clavicle fractures are common , representing 2.6 - 12% of all adult fractures[14 ] and 35 - 44% of all fractures to the shoulder girdle . it has been shown that patient - specific and fracture - specific factors such as increasing patient age , female gender , fracture displacement , comminution , and shortening are predictive of increased risk of symptomatic nonunion or malunion with nonoperative management [ table 1 ] . early studies reported low rates of nonunion and high rates of satisfaction . however , more recent studies have demonstrated significantly greater nonunion ( up to 15% ) and symptomatic malunion rates with nonoperative management . further , operative treatment of displaced fractures has demonstrated significantly lower rates of nonunion and symptomatic malunion , improved functional outcomes , and earlier return to activities versus that of nonoperative treatment . factors predictive of outcome following nonoperative management of clavicle fractures the recommendation of surgical treatment of clavicle fractures is made on a case - by - case , individualized basis with a prerequisite discussion of the known potential risks and benefits of both operative and nonoperative management . surgical treatment is an option that may be offered to patients within the premise of a reduction in the relative risk of nonunion and symptomatic malunion and an earlier return to work or sport . in most fractures of long bones , it is essential to gain orthogonal views of the whole bone to assess angulation , translation , and rotation . this sound management theory may apply to clavicle fractures , but traditionally nonorthogonal views have been used . currently , most published literature and orthopedic surgery textbooks do not recommend orthogonal views of clavicle fractures , and some even claim they are impossible to achieve due to thoracic structures obscuring the view . further , there is recognition that superimposed ends of a fracture on one view may appear united ; however an orthogonal view may demonstrate residual displacement . the authors of this manuscript recommend an easy and safe method of acquiring orthogonal views of the clavicle without any manipulation of the patients upper extremity . the authors hypothesize that the additional view serves three purposes that may improve upon the standard anteroposterior ( ap ) or posteroanterior ( pa ) , minimally tilted ( < 30 ) views : ( 1 ) preoperative information relative to the amount of fracture displacement , shortening , and comminution . ( 2 ) intraoperative information related to fracture reduction and plate placement . ( 3 ) postoperative information relative to bridged cortices seen with fracture healing . therefore , the clinical outcomes of patients managed with the additional radiographs described herein are being analyzed in a prospective validation study of the current pilot provisional study . further , the additional radiographic information has improved both the understanding and treatment of these injuries . all clavicle and shoulder injuries that present to our institution are imaged with the patient upright , if possible . all patients with known or suspected clavicle fractures or ac joint injuries receive an additional three views : ( 1 ) ap view of the clavicle [ figures 1 and 2 ] , an orthogonal view taken at 60 above [ figures 2 and 3 ] , and an orthogonal view 30 below the horizontal [ figure 2 ] . this series has been standardized at our institution and easily reproduced by all radiology technicians . these views are applicable with the patient standing with or without any immobilization device ( sling , figure - of - eight dressing , or various other shoulder immobilizers ) . thus , they are able to be utilized in the preoperative evaluation and postoperative assessment . x - ray cassette parallel to coronal plane of body ( a ) ap view , with x - ray beam angled 30 superiorly ( cephalic ) . ( b ) ap view , with x - ray beam angled 60 inferiorly ( caudal ) ( a ) fluoroscopic image angled 30 superiorly ( cephalic ) . ( b ) fluoroscopic image angled 60 inferiorly ( caudal ) in the operating room , these views are easily obtained with use of the mobile c - arm fluoroscopic unit [ figure 3 ] . the patient is placed in the semiseated position , with hips and knees flexed approximately 30. any radiographic image taken should be free of any metallic radiodensities that may obscure the view of the clavicle . the base of the c - arm is positioned on the contralateral side of the fracture . a sterile c - arm cover is applied to this part of the machine , allowing it access to the surgical field and not risking contamination of the surgeon , the surgical assistant , or the field itself . in this position , the surgeon and surgical assistant may stand in the usual position at the side of the patient , anterolateral to the operative field . the radiology technician only has to arc the beam 90 in the sagittal plane to obtain the two orthogonal views . these views may be taken prior to standard preparation and draping of the operative field to ensure adequate imaging may be obtained . the senior author 's ( jcl ; shoulder and elbow fellowship - trained ) practice primarily evaluates and treats shoulder and upper extremity injuries , both acute and chronic . from january 2010 to august 2011 , all patients that presented to the senior author 's office or were evaluated and treated in hospital were analyzed . inclusion criteria for reporting in this study were age greater than 18 years and an acute clavicle fracture ( icd-9 [ international classification of diseases ] code 810.0x ) that was treated via cpt ( current procedural terminology ) code 23500 ( closed treatment of clavicle fracture , without manipulation ) or 23515 ( open treatment of clavicle fracture , includes internal fixation , when performed ) . the introduction and standard use of this study 's proposed clavicle views have demonstrated better fracture anatomy characteristics . the ability to see anterior or posterior comminution or displacement that was previously less well visualized on typical clavicle series was greatly improved . based on these criteria , 34 patients were treated with sling immobilization and 52 patients were treated surgically with superior plate and screw internal fixation . prior to the introduction of orthogonal views , 19 patients were treated nonoperatively and 22 treated with internal fixation . addition of orthogonal views increased the number of patients treated