The American Journal of Orthopedics

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Chronic exertional compartment syndrome (CECS) is a common cause of leg pain during exertion in athletic and active-duty populations.¹ It is caused by an increase in intramuscular pressure to a point that the tissues within the involved compartment become ischemic because of a decrease in arteriolar blood flow.² This relative ischemia causes pain and may also be associated with neurologic symptoms. By definition, the pain associated with CECS resolves with rest. Patients typically describe a feeling of fullness or tightness, which eventually evolves into pain as they continue exercising. Pain onset is usually predictable and reproducible after a finite amount of time and/or intensity of exercise.

The differential diagnosis of leg pain during exercise includes CECS, medial tibial stress syndrome, popliteal entrapment syndrome, myopathy, peripheral nerve entrapment syndromes, stress fracture, and effort-induced rhabdomyolysis.³ CECS can be differentiated from other causes of leg pain with measurement of compartment pressures (the standard recommendation).⁴ Compartment pressure measurement, however, is invasive, time-consuming, and painful and may be associated with bleeding risk, infection, and nerve injury. Noninvasive means of testing for CECS (eg, magnetic resonance imaging [MRI], near-infrared spectroscopy [NIRS], thallium stress testing) remain experimental and expensive and are not easily accessible at all institutions.^5-8 While invasive compartment pressure (ICP) testing remains an important tool in the diagnosis of CECS, its criteria and execution vary considerably. Aweid and colleagues⁴ performed a meta-analysis of use of ICP testing in the diagnosis of CECS and concluded that, though elevated ICP measurements are accepted as the gold standard for diagnosing CECS, the criteria outlined for a positive test lack high-level supporting evidence. In addition, how the test is performed has been inconsistent across studies—further clouding the literature.⁴

The review by Aweid and colleagues⁴ highlights the deficiencies in diagnosing CECS by ICP testing. In clinical practice, ICP testing is challenging for both the patient and physician. As other validated, less-invasive tests are lacking, emphasis should remain on the history and the physical examination. Although all athletic populations are at risk for CECS, the active-duty military population is at particularly high risk because of the physical requirements and demands of military service.^1,9

We surveyed military orthopedic surgeons to investigate the clinical practice of performing ICP testing in patients with suspected CECS. We hypothesized that the rate of ICP testing among military orthopedic surgeons would not be 100% for patients with the typical signs and symptoms of CECS.

Materials and Methods

This study was approved by the institutional review board at Wright-Patterson Medical Center at Wright-Patterson Air Force Base in Ohio. A link to an online survey was distributed by email to members of the Society of Military Orthopaedic Surgeons. The anonymous survey polled the surgeons regarding basic demographic data and clinical practice as it pertains to the evaluation and treatment of CECS. No patient-protected health information was obtained. Survey results were compiled in a Microsoft Excel file for analysis.

Results

The survey was distributed to 606 email accounts; the response rate was 19% (114/606). Ninety-one surgeons (80%) indicated they have patients with CECS in their practice (Figure 1). Surgeons were asked how many CECS patients they see per year (responses are summarized in Figure 2) and how many years they have been in practice (Table).

Ninety-three percent of the respondents agreed or strongly agreed that ICP testing is unpleasant for the patient (Figure 3), and 90% would prefer a less-invasive test for confirmatory testing for CECS (Figure 4). Only 13% of respondents indicated they actually use noninvasive modalities (eg, MRI, NIRS) to confirm the diagnosis of CECS (Figure 5).

Respondents were asked about the practice of using ICP testing in the diagnosis of CECS (responses are summarized in Figures 6, 7). Although 85% of respondents agreed or strongly agreed with always confirming the diagnosis of CECS with ICP testing, 39% stated they would recommend surgical treatment without ICP testing if they were confident about the diagnosis based on clinical examination findings.

To better understand the apparent discrepancy between the percentage of surgeons who agreed or strongly agreed with always recommending ICP testing (85%) and the percentage who would recommend treatment without testing (39%), responses were stratified by clinical experience. Surgeons in practice more than 11 years (n = 35) were compared with those in practice 5 years or less (n = 31) (Table). Although the vast majority (85%) of respondents from both groups agreed or strongly agreed with always recommending ICP testing, 49% of those in practice more than 11 years and 29% in practice 5 years or less indicated they would recommend surgical treatment for CECS based solely on clinical examination findings (Figures 8, 9).

Responses were also stratified by number of CECS patients seen by each surgeon per year. Twenty-eight respondents saw 1 or 2 patients per year, and 12 saw more than 8 patients per year—31% and 13% of the total number of respondents, respectively. Of the respondents who saw 1 or 2 patients, 86% (24/28) agreed or strongly agreed with always recommending ICP testing—comparable to the 75% (9/12) who saw more than 8 patients (Figure 10). However, of the respondents who saw 1 or 2 patients, 36% (10/28) indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% (9/12) who saw more than 8 patients (Figure 11).

Discussion

CECS is a common cause of leg pain and a significant cause of disability among the active-duty military population. This was illustrated in 2 recent studies by Waterman and colleagues.^1,9 The first¹ investigated failure rates and disability after surgery for CECS among those on active duty. The authors showed that CECS is a substantial contributor to lower extremity disability in the military population and that there is a substantial risk for persistent symptoms despite surgical treatment. Nearly 1 in 5 patients experienced surgical failure after elective fasciotomy, and about 28% of patients were unable to return to the full activity required in the military. The second, more recent study⁹ was an epidemiologic study of risk factors associated with CECS in a physically active military population. The authors identified 4100 cases diagnosed between 2006 and 2011—representing an overall annual incidence of 0.49 per 1000 at-risk person-years, or about 683 cases per year; the authors also showed the incidence increased during the time period studied.

