle fracture with a hollow screw.Methods Data of 65 patients,who had undergone minimally invasive treatment with a hollow screw for clavicle fracture from April 2009 to October 2010,were retrospectively analyzed.There were 41 males and 24 females,aged from 19 to 67 years (average,35.8 years).According to the Craig's classification,there were 29 of group I and 36 of group Ⅱ-Ⅱ.A 4-5 cm transverse incision was made to expose the clavicle fracture.A guide pin was inserted into the marrow cavity,and then moved towards the acromion,after the fracture was reduced the pin was moved back to the proximal clavicle,finally a hollow screw was implanted to fix the fracture.The Neer score was used to evaluate the function of the shoulder.Radiographs were taken to observe the condition of the fracture union.The operative duration,intra-operative blood loss,fracture healing time,Neer score,and complications were compared with those of 65 patients with clavicle fracture who were treated by the same surgeons with plates.Results The incision length was 4-5 cm in hollow screw group and 10-11 cm in plate group.X-rays showed bone union was achieved in both groups,and the average bone healing time was 13.2±6.9 weeks in hollow screw group and 16.3±8.7 weeks in plate group.All patients were followed up for 6 to 20 months (average,10.6 months).The average Neer score was 96.6±3.4 in hollow screw group and 94.2±5.8 in plate group.There was no infection,local skin necrosis and fracture nonunion in both groups.In hollow screw group,screw loosing occurred in 5,and fracture displacement in 3,fortunately,the fracture healed by controlling activities.There was a significant difference in fracture healing time between two groups.However,no significant difference was observed between two groups in Neer score.Conclusion Minimally invasive treatment of clavicle fracture with a hollow screw has several advantages,such as mini-invasion,short bone healing time,good clinical outcomes,and lower expense. Key words: Clavicle; Fractures, bone; Bone screws; Fracture fixation, intramedullary

Perioperative risks associated with the operative treatment of clavicle fractures

BackgroundClavicle fractures are a common injury among young adults who were historically treated non-operatively with satisfactory outcomes. However, more recent studies have shown a higher nonunion rate for displaced clavicle fractures treated conservatively. The purpose of this study is to investigate the midterm complications, clinical outcomes and overall patient satisfaction after osteosynthesis of midshaft clavicular fractures. Patients and methodsA total of 37 patients treated for a clavicle fracture from January 2007 to December 2008 with at least 12 months’ follow-up were identified from a billing code search. At the latest follow-up appointment, the patients completed the Constant Shoulder, the Disabilities of the Arm, Shoulder and Hand scale (DASH) and the Medical Outcomes Study 36-Item Short-Form Health Survey version 2.0 (SF36v2) functional outcome surveys as well as a custom questionnaire to assess hand dominance, employment status, the amount of time taken before returning to work, the presence of numbness around the incision site (a surrogate marker of a supraclavicular nerve palsy), whether the patient desired the plate removed and/or if it was worth another surgery. ResultsWith regard to the functional outcome surveys, the average DASH score was 11.8±16.4, the Constant score was 93.3±7.2, the SF36v2 physical component summary (PCS) was 50.7±10.1 and the SF36v2 mental component summary (MCS) 50.6±11.2. From the custom questionnaire, 27 patients (73%) found their cosmetic appearance acceptable while the remaining 10 patients (27%) were bothered by the appearance of the plate. The average time to return to work was 82.1±77.4 days. There were no infections, refractures or nonunions of the clavicle. ConclusionAs the relative indications for open reduction and internal fixation of clavicle fractures become more popular, such as cosmetic concerns or faster recovery, we wish to demonstrate that the procedure is not without risks, including implant discomfort requiring a subsequent operation for removal, numbness around the incision site and infection. Despite these risks, patients tend to be satisfied with the procedure and are able to function at levels equal to that of the general population. The purpose of this study is not to recommend for or against operative treatment of clavicle fractures but merely to demonstrate risks associated with the procedure.

Comment on Liu et al.: Operative versus non-operative treatment for clavicle fracture: a meta-analysis

Dear Editor and Authors, In International Orthopaedics, Liu and his colleagues recently published an updated meta-analysis [1] regarding operative or nonoperative treatment for clavicle fractures. In this study, they concluded that operation is better than nonoperation for clavicle fracture. However, we have several suggestions and queries that we would like to communicate with the authors. We suggest that reporting of meta-analysis should conform to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement criteria. (available at http://www.prisma-statement.org/). The flow diagram [2] is necessary in meta-analysis. The recruitment of a controlled clinical trial (CCT) may affect the outcomes of meta-analysis. Therefore, on the one hand, acautious attitude should be taken towards the conclusions. On the other hand, we suggest that the authors should perform sensitivity analyses to explore whether CCTs biased the conclusions. Different internal fixation methods in the operative group may result in different bone healing processes and outcomes. Therefore, in order to obtain more precise conclusions, we suggest that the operative group should be further sorted as a plate subgroup and an intramedullary subgroup. We should also pay attention to another point that the follow-up time in some eligible studies was a little short, which may also affect the outcomes of the meta-analysis. To date, controversy still surrounds the optimal treatment for clavicle fracture. Therefore, more RCTs are in need in the future. We agree with the authors that in clinical applications, decisions should be made based on specific conditions.