surgically : in the same time period , 15 patients were treated nonoperatively and 30 treated with internal fixation . following surgery , patients were evaluated in the outpatient office at 2 and 6 weeks and 3 and 6 months . nonoperatively treated patients were evaluated at 1 , 2 , and 4 weeks and 3 and 6 months postinjury . the senior author 's ( jcl ; shoulder and elbow fellowship - trained ) practice primarily evaluates and treats shoulder and upper extremity injuries , both acute and chronic . from january 2010 to august 2011 , all patients that presented to the senior author 's office or were evaluated and treated in hospital were analyzed . inclusion criteria for reporting in this study were age greater than 18 years and an acute clavicle fracture ( icd-9 [ international classification of diseases ] code 810.0x ) that was treated via cpt ( current procedural terminology ) code 23500 ( closed treatment of clavicle fracture , without manipulation ) or 23515 ( open treatment of clavicle fracture , includes internal fixation , when performed ) . the introduction and standard use of this study 's proposed clavicle views have demonstrated better fracture anatomy characteristics . the ability to see anterior or posterior comminution or displacement that was previously less well visualized on typical clavicle series was greatly improved . based on these criteria , 34 patients were treated with sling immobilization and 52 patients were treated surgically with superior plate and screw internal fixation . prior to the introduction of orthogonal views , addition of orthogonal views increased the number of patients treated surgically : in the same time period , 15 patients were treated nonoperatively and 30 treated with internal fixation . following surgery , patients were evaluated in the outpatient office at 2 and 6 weeks and 3 and 6 months . nonoperatively treated patients were evaluated at 1 , 2 , and 4 weeks and 3 and 6 months postinjury . we have presented a technique that completely assesses the radiographic characteristics of clavicle fractures . a need existed to obtain all the pertinent information regarding fracture location , direction , displacement , shortening , comminution , and healing . an operative strategy can not be confidently undertaken without having all the information , nor can the appraisal of fracture healing with or without operative intervention . in order to better evaluate fracture personality , we devised a standardized clavicle fracture series with orthogonal views that may be safely and easily acquired without any manipulation of the ipsilateral upper extremity . the introduction of these orthogonal views has changed our treatment pattern to address more clavicle fractures operatively . only after an informed discussion with the patient about the risks , benefits , and expected outcomes of both nonoperatively and it must be emphasized that this study is a pilot provisional study with introduction of a new radiograph . based on the encouraging preliminary results , the authors are now prospectively analyzing patient outcomes with a validation study to be subsequently reported . this view was initially used to better evaluate acute clavicle fractures in the decision - making discussion with the patient . several patients had traditional ap views of the clavicle ( separate by 30 of cephalic tilt ) that demonstrated minimal superior or inferior displacement and looked relatively well aligned on both views [ figure 4a and b ] . thus , it was possible that an apparently minimally displaced fracture on standard ap views may be displaced significantly in the axial plane ( anterior to posterior ) . this is a valuable component of an informed consent process if we are to truly describe displacement and comminution of a fracture [ figure 5a and b ] . patients need to have all the relevant pieces of information regarding radiographic characteristics of their injury in order to make a decision with their surgeon . further , the surgeon has all the information to recommend with greater confidence the decision to proceed with surgery if indicated . in addition , recent studies have shown that up to 2/3 of initially minimally displaced fractures ( less than 2 cm shortening ) may progressively displace ( to greater than 2 cm shortening ) in the horizontal plane ( not used in the study , but would have been optimally assessed with our orthogonal views ) over a mean of 14.8 days postinjury with nonoperative treatment . of this latter group , many went on to surgical intervention . caudally angled view , the long oblique fracture line would have been easily missed ( a and b ) orthogonal views of comminuted , segmental clavicle fracture . the ap view illustrates approximately 100% displacement with an irregular complex appearance of the medial aspect of the lateral fracture fragment , not clearly depicting this area . the 60 caudally angled view identifies a segmental fragment that is angled more in the sagittal plane , plainly seen as the round tubular structure of the midshaft of the clavicle on the traditional clavicle ap view . this segmental fragment could have been easily missed without the former view if surgery is chosen , these orthogonal views may be easily integrated into the operative theatre without any significant increase in radiation exposure and any increase in risk of sterile field contamination . despite the open nature of surgical treatment and direct visualization of superior plate placement , the addition of one c - arm fluoroscopic image adds minimal additional exposure to the site and the operative theater , while adding significant confidence in plate location and screw placement . if esin ( elastic stable intramedullary nailing ) is chosen surgically rather than a plate / screw construct , the use of orthogonal views may reduce the significant learning curve that is associated with increased radiation exposure . it is especially useful for mid - distal 1/3 fractures in which plate selection and the potential ability to even use a plate was in question . given the known sigmoid anatomy of the clavicle , which changes from circular at mid - shaft to flatter in the axial plane at the distal end , there is ample room to place several screws distally through an accommodating plate despite an ap view that demonstrates little room distally . with several newer anatomic plate designs on the market , distal locking screw options allow for the placement of anywhere from three to eight screws in the distal