The diagnosis of CECS remains imperfect. A clinical history of exercise-induced lower leg pain that is relieved with rest suggests the diagnosis, but a confirmatory test is needed to distinguish CECS from other causes of exercise-induced leg pain. Although direct measurement of compartment pressures is the test used most often, it is invasive and time-consuming, can be uncomfortable for the patient, and may be associated with bleeding risk, infection, and nerve injury. Pedowitz and colleagues¹⁰ described the ICP testing criteria now generally used in the diagnosis of CECS. Unfortunately, there is little objective evidence supporting these criteria.⁴ Although less invasive tests (eg, MRI, NIRS) have been described,^5-8 they may not be readily available across institutions, and further study is needed to validate their use in diagnosing CECS.

While an objective, validated test or measurement for confirming the diagnosis of CECS remains elusive, the outcomes after surgical treatment of CECS also remain imperfect. Surgery consists of both open and endoscopically assisted fasciotomy of the involved compartments.^2,11-17 Reports of improvement after treatment range from 81% to 100%³; however, symptom relief does not come for all patients, particularly those in the military. Waterman and colleagues¹ found a failure rate of about 20% among an active-duty military population. Packer and colleagues¹⁸ examined civilians with CECS, treated both operatively and nonoperatively. Patients in this series were diagnosed with CECS based on clinical symptoms as well as compartment pressure measurements according to the Pedowitz criteria. Although overall outcomes were better for operatively treated patients than for nonoperatively treated patients, only 47% of patients were completely pain-free, and 21% were unable to return to full activity.

More recent studies have explored use of other nonoperative treatment modalities. Diebal and colleagues^19,20 used a running retraining program to treat patients with CECS. They based this treatment on the hypothesis that a heel-strike running pattern is associated with increased anterior compartment pressures.²¹ CECS patients who underwent a 6-week systematic treatment program focused on forefoot running, stride shortening, and hamstring activation during push-off experienced a decrease in clinical symptoms and posttreatment intracompartmental pressures.²⁰ The improvements in clinical scores were maintained at 1-year follow-up. Another nonoperative intervention, recently described by Isner-Horobeti and colleagues,²² involves injecting botulinum toxin A (BoNT-A) into the anterior and lateral compartments of the leg. Sixteen patients with CECS received BoNT-A injections. On average, intracompartmental pressures were lower after injection than they were before injection. In addition, exertional pain was eliminated in 15 patients at an average follow-up of 4.4 months.

This survey-based study examined the practice patterns of military orthopedic surgeons who performed ICP testing for cases of suspected CECS. Our hypothesis was that, though ICP testing is the most commonly accepted method for confirming the diagnosis of CECS, the ICP testing rate would not be 100% among those surveyed.

The results of our study uncover an apparent inconsistency in survey responses among physicians who evaluate and treat patients with CECS. About 85% of respondents stated they would always recommend confirming the diagnosis of CECS with ICP testing. However, about 40% stated they would recommend surgical treatment without confirmatory testing if they were confident about the diagnosis based on clinical findings. In other words, only 60% of the respondents disagreed or strongly disagreed with pursuing surgical treatment without testing. One would expect a closer correlation between respondents who would always recommend ICP testing and those who disagreed with recommending surgical treatment without ICP testing. This raises the question of what actually occurs when CECS is suspected in clinical practice.

To better understand the apparent discrepancy between respondents who agreed or strongly agreed with always recommending ICP testing and respondents who would recommend treatment without testing, we grouped responses by clinical experience. Although 85% of respondents (no matter the number of years in practice) agreed or strongly agreed with the statement, “I always recommend confirming the diagnosis of CECS with ICP measurements,” 49% of those in practice more than 11 years (vs. 29% of those in practice 5 years or less) agreed or strongly agreed with recommending surgery without testing if they were 100% confident about the diagnosis of CECS based solely on clinical findings. This may suggest that, though most agreed that the gold standard for confirming the diagnosis of CECS remains ICP testing, those with more clinical experience were more comfortable forgoing this diagnostic measure and recommending treatment without testing.

Another measure of clinical experience used in this survey was based on number of CECS patients seen per year. Responses of surgeons who saw 1 or 2 patients with CECS per year were compared with responses of surgeons who saw more than 8 patients with CECS per year. Of the respondents who saw 1 or 2 patients, 86% agreed or strongly agreed with always recommending ICP testing to confirm CECS—comparable to the 75% who saw more than 8 patients. However, of the respondents who saw 1 or 2 patients, 36% indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% who saw more than 8 patients.

Responses regarding the absolute of always recommending ICP testing and the absolute of being 100% confident about the clinical diagnosis of CECS highlight differences between the surgeons with more experience (>11 years in practice, >8 CECS patients per year) and those with less experience (≤5 years in practice, 1 or 2 CECS patients per year). Surgeons in practice longer, and surgeons who saw more patients with suspected CECS per year, were more likely to recommend surgical treatment based solely on clinical findings.

