Eur J Trauma Emerg Surg (2019) 45:59–63 https://doi.org/10.1007/s00068-016-0673-6 ORIGINAL ARTICLE Associated thoracic injury in patients with a clavicle fracture: a retrospective analysis of 1461 polytrauma patients J. J. E. M. van Laarhoven1 · F. Hietbrink1 · S. Ferree1 · A. C. Gunning1 · R. M. Houwert3 · E. M. M. Verleisdonk2 · L. P. H. Leenen1 Received: 25 August 2015 / Accepted: 4 January 2016 / Published online: 23 April 2016 © Springer-Verlag Berlin Heidelberg 2016 Abstract Results Of 1461 polytrauma patients in 160 patients a Purpose During primary survey the main goal is to clavicle fracture was diagnosed, and 95 % was diagnosed ascertain life-threatening injuries. A chest X-ray is recom- on chest X-ray. Patients with a clavicle fracture had a mended in all polytrauma patients as thoracic injury plays higher mean Injury Severity Score (ISS) (29.2 10.1 vs. ± an important role in mortality. However, treatment-dictat- 24.9 9.1; P < 0.001). Additional thoracic injuries were ± ing injuries are often missed on the chest X-ray. In contrast, more prevalent in patients with a clavicle fracture (76 vs. clavicle fractures should be relatively easy to diagnose on 47 %; OR 3.6; 95 % CI 2.45–5.24) and they had a higher a chest X-ray. We previously showed that clavicle fractures rate of thoracic injury with an AIS 3 (66 vs. 41 %; OR ≥ occur in approximately 10 % of all polytrauma patients 2.8; 95 % CI 1.97–3.93). in our population. The aim was to compare polytrauma Conclusions The clavicle can be seen as the gatekeeper patients, with and without a clavicle fracture, to investigate of the thorax. In polytrauma patients, a clavicle fracture is if a clavicle fracture is associated with concomitant tho- easily diagnosed during primary survey and may indicate racic injury. underlying thoracic injury, as the rate and extent of con- Methods A retrospective cohort study of polytrauma comitant thoracic injury are high. patients (ISS 16) from 2007 until 2011. Thoracic injuries ≥ were defned as: ribfracture, pneumothorax, lung contu- Keywords Clavicle fracture · Polytrauma patient · sion, sternum fracture, hemothorax, myocardial contusion, Primary care · Thoracic injury · Associated injury thoracic aorta injury and thoracic spine injury. Introduction Meeting presentation of the manuscript: Dutch National Trauma Congres (Amsterdam, November 2013), European Congress of Trauma and Emergency Surgery (ECTES Frankfurt, May According to ATLS principles, the main purpose of the 2014), winner of the Residents Trauma Paper Competition ATLS primary survey is to ascertain life-threatening injuries. region 15; Annual Meeting of the American College of Surgeons Guidelines recommend that all polytrauma patients should Committee on Trauma, (ACS COT, Chicago, March 2015), undergo a chest X-ray as an adjunct to the primary survey Annual ATLS Europe Meeting London May 2015. [1]. Thoracic injuries play an important role in mortality of * J. J. E. M. van Laarhoven trauma patients, resulting in 20 % of all trauma deaths [2, [email protected] 3]. Presence of thoracic injury is also an important risk fac- 1 Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, Suite G04.228, 3584 CX Utrecht, tor for ICU admittance and may infuence the choice of fur- The Netherlands ther surgical treatment [4–6]. However, treatment-dictating 2 Diakonessenhuis, Bosboomstraat 1, 3582 KE Utrecht, The thoracic injuries such as pneumothorax, rib fractures, ster- Netherlands num fractures and lung contusion are often missed on the 3 Utrecht Traumacenter, Heidelberglaan 100, 3584 CX Utrecht, primary chest X-ray [7–9]. In contrast, clavicle fractures The Netherlands should be relatively easy to diagnose on a chest X-ray. 1 3 60 J. J. E. M. Laarhoven et al. Our study group previously showed that clavicle frac- Thoracic injuries included rib fracture, pneumothorax, lung tures occur in approximately 10 % of all polytrauma contusion, sternum fracture, hemothorax, myocardial con- patients treated at our level one trauma center. Concomitant tusion, thoracic aorta injury (dissection or rupture), and thoracic injuries occurred in the majority of polytrauma thoracic spine injury. patients with a clavicle fracture (77 %) [10]. Therefore, Interventions performed within 24 h of admission were clavicle fractures may be used to raise awareness for con- also recorded, which included intubation, chest tube inser- comitant thoracic injuries. tion, invasive hemodynamic and pulmonary monitoring on The aim of this study was to compare polytrauma a medium or intensive care unit, thoracic surgery, and epi- patients with and without a clavicle fracture diagnosed on dural analgesia. the initial chest X-ray in order to investigate if a clavicle Parametric data were reported as means