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Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study
  1. Marie-Pier Lirette1,2,
  2. Benoit Bailey3,
  3. Samuel Grant4,
  4. Michael Jackson5,
  5. Paul Leonard2
  1. 1 Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  2. 2 Division of Emergency Medicine, Department of Pediatrics, Royal Hospital for Sick Children, Edinburgh, UK
  3. 3 Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
  4. 4 Orthopaedics, Royal Blackburn Hospital, Blackburn, UK
  5. 5 Radiology Department, Royal Hospital for Sick Children, Edinburgh, UK
  1. Correspondence to Dr Marie-Pier Lirette; marie-pier.lirette{at}


Background Paediatric clavicle fractures are commonly seen in the emergency department (ED), and the current standard of care is to obtain a radiograph for all suspected clavicle fractures. We are yet to determine whether radiographs add valuable information to clinicians’ assessment and therefore if they are necessary in the management of paediatric clavicle fractures.

Objective To determine whether clinicians can manage paediatric clavicle fractures without radiographs, first by determining the accuracy of clinicians in identifying the presence of a clavicle fracture, and second by evaluating the level of agreement (kappa (κ)) between the ultimate management of children with suspected clavicle fractures and clinicians’ blinded prediction prior to the radiograph.

Methods This prospective study enrolled patients presenting to a paediatric ED with a suspected clavicle fracture. Prior to requesting a radiograph, clinicians completed a standardised form, where they predicted the presence of a fracture and their ultimate management based on their clinical findings, and rated their confidence.

Results Of the 50 patients aged 7.2±3.9 years included, 40 (80%) had a radiologically proven clavicle fracture, and clinicians were able to accurately identify them (sensitivity 93%, positive predictive value 88%). There were five (50%) patients without a radiological fracture that were treated with broad arm sling. Clinicians’ prediction of ultimate management had the highest agreement with the ultimate management of the patient on leaving the ED, compared with clinicians’ prediction of the presence of fracture and the final radiograph findings: κ of 0.88 (95% CI 0.64 to 1), 0.67 (95% CI 0.36 to 0.98) and 0.62 (95% CI 0.30 to 0.94), respectively. Thirty-six (72%) of the clinicians felt comfortable treating without radiographs, and this was dependent on their level of training.

Conclusions Clinicians can identify the presence of a fracture and tend to be overconservative in their management. Despite negative radiological findings, some patients were treated as though they had a fracture, based on clinical judgement. This adds evidence that radiographs are not routinely required for uncomplicated paediatric clavicle fractures.

  • clavicle
  • fracture
  • pediatrics
  • emergency department
  • x-ray

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  • Contributors M-PL and PL led the project and were involved in all parts of the study, including planning, acquisition of data, analysis and interpretation of the work, and drafting the manuscript as well as the final version of this manuscript. MJ had substantial contributions to the acquisition of data, and revising various versions as well as the final version of this manuscript. SG provided significant contributions to the interpretation of the data for the work, and revising the various versions as well as the final approval of this manuscript. BB was heavily involved in the statistical analysis of the data, contributed a significant amount to the interpretation of the data, writing of all parts of the manuscript, and editing multiple versions including the final approval of this manuscript. All authors agree to be accountable for all aspects of the work and believe it is an honest and valid work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Royal Hospital for Sick Children, Edinburgh, Scotland, UK. The ethics committee of the University of Edinburgh approved this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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