fragment of a distal 1/3 fracture . without orthogonal views , extensive acromioclavicular ( ac ) joint ligament stripping would be required to visualize this intraoperatively and then make a decision whether plate placement was possible . our radiographs gave us the confidence to take down the ac ligaments to place a plate / screw construct , and then repair the ligaments after . following surgical or nonsurgical treatment , the same radiographic characteristics of the fracture can be assessed to estimate fracture healing . this is especially useful if the patient has persistent pain following nonoperative management , indicative of potential symptomatic malunion or nonunion . at our institution , we generally obtain the orthogonal clavicle series at the first postoperative visit . at this point , our radiographic views do not require any arm manipulation , thus not stressing the fixation construct at all . patients seem to appreciate seeing the two orthogonal views and better understand their injury and how it was treated . as surgeons , we have come to understand plate placement better in the axial plane when we visualize these films . radiographic views , such as the abduction lordotic view , apical oblique view , and quesada views have been described to assist in clavicle fracture evaluation . the abduction lordotic view is obtained with arm abduction to 135 and the x - ray beam angled 25 cephalad . the apical oblique view is obtained by angling the patients injured side toward the x - ray beam 45 and the x - ray beam angled cephalad 20. this view is best utilized for nondisplaced neonatal clavicle trauma and has been shown to be less effective than even a standard ap view . further , the apical oblique view is more appropriate as a tool to assess glenohumeral joint anterior and posterior instability , glenoid fractures , and hill - sachs defects . quesada views were originally described in 1926 as 45 caudad and 45 cephalad views ( true orthogonal views ) . although would provide true orthogonal projections , these views have not been integrated into clinical practice in nearly 100 years . many references conclude that a single ap with or without the addition of a 20 cephalic tilt film provides adequate information without interference by thoracic structures . this manuscript simply introduces the technique of acquisition of orthogonal views of the clavicle in the pre- , intra- , and postoperative settings . while these views lack validation in the ability to detect a significant difference in the need for surgical intervention and subsequent clinical outcomes , we have demonstrated that our treatment strategy has favored operative intervention with introduction of a complete clavicle radiograph series , based on numbers of patients treated nonoperatively and surgically . although surgical treatment is increasingly used , the clinical outcomes of these patients have yet to be elucidated . this study is moreover limited in that a gold standard of assessment of displacement , shortening , and comminution of clavicle fractures does not yet exist to make a valid comparison . while it is recognized that many surgical treatment options exist to treat clavicle fractures , including different plate and screw constructs ( such as the ones used in this study ) , other options are widely used internationally , including esin . although not evaluated specifically for the purposes of this study , we speculate that the addition of intraoperative orthogonal views would provide substantial benefit in intramedullary nail placement , potentially reducing operative time , avoiding aberrant nail placement , and obviating an incision over the fracture for reduction . further , these views assist in selection of implant ( plate and screws versus esin ) as esin may not be ideal for fractures with significant comminution . an easy and safe method of acquiring orthogonal views of the clavicle without any manipulation of the patients upper extremity has been presented . the additional view serves three purposes that improve upon the standard ap or pa , minimally tilted ( < 30 ) views : ( 1 ) preoperative information relative to the amount of fracture displacement , shortening , and comminution . ( 2 ) intraoperative information related to fracture reduction and plate placement . ( 3 ) postoperative information relative to bridged cortices seen with fracture healing . the standard use of these views has led to greater utilization of surgical treatment of clavicle fractures at our institution based on fully informed patient - surgeon discussions . the authors have used this radiograph without any difficulty by the radiology technicians in the clinic or the operating room . encouraging preliminary results of the introduction of this newly described radiographic series in this pilot study has thus instigated a prospective validation outcomes study at our institution to be subsequently reported .
operative treatment of displaced clavicle fractures has demonstrated lower rates of nonunion and symptomatic malunion , improved functional outcomes , and earlier return to activities versus nonoperative treatment . 
 surgical treatment may offer a reduction in the relative risk of nonunion and symptomatic malunion and an earlier return to work or sport . to present an easy and safe method of acquiring orthogonal views of the clavicle without any manipulation of the patients upper extremity . academic medical center and private clinic in the midwestern united states ; retrospective patient cohort . 
 we reviewed records of patients with acute clavicle fractures between january 2010 and august 2011 . 
 thirty - four patients were treated with sling immobilization and 52 patients were treated surgically with superior plate and screw internal fixation . 
 prior to the introduction of orthogonal views , 19 patients were treated nonoperatively and 22 treated with internal fixation . 
 addition of orthogonal views increased the number of patients treated surgically : in the same period , 15 patients were treated nonoperatively and 30 with internal fixation . following surgery , 
 patients were evaluated in the outpatient office at 2 and 6 weeks and 3 and 6 months . 
 nonoperatively treated patients were evaluated at 1 , 2 , and 4 weeks and 3 and 6 months postinjury . 
 standard use of orthogonal views has led to greater utilization of surgical treatment of clavicle fractures at our institution and improved both the understanding and treatment of these injuries .