Conclusion

CECS can cause debilitating activity-related leg pain in both civilian and military populations. Treatment with fasciotomy is often curative, but a significant number of patients may continue to have pain and disability. As the incidence of treatment failures may be higher in the military than in civilians, proper evaluation of patients with suspected CECS is particularly important for military orthopedic surgeons. The diagnosis of CECS can be challenging to both the clinician and patient, and diagnostic modalities remain imperfect. The results of this study highlight this, revealing less than 100% agreement regarding use of ICP testing (the gold standard) for diagnosis of CECS.

This study also highlights the need for an improved method of diagnosing CECS since 93% of respondents agreed or strongly agreed that ICP testing is unpleasant for the patient, and 90% would prefer a less-invasive test. In addition, the ICP testing criteria for establishing the diagnosis of CECS remain inconsistent. If a reliable, consistent, and less-invasive test were available, perhaps there would be less variability in practitioners’ evaluations of patients with CECS.

This study shows an inconsistency among military orthopedic surgeons evaluating and treating patients with CECS. As testing modalities for CECS remain imperfect, clinical acumen and experience assume an important role in the assessment of patients with suspected CECS.

Chronic exertional compartment syndrome (CECS) is a common cause of leg pain during exertion in athletic and active-duty populations.¹ It is caused by an increase in intramuscular pressure to a point that the tissues within the involved compartment become ischemic because of a decrease in arteriolar blood flow.² This relative ischemia causes pain and may also be associated with neurologic symptoms. By definition, the pain associated with CECS resolves with rest. Patients typically describe a feeling of fullness or tightness, which eventually evolves into pain as they continue exercising. Pain onset is usually predictable and reproducible after a finite amount of time and/or intensity of exercise.

The differential diagnosis of leg pain during exercise includes CECS, medial tibial stress syndrome, popliteal entrapment syndrome, myopathy, peripheral nerve entrapment syndromes, stress fracture, and effort-induced rhabdomyolysis.³ CECS can be differentiated from other causes of leg pain with measurement of compartment pressures (the standard recommendation).⁴ Compartment pressure measurement, however, is invasive, time-consuming, and painful and may be associated with bleeding risk, infection, and nerve injury. Noninvasive means of testing for CECS (eg, magnetic resonance imaging [MRI], near-infrared spectroscopy [NIRS], thallium stress testing) remain experimental and expensive and are not easily accessible at all institutions.^5-8 While invasive compartment pressure (ICP) testing remains an important tool in the diagnosis of CECS, its criteria and execution vary considerably. Aweid and colleagues⁴ performed a meta-analysis of use of ICP testing in the diagnosis of CECS and concluded that, though elevated ICP measurements are accepted as the gold standard for diagnosing CECS, the criteria outlined for a positive test lack high-level supporting evidence. In addition, how the test is performed has been inconsistent across studies—further clouding the literature.⁴

The review by Aweid and colleagues⁴ highlights the deficiencies in diagnosing CECS by ICP testing. In clinical practice, ICP testing is challenging for both the patient and physician. As other validated, less-invasive tests are lacking, emphasis should remain on the history and the physical examination. Although all athletic populations are at risk for CECS, the active-duty military population is at particularly high risk because of the physical requirements and demands of military service.^1,9

We surveyed military orthopedic surgeons to investigate the clinical practice of performing ICP testing in patients with suspected CECS. We hypothesized that the rate of ICP testing among military orthopedic surgeons would not be 100% for patients with the typical signs and symptoms of CECS.

Materials and Methods

This study was approved by the institutional review board at Wright-Patterson Medical Center at Wright-Patterson Air Force Base in Ohio. A link to an online survey was distributed by email to members of the Society of Military Orthopaedic Surgeons. The anonymous survey polled the surgeons regarding basic demographic data and clinical practice as it pertains to the evaluation and treatment of CECS. No patient-protected health information was obtained. Survey results were compiled in a Microsoft Excel file for analysis.

Results

The survey was distributed to 606 email accounts; the response rate was 19% (114/606). Ninety-one surgeons (80%) indicated they have patients with CECS in their practice (Figure 1). Surgeons were asked how many CECS patients they see per year (responses are summarized in Figure 2) and how many years they have been in practice (Table).

Ninety-three percent of the respondents agreed or strongly agreed that ICP testing is unpleasant for the patient (Figure 3), and 90% would prefer a less-invasive test for confirmatory testing for CECS (Figure 4). Only 13% of respondents indicated they actually use noninvasive modalities (eg, MRI, NIRS) to confirm the diagnosis of CECS (Figure 5).

Respondents were asked about the practice of using ICP testing in the diagnosis of CECS (responses are summarized in Figures 6, 7). Although 85% of respondents agreed or strongly agreed with always confirming the diagnosis of CECS with ICP testing, 39% stated they would recommend surgical treatment without ICP testing if they were confident about the diagnosis based on clinical examination findings.

To better understand the apparent discrepancy between the percentage of surgeons who agreed or strongly agreed with always recommending ICP testing (85%) and the percentage who would recommend treatment without testing (39%), responses were stratified by clinical experience. Surgeons in practice more than 11 years (n = 35) were compared with those in practice 5 years or less (n = 31) (Table). Although the vast majority (85%) of respondents from both groups agreed or strongly agreed with always recommending ICP testing, 49% of those in practice more than 11 years and 29% in practice 5 years or less indicated they would recommend surgical treatment for CECS based solely on clinical examination findings (Figures 8, 9).

