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Fractures of the clavicle are extremely common accounting for 5%–10% of all fractures.1 It is well recognised that the initial radiograph may be negative in children and such children often present at a later date with a complaint of a palpable lump in the region of the clavicle. This has led to the practice of treating all clinically fractured clavicles with a normal radiograph as a fracture.2 A search of the English literature and standard orthopaedic text failed to find such a recommendation for adults. We present a case series of three adults who had a normal initial radiograph of the clavicle after trauma and who subsequently had a fracture verified at re-presentation.
Over a two year period the authors were involved in the management of three adult patients who were suspected of fractured clavicle on clinical grounds but whose initial anterior-posterior (A-P) radiographs were normal. The patients re-presented within two weeks with persistent symptoms and repeat radiographs showed fractured clavicle. All three patients had a fracture of the mid-shaft of the clavicle (see table 1 and fig 1).
Occult fracture is well described in the hip and the scaphoid and failure to recognise this could lead to serious consequences. While clavicular fracture is often viewed as benign, it is important for patients to be aware if they have a fracture as it has implications on expected time of recovery and when they can return to work. In addition complications such as non-union do occur and inadequate initial immobilisation is a common cause.3,4 Two views of the clavicle, A-P and 45° cephalic tilt were advocated by Widner5 however, it is the standard practice in most radiology departments to produce a single A-P view. In addition the standard exposure for the shaft of clavicle over exposes the lateral third of the clavicle while the medial third is often obscured by overlapping ribs, vertebral, and mediastinal shadows. All our patients had a single A-P view radiograph. It is possible that these fractures would not have been missed had a 45° cephalic tilt view been obtained. Clinicians should be aware that some clavicular fractures will be occult in the standard A-P view. We therefore recommend that if there is a strong clinical suspicion of a fracture of the clavicle further views should be obtained. If radiographs remained negative the patient should be treated as though there was a fracture and this possibility must be communicated to the patient. Patients with a strong clinical suspicion of a fracture should be asked to re-attend in about 10 days, if symptoms persist, for a repeat radiograph as is commonly practised for fractured scaphoid.