with standard fracture is associated with thoracic injury. deviation (SD), and non-parametric data were reported as medians with corresponding interquartile range (IQR). To compare proportions, Chi square contingency tables were Methods used when expected frequencies were equal to or greater than fve, and Fisher’s exact test was performed when We conducted a retrospective cohort study of trauma expected frequencies were less than fve. The independent patients admitted to our level I trauma center from Janu- sample t test was used for parametric continuous variables, ary 2007 through until December 2011. Patients with an and the Mann–Whitney U test was used for non-parametric Injury Severity Score(ISS) 16 as a result of blunt trauma continuous variables. Odds ratios (OR) were calculated ≥ were included in this study. Injury after explosion was with binary logistic regression analysis and were adjusted considered blunt trauma. Exclusion criteria were patients for age and ISS. A two-sided p value of <0.05 was consid- with penetrating injury, submersion, patients aged 15, ered statistically signifcant. Data were analyzed with SPSS ≤ and patients who were dead upon arrival. Patients with and Version 20.0, (IBM Corp., Armonk, NY) for Windows. without a clavicle fracture were compared. Data were collected from the Dutch National Trauma Database (DNTD) for the area Central Netherlands. This Results database contains patient demographics, description of the traumatic event, primary survey fndings, initial treatment, A total of 5357 trauma patients were admitted to the Emer- and all injuries diagnosed during initial trauma care, subse- gency Room from January 2007 through December 2011. quent surgery, or during admission. Fifteen patients were found dead upon arrival. A total Chest X-ray imaging was performed in most trauma of 1,461 patients (27.3 %) had an ISS 16 due to blunt ≥ patients during primary survey. All chest X-rays were per- trauma and were included in this analysis. A clavicle frac- formed in anterior-posterior direction in the critical care ture was diagnosed in 160 patients (11 %). Of these clavi- bay with the patient in supine position. Computed tomog- cle fractures 95 % were diagnosed by the chest X-ray dur- raphy (CT) scan and ultrasound were performed when ing the primary survey and the remaining fractures were indicated. Indications for thoracic CT scan included: (1) diagnosed by CT scan. Of the fractures diagnosed at the CT tenderness on palpation of the thorax, (2) signs of thoracic scan, seven fractures were insuffciently visualized on chest trauma (e.g., hematoma or excoriation), (3) altered mental X-ray as the entire clavicle was not shown and the remain- status or intoxication, (4) thoracic injury on chest X-ray, (5) ing fracture was an undisplaced midshaft fracture. All clav- high energy trauma. A radiologic resident, a surgical resi- icle fractures were included in this analysis. dent, and a trauma surgeon evaluated the imaging studies. A thoracic CT scan was performed in 81.2 % of the All radiological fndings were prospectively recorded. If patients with a clavicle fracture and in 60.5 % of the the surgical electronic patient documentation (EPD) or the patients without a clavicle fracture (P < 0.0001). 98.1 % radiology report did not include the clavicle fracture, it was of the patients with a clavicle fracture and 90.5 % of the reported as a missed diagnosis. patients without a clavicle fracture received either chest All diagnosed injuries were allocated to one of six body X-ray or thoracic CT scan. No chest imaging was per- regions and coded using Abbreviated Injury Scale (AIS) formed in patients who died at the emergency department location codes. The ISS ranges from 0, no injury, to 75, or neurotrauma patients who were transferred to our hospi- injury resulting in death [11]. The AIS codes of all injuries tal with previous imaging of the head. were used to calculate the ISS to quantify the severity of There was a signifcant difference in mean ISS between injury in trauma patients [12]. Patients with a clavicle frac- the patients with a clavicle fracture (29.2 SD 10.1) ± ture were selected using the AIS location code 752200.2. and patients without a clavicle fracture (24.9 SD 9.1; ± Injuries with an AIS 3 were considered serious injuries. P < 0.001) (Table 1). ≥ 1 3 Associated thoracic injury in patients with a clavicle fracture: a retrospective analysis of… 61 Table 1 Baseline characteristics of the study population Characteristics Clavicle fracture (n 160) No clavicle fracture (n 1301) P value = = Age overall (years) 47.5 ( 20.9) 49.2 ( 21.6) 0.343 ± ± Gender (M/F) 107/53 915/386 0.368 Mechanism Motor vehicle accident 70 (43.8 %) 414 (31.8 %) Bicycle accident 29 (18.1%) 229