Responses were also stratified by number of CECS patients seen by each surgeon per year. Twenty-eight respondents saw 1 or 2 patients per year, and 12 saw more than 8 patients per year—31% and 13% of the total number of respondents, respectively. Of the respondents who saw 1 or 2 patients, 86% (24/28) agreed or strongly agreed with always recommending ICP testing—comparable to the 75% (9/12) who saw more than 8 patients (Figure 10). However, of the respondents who saw 1 or 2 patients, 36% (10/28) indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% (9/12) who saw more than 8 patients (Figure 11).

Discussion

CECS is a common cause of leg pain and a significant cause of disability among the active-duty military population. This was illustrated in 2 recent studies by Waterman and colleagues.^1,9 The first¹ investigated failure rates and disability after surgery for CECS among those on active duty. The authors showed that CECS is a substantial contributor to lower extremity disability in the military population and that there is a substantial risk for persistent symptoms despite surgical treatment. Nearly 1 in 5 patients experienced surgical failure after elective fasciotomy, and about 28% of patients were unable to return to the full activity required in the military. The second, more recent study⁹ was an epidemiologic study of risk factors associated with CECS in a physically active military population. The authors identified 4100 cases diagnosed between 2006 and 2011—representing an overall annual incidence of 0.49 per 1000 at-risk person-years, or about 683 cases per year; the authors also showed the incidence increased during the time period studied.

The diagnosis of CECS remains imperfect. A clinical history of exercise-induced lower leg pain that is relieved with rest suggests the diagnosis, but a confirmatory test is needed to distinguish CECS from other causes of exercise-induced leg pain. Although direct measurement of compartment pressures is the test used most often, it is invasive and time-consuming, can be uncomfortable for the patient, and may be associated with bleeding risk, infection, and nerve injury. Pedowitz and colleagues¹⁰ described the ICP testing criteria now generally used in the diagnosis of CECS. Unfortunately, there is little objective evidence supporting these criteria.⁴ Although less invasive tests (eg, MRI, NIRS) have been described,^5-8 they may not be readily available across institutions, and further study is needed to validate their use in diagnosing CECS.

While an objective, validated test or measurement for confirming the diagnosis of CECS remains elusive, the outcomes after surgical treatment of CECS also remain imperfect. Surgery consists of both open and endoscopically assisted fasciotomy of the involved compartments.^2,11-17 Reports of improvement after treatment range from 81% to 100%³; however, symptom relief does not come for all patients, particularly those in the military. Waterman and colleagues¹ found a failure rate of about 20% among an active-duty military population. Packer and colleagues¹⁸ examined civilians with CECS, treated both operatively and nonoperatively. Patients in this series were diagnosed with CECS based on clinical symptoms as well as compartment pressure measurements according to the Pedowitz criteria. Although overall outcomes were better for operatively treated patients than for nonoperatively treated patients, only 47% of patients were completely pain-free, and 21% were unable to return to full activity.

More recent studies have explored use of other nonoperative treatment modalities. Diebal and colleagues^19,20 used a running retraining program to treat patients with CECS. They based this treatment on the hypothesis that a heel-strike running pattern is associated with increased anterior compartment pressures.²¹ CECS patients who underwent a 6-week systematic treatment program focused on forefoot running, stride shortening, and hamstring activation during push-off experienced a decrease in clinical symptoms and posttreatment intracompartmental pressures.²⁰ The improvements in clinical scores were maintained at 1-year follow-up. Another nonoperative intervention, recently described by Isner-Horobeti and colleagues,²² involves injecting botulinum toxin A (BoNT-A) into the anterior and lateral compartments of the leg. Sixteen patients with CECS received BoNT-A injections. On average, intracompartmental pressures were lower after injection than they were before injection. In addition, exertional pain was eliminated in 15 patients at an average follow-up of 4.4 months.

This survey-based study examined the practice patterns of military orthopedic surgeons who performed ICP testing for cases of suspected CECS. Our hypothesis was that, though ICP testing is the most commonly accepted method for confirming the diagnosis of CECS, the ICP testing rate would not be 100% among those surveyed.

The results of our study uncover an apparent inconsistency in survey responses among physicians who evaluate and treat patients with CECS. About 85% of respondents stated they would always recommend confirming the diagnosis of CECS with ICP testing. However, about 40% stated they would recommend surgical treatment without confirmatory testing if they were confident about the diagnosis based on clinical findings. In other words, only 60% of the respondents disagreed or strongly disagreed with pursuing surgical treatment without testing. One would expect a closer correlation between respondents who would always recommend ICP testing and those who disagreed with recommending surgical treatment without ICP testing. This raises the question of what actually occurs when CECS is suspected in clinical practice.

To better understand the apparent discrepancy between respondents who agreed or strongly agreed with always recommending ICP testing and respondents who would recommend treatment without testing, we grouped responses by clinical experience. Although 85% of respondents (no matter the number of years in practice) agreed or strongly agreed with the statement, “I always recommend confirming the diagnosis of CECS with ICP measurements,” 49% of those in practice more than 11 years (vs. 29% of those in practice 5 years or less) agreed or strongly agreed with recommending surgery without testing if they were 100% confident about the diagnosis of CECS based solely on clinical findings. This may suggest that, though most agreed that the gold standard for confirming the diagnosis of CECS remains ICP testing, those with more clinical experience were more comfortable forgoing this diagnostic measure and recommending treatment without testing.