Anatomical study of the clavicle: endomedullary morphology

The treatment of clavicle fractures remains controversial. The objective of this study was to investigate the possibility of clavicular intramedullary fixation by nailing through an anatomic study combined with CT scan studies. For the anatomic study, 20 clavicles of donated bodies to science (10 men, 10 women, 10 right, 10 left) were used. We measured the length of the clavicle, lateral epiphysis diameter, mean diaphysis diameter, medial epiphysis diameter, lateral width, lateral radius of curvature, medial width and medial radius of curvature. Intramedullary cavity diameter (anteroposterior and superoinferior) and calibration were measured by CT scan study on 20 clavicles. Average length was 152mm for men and 140mm for women. The anteroposterior curvature was most pronounced. The medullary canal had a gradually decreasing size from the distal portion to the middle segment, but never disappeared. Evaluation of morphological data can clarify the specifications of an intramedullary nail: flexibility of the nail to match clavicle curvature and a locking system to ensure primary stability. Intramedullary fixation by nailing in displaced fractures of the middle portion of the clavicle is a minimally invasive surgical technique, with excellent functional and cosmetic results.

Operative versus non-operative treatment for clavicle fracture: a meta-analysis

The purpose of this study was to assess the effects of operative and non-operative treatment on clavicle fractures. Relevant clinical trials on the operative and non-operative treatment for clavicle fractures were retrieved through searching the databases MEDLINE, Embase, OVID and the Cochrane Central Register of Controlled Trials up to December 2011. The quality of the included studies was assessed by two authors. A meta-analysis was carried out on homogeneous studies. Five studies involving 633 clavicle fractures were included. The differences in nonunion [risk ratio (RR) 0.12, 95 % confidence interval (CI) 0.05-0.29], malunion (RR 0.11, 95 % CI 0.04-0.29) and neurological complications (RR 0.45, 95 % CI 0.25-0.81) were statistically significant between operative and non-operative treatment. There was no statistically significant difference in delayed union (RR 0.78, 95 % CI 0.31-1.95). Operative treatment is better than non-operative treatment, but decisions should be made in accordance with specific conditions for clinical application.

Reliability of Measurements of Clavicle Shaft Fracture Shortening in Adolescents

A relative indication for surgical treatment of midshaft clavicle fractures is shortening ≥2.0 cm. A standard method for determining shortening with routine clavicle radiographs has not been established. This study evaluated the interobserver and intraobserver reliability when measuring shortening of midshaft clavicle fractures in adolescents. We identified all clavicle radiographs of simple midshaft clavicle fractures in adolescents from 2006 to 2010. Thirty-two radiographs were chosen following a power analysis for 7 observers. Each film was measured twice by each evaluator using 2 separate methods. Method 1 was the evaluator's method of choice to determine shortening on the digital radiographs. Method 2 was standardized. Intraclass correlation coefficient and confidence intervals (CI) were calculated to determine interrater reliability, and average differences between the 2 time points with 95% CI were calculated to determine intrarater reliability. Interrater reliability for method 1 was 0.771 (95% CI, 0.655-0.865) and 0.743 (95% CI, 0.604-0.851) at the 2 time points for fair agreement. Interrater reliability for method 2 was 0.741 (95% CI, 0.629-0.842) and 0.685 (95% CI, 0.554-0.805) at the 2 time points, for fair and poor agreement, respectively. Neither method was statistically superior to the other. For method 1, the SD for the measurements averaged 3.1 mm. For method 2, the average SD was 3.0 mm. Intrarater reliability for method 1 was 2.62 mm average difference between the 2 time points (95% CI, 2.24-3.00), and for method 2 it was 3.34 mm average (95% CI, 2.88-3.80). Method 2 had a significantly greater difference at the 2 time points than method 1 (P=0.027). There is only fair agreement among observers when measuring the shortening of clavicle fractures in adolescents on digital clavicle radiographs by either method described. However, as the average difference among measurers was only 3 mm, this is unlikely to influence clinical decision making. A lack of standardization of measurement in previous studies on clavicle fracture treatment may not represent a significant problem. Level III diagnostic study.