Another measure of clinical experience used in this survey was based on number of CECS patients seen per year. Responses of surgeons who saw 1 or 2 patients with CECS per year were compared with responses of surgeons who saw more than 8 patients with CECS per year. Of the respondents who saw 1 or 2 patients, 86% agreed or strongly agreed with always recommending ICP testing to confirm CECS—comparable to the 75% who saw more than 8 patients. However, of the respondents who saw 1 or 2 patients, 36% indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% who saw more than 8 patients.

Responses regarding the absolute of always recommending ICP testing and the absolute of being 100% confident about the clinical diagnosis of CECS highlight differences between the surgeons with more experience (>11 years in practice, >8 CECS patients per year) and those with less experience (≤5 years in practice, 1 or 2 CECS patients per year). Surgeons in practice longer, and surgeons who saw more patients with suspected CECS per year, were more likely to recommend surgical treatment based solely on clinical findings.

Conclusion

CECS can cause debilitating activity-related leg pain in both civilian and military populations. Treatment with fasciotomy is often curative, but a significant number of patients may continue to have pain and disability. As the incidence of treatment failures may be higher in the military than in civilians, proper evaluation of patients with suspected CECS is particularly important for military orthopedic surgeons. The diagnosis of CECS can be challenging to both the clinician and patient, and diagnostic modalities remain imperfect. The results of this study highlight this, revealing less than 100% agreement regarding use of ICP testing (the gold standard) for diagnosis of CECS.

This study also highlights the need for an improved method of diagnosing CECS since 93% of respondents agreed or strongly agreed that ICP testing is unpleasant for the patient, and 90% would prefer a less-invasive test. In addition, the ICP testing criteria for establishing the diagnosis of CECS remain inconsistent. If a reliable, consistent, and less-invasive test were available, perhaps there would be less variability in practitioners’ evaluations of patients with CECS.

This study shows an inconsistency among military orthopedic surgeons evaluating and treating patients with CECS. As testing modalities for CECS remain imperfect, clinical acumen and experience assume an important role in the assessment of patients with suspected CECS.

Chronic exertional compartment syndrome (CECS) is a common cause of leg pain during exertion in athletic and active-duty populations.¹ It is caused by an increase in intramuscular pressure to a point that the tissues within the involved compartment become ischemic because of a decrease in arteriolar blood flow.² This relative ischemia causes pain and may also be associated with neurologic symptoms. By definition, the pain associated with CECS resolves with rest. Patients typically describe a feeling of fullness or tightness, which eventually evolves into pain as they continue exercising. Pain onset is usually predictable and reproducible after a finite amount of time and/or intensity of exercise.

The differential diagnosis of leg pain during exercise includes CECS, medial tibial stress syndrome, popliteal entrapment syndrome, myopathy, peripheral nerve entrapment syndromes, stress fracture, and effort-induced rhabdomyolysis.³ CECS can be differentiated from other causes of leg pain with measurement of compartment pressures (the standard recommendation).⁴ Compartment pressure measurement, however, is invasive, time-consuming, and painful and may be associated with bleeding risk, infection, and nerve injury. Noninvasive means of testing for CECS (eg, magnetic resonance imaging [MRI], near-infrared spectroscopy [NIRS], thallium stress testing) remain experimental and expensive and are not easily accessible at all institutions.^5-8 While invasive compartment pressure (ICP) testing remains an important tool in the diagnosis of CECS, its criteria and execution vary considerably. Aweid and colleagues⁴ performed a meta-analysis of use of ICP testing in the diagnosis of CECS and concluded that, though elevated ICP measurements are accepted as the gold standard for diagnosing CECS, the criteria outlined for a positive test lack high-level supporting evidence. In addition, how the test is performed has been inconsistent across studies—further clouding the literature.⁴

The review by Aweid and colleagues⁴ highlights the deficiencies in diagnosing CECS by ICP testing. In clinical practice, ICP testing is challenging for both the patient and physician. As other validated, less-invasive tests are lacking, emphasis should remain on the history and the physical examination. Although all athletic populations are at risk for CECS, the active-duty military population is at particularly high risk because of the physical requirements and demands of military service.^1,9

We surveyed military orthopedic surgeons to investigate the clinical practice of performing ICP testing in patients with suspected CECS. We hypothesized that the rate of ICP testing among military orthopedic surgeons would not be 100% for patients with the typical signs and symptoms of CECS.

Materials and Methods

This study was approved by the institutional review board at Wright-Patterson Medical Center at Wright-Patterson Air Force Base in Ohio. A link to an online survey was distributed by email to members of the Society of Military Orthopaedic Surgeons. The anonymous survey polled the surgeons regarding basic demographic data and clinical practice as it pertains to the evaluation and treatment of CECS. No patient-protected health information was obtained. Survey results were compiled in a Microsoft Excel file for analysis.

Results

The survey was distributed to 606 email accounts; the response rate was 19% (114/606). Ninety-one surgeons (80%) indicated they have patients with CECS in their practice (Figure 1). Surgeons were asked how many CECS patients they see per year (responses are summarized in Figure 2) and how many years they have been in practice (Table).

Ninety-three percent of the respondents agreed or strongly agreed that ICP testing is unpleasant for the patient (Figure 3), and 90% would prefer a less-invasive test for confirmatory testing for CECS (Figure 4). Only 13% of respondents indicated they actually use noninvasive modalities (eg, MRI, NIRS) to confirm the diagnosis of CECS (Figure 5).

Respondents were asked about the practice of using ICP testing in the diagnosis of CECS (responses are summarized in Figures 6, 7). Although 85% of respondents agreed or strongly agreed with always confirming the diagnosis of CECS with ICP testing, 39% stated they would recommend surgical treatment without ICP testing if they were confident about the diagnosis based on clinical examination findings.

To better understand the apparent discrepancy between the percentage of surgeons who agreed or strongly agreed with always recommending ICP testing (85%) and the percentage who would recommend treatment without testing (39%), responses were stratified by clinical experience. Surgeons in practice more than 11 years (n = 35) were compared with those in practice 5 years or less (n = 31) (Table). Although the vast majority (85%) of respondents from both groups agreed or strongly agreed with always recommending ICP testing, 49% of those in practice more than 11 years and 29% in practice 5 years or less indicated they would recommend surgical treatment for CECS based solely on clinical examination findings (Figures 8, 9).

Responses were also stratified by number of CECS patients seen by each surgeon per year. Twenty-eight respondents saw 1 or 2 patients per year, and 12 saw more than 8 patients per year—31% and 13% of the total number of respondents, respectively. Of the respondents who saw 1 or 2 patients, 86% (24/28) agreed or strongly agreed with always recommending ICP testing—comparable to the 75% (9/12) who saw more than 8 patients (Figure 10). However, of the respondents who saw 1 or 2 patients, 36% (10/28) indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% (9/12) who saw more than 8 patients (Figure 11).

Discussion

CECS is a common cause of leg pain and a significant cause of disability among the active-duty military population. This was illustrated in 2 recent studies by Waterman and colleagues.^1,9 The first¹ investigated failure rates and disability after surgery for CECS among those on active duty. The authors showed that CECS is a substantial contributor to lower extremity disability in the military population and that there is a substantial risk for persistent symptoms despite surgical treatment. Nearly 1 in 5 patients experienced surgical failure after elective fasciotomy, and about 28% of patients were unable to return to the full activity required in the military. The second, more recent study⁹ was an epidemiologic study of risk factors associated with CECS in a physically active military population. The authors identified 4100 cases diagnosed between 2006 and 2011—representing an overall annual incidence of 0.49 per 1000 at-risk person-years, or about 683 cases per year; the authors also showed the incidence increased during the time period studied.

The diagnosis of CECS remains imperfect. A clinical history of exercise-induced lower leg pain that is relieved with rest suggests the diagnosis, but a confirmatory test is needed to distinguish CECS from other causes of exercise-induced leg pain. Although direct measurement of compartment pressures is the test used most often, it is invasive and time-consuming, can be uncomfortable for the patient, and may be associated with bleeding risk, infection, and nerve injury. Pedowitz and colleagues¹⁰ described the ICP testing criteria now generally used in the diagnosis of CECS. Unfortunately, there is little objective evidence supporting these criteria.⁴ Although less invasive tests (eg, MRI, NIRS) have been described,^5-8 they may not be readily available across institutions, and further study is needed to validate their use in diagnosing CECS.

While an objective, validated test or measurement for confirming the diagnosis of CECS remains elusive, the outcomes after surgical treatment of CECS also remain imperfect. Surgery consists of both open and endoscopically assisted fasciotomy of the involved compartments.^2,11-17 Reports of improvement after treatment range from 81% to 100%³; however, symptom relief does not come for all patients, particularly those in the military. Waterman and colleagues¹ found a failure rate of about 20% among an active-duty military population. Packer and colleagues¹⁸ examined civilians with CECS, treated both operatively and nonoperatively. Patients in this series were diagnosed with CECS based on clinical symptoms as well as compartment pressure measurements according to the Pedowitz criteria. Although overall outcomes were better for operatively treated patients than for nonoperatively treated patients, only 47% of patients were completely pain-free, and 21% were unable to return to full activity.

More recent studies have explored use of other nonoperative treatment modalities. Diebal and colleagues^19,20 used a running retraining program to treat patients with CECS. They based this treatment on the hypothesis that a heel-strike running pattern is associated with increased anterior compartment pressures.²¹ CECS patients who underwent a 6-week systematic treatment program focused on forefoot running, stride shortening, and hamstring activation during push-off experienced a decrease in clinical symptoms and posttreatment intracompartmental pressures.²⁰ The improvements in clinical scores were maintained at 1-year follow-up. Another nonoperative intervention, recently described by Isner-Horobeti and colleagues,²² involves injecting botulinum toxin A (BoNT-A) into the anterior and lateral compartments of the leg. Sixteen patients with CECS received BoNT-A injections. On average, intracompartmental pressures were lower after injection than they were before injection. In addition, exertional pain was eliminated in 15 patients at an average follow-up of 4.4 months.

This survey-based study examined the practice patterns of military orthopedic surgeons who performed ICP testing for cases of suspected CECS. Our hypothesis was that, though ICP testing is the most commonly accepted method for confirming the diagnosis of CECS, the ICP testing rate would not be 100% among those surveyed.

The results of our study uncover an apparent inconsistency in survey responses among physicians who evaluate and treat patients with CECS. About 85% of respondents stated they would always recommend confirming the diagnosis of CECS with ICP testing. However, about 40% stated they would recommend surgical treatment without confirmatory testing if they were confident about the diagnosis based on clinical findings. In other words, only 60% of the respondents disagreed or strongly disagreed with pursuing surgical treatment without testing. One would expect a closer correlation between respondents who would always recommend ICP testing and those who disagreed with recommending surgical treatment without ICP testing. This raises the question of what actually occurs when CECS is suspected in clinical practice.

To better understand the apparent discrepancy between respondents who agreed or strongly agreed with always recommending ICP testing and respondents who would recommend treatment without testing, we grouped responses by clinical experience. Although 85% of respondents (no matter the number of years in practice) agreed or strongly agreed with the statement, “I always recommend confirming the diagnosis of CECS with ICP measurements,” 49% of those in practice more than 11 years (vs. 29% of those in practice 5 years or less) agreed or strongly agreed with recommending surgery without testing if they were 100% confident about the diagnosis of CECS based solely on clinical findings. This may suggest that, though most agreed that the gold standard for confirming the diagnosis of CECS remains ICP testing, those with more clinical experience were more comfortable forgoing this diagnostic measure and recommending treatment without testing.

Another measure of clinical experience used in this survey was based on number of CECS patients seen per year. Responses of surgeons who saw 1 or 2 patients with CECS per year were compared with responses of surgeons who saw more than 8 patients with CECS per year. Of the respondents who saw 1 or 2 patients, 86% agreed or strongly agreed with always recommending ICP testing to confirm CECS—comparable to the 75% who saw more than 8 patients. However, of the respondents who saw 1 or 2 patients, 36% indicated they would recommend surgical treatment, without ICP testing, if they were confident about the clinical diagnosis of CECS—in contrast to the 75% who saw more than 8 patients.

Responses regarding the absolute of always recommending ICP testing and the absolute of being 100% confident about the clinical diagnosis of CECS highlight differences between the surgeons with more experience (>11 years in practice, >8 CECS patients per year) and those with less experience (≤5 years in practice, 1 or 2 CECS patients per year). Surgeons in practice longer, and surgeons who saw more patients with suspected CECS per year, were more likely to recommend surgical treatment based solely on clinical findings.

Conclusion

CECS can cause debilitating activity-related leg pain in both civilian and military populations. Treatment with fasciotomy is often curative, but a significant number of patients may continue to have pain and disability. As the incidence of treatment failures may be higher in the military than in civilians, proper evaluation of patients with suspected CECS is particularly important for military orthopedic surgeons. The diagnosis of CECS can be challenging to both the clinician and patient, and diagnostic modalities remain imperfect. The results of this study highlight this, revealing less than 100% agreement regarding use of ICP testing (the gold standard) for diagnosis of CECS.

This study also highlights the need for an improved method of diagnosing CECS since 93% of respondents agreed or strongly agreed that ICP testing is unpleasant for the patient, and 90% would prefer a less-invasive test. In addition, the ICP testing criteria for establishing the diagnosis of CECS remain inconsistent. If a reliable, consistent, and less-invasive test were available, perhaps there would be less variability in practitioners’ evaluations of patients with CECS.

This study shows an inconsistency among military orthopedic surgeons evaluating and treating patients with CECS. As testing modalities for CECS remain imperfect, clinical acumen and experience assume an important role in the assessment of patients with suspected CECS.

With the increasing complexity of health care policy, significant changes in reimbursement and payer sources, and constant push to improve the cost-efficiency of care delivery, there has been a growing focus on the importance of business knowledge and practice management (PM) skills among physicians. Family medicine was the first specialty to require PM training during residency; other specialities have begun implementing business training into their residency curriculum.¹ In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 core competencies that should be included in resident training. One of these core competencies involves training in health care systems and PM.^2,3

 Residency program directors have also recognized the need for business training among residents. One study that surveyed general surgery program directors found that more than 87% agreed that residents should be trained in business and PM.⁴ Although these directors recognized the need for training, they also acknowledged the current deficiency: more than 70% thought their current trainees were inadequately trained in business and PM. Similarly, residents and physicians in multiple specialties have reported significant deficiencies in their training and knowledge of PM and business principles.^5-11 For example, in a recent survey of ophthalmologists who had been in practice less than 5 years, 70% reported being not very well or not at all trained in overall PM skills during residency.⁵ Yet, most respondents thought training in this area was the responsibility of the training program.

The call for more business and PM training during residency has been tempered by increasing demands on medical and surgical skills training and time limitations such as duty-hour restrictions. These limitations reinforce the need to find efficient and effective means of teaching necessary business knowledge and PM skills. Paramount to doing this is recognizing the difference between general knowledge and functional knowledge—essentially, what is specifically needed to function effectively in practice.

We conducted a study not only to determine the general level of knowledge that physicians have in different business and PM topics when they complete their residency, but also to evaluate the level of knowledge that graduating physicians need in different business and PM topics in order to function effectively in a medical practice. Toward this end, we developed a novel model that could help determine the level of the functional knowledge deficiency (FKD) of particular business topics. We thought this model would allow us to quantify how much knowledge physicians needed to acquire in a given topic in order to function effectively in practice. We hypothesized that graduating residents would report overall low levels of business knowledge and high FKDs.

Materials and Methods

To minimize variability in the specific type and amount of business training received, we focused this study on a single institution that had maintained a uniform business management curriculum over an extended period. The business training program provided to residents in the orthopedic surgery residency at this institution included 6 hours of didactic lectures on various business topics annually. This program has been in place for more than 15 years and has not undergone any significant changes during that time.

Using the program’s alumni directory, we emailed a cover letter and an 11-question survey to all 332 residents and fellows who had completed their residency or fellowship training at our institution between 1970 and 2008. Anyone who did not reply to the email was mailed a copy of the cover letter and the survey.

The first 4 survey questions involved the demographics of the surgeon and the surgeon’s practice. Subsequent questions focused on the surgeon’s understanding of 9 different general business and PM topics and their importance in the practice. The topics were marketing, business operations, human resources, contract negotiations, malpractice issues, coding/billing, medical records management, accounting, and economic analytical tools. The surgeon was asked to use a 10-point scale ranging from 1 (“knew nothing at all”) to 10 (“complete understanding”) to rate his or her understanding of each topic at the completion of residency. The surgeon was also asked to rate how important it was to understand that topic in the surgeon’s current practice. Again, a 10-point scale was used: 1 (“not important at all”) to 10 (“absolutely vital”) (Figure).

When the surveys were returned, their data were compiled and analyzed to determine the overall knowledge levels for each topic and the levels based on years in practice, type of practice, and level of involvement in PM. We also wanted to determine the amount of business knowledge that they needed in order to function effectively in practice (and that they lacked at time of graduation). We defined this as the FKD at graduation and calculated it as the difference between the surgeon’s reported importance of a topic in his or her current practice and his or her level of understanding of that topic at graduation. A larger FKD score represented greater deficiency, with a maximal possible FKD score of 9. A score of 0 would reflect an appropriate amount of knowledge to function effectively, and a negative score would reflect a knowledge surplus. Using the demographic information from the survey, we were then able to further analyze the levels of overall knowledge as well as the FKD for each topic with respect to length of time in practice, type of practice, and the surgeon’s involvement in PM.

We evaluated the reported levels of knowledge based on both type of practice (academic, hospital-employed, private practice) and who managed the practice (physician, nonphysician). Academic practices were defined as those associated with an academic medical center; hospital-employed practices were those in which the physician was an employee of a health system not associated with an academic medical center; and private practices were defined as physician-owned orthopedic practices not associated with an academic medical center. Regarding management, practices in which physicians were primarily responsible for the daily operations of the practice were considered physician-managed; conversely, practices in which operations were controlled by either employed or institutionally assigned administration were defined as nonphysician-managed.

Statistical analysis of the results for different practice types and levels of involvement in management was performed for both general knowledge and FKD. Means, medians, and standard deviations were calculated. One-way analysis of variance or t tests were then used to examine mean differences overall and within each business topic. When a difference was found, a post hoc Tukey multiple range test was performed to identify it. Differences at P < .05 were considered significant.

Results

One hundred eighty-two surgeons answered the survey, yielding a response rate of 55%. All had completed their training at our institution. Seven respondents were removed from the study because they had retired from practice (5) or had returned incomplete surveys (2).

The overall self-rated level of business knowledge of all responding surgeons at the conclusion of their training was 2.4 on the 10-point scale (Table 1). Specifically, physicians reported the lowest levels of business understanding in economic analytical tools (1.5), human resources (1.7), and contract negotiations (1.9), suggesting minimal knowledge of these topics generally. They reported the highest levels of knowledge in medical records management (3.8) and malpractice issues (3.3). Even these topics, however, still reflected overall low levels of knowledge.

There was no statistically significant difference between private practice and academic physicians. In addition, surgeons in physician-managed practices reported significantly (P = .045) higher levels of understanding of economic analytical tools than surgeons in nonphysician-managed practices (Table 1). There were no other statistically significant differences among groups.

The overall calculated FKD for all surgeons was 5.6. FKDs were calculated for all 9 business topics. The worst FKDs were in business operations (6.4) and coding/billing (6.3). The topic with the least deficiency (lowest FKD) was in medical records management (4.2) (Table 2).

Surgeons’ FKDs based on practice type (academic, hospital-employed, private practice) were compared to identify potentially significant differences. Hospital-employed physicians had the lowest overall FKD (4.0), followed by physicians in academic practices (5.1) and private practices (5.9). Hospital-employed physicians reported statistically significantly better (lower) FKDs in comparison with physicians in private practice in multiple topics, including human resources, contract negotiations, malpractice issues, coding/billing, and accounting (Table 2). Similarly, physicians in academic practices also had statistically significantly better FKDs than physicians in private practice in the topics of business operations, contract negotiations, and billing/coding. Compared with hospital-employed physicians, physicians in academic practices had significantly more knowledge about marketing, business operations, and accounting. Physicians in private practice did not have significantly better FKDs in any topic in comparison with hospital-employed or academic physicians. There was no significant difference in FKDs for medical records management or economic analytical tools based on practice type.

Comparisons based on PM involvement showed that physicians in practices with nonphysician management had only a slightly better FKD (5.6) at graduation than those in practices with physician involvement (5.7). None of the 9 topics was statistically significant different based on physician involvement in PM.

Discussion

Building a successful medical practice has become more difficult for graduating orthopedic surgery residents because of an increasingly complex health care system, shrinking reimbursement rates, and looming regulatory changes. These challenges have reinforced the importance of teaching residents the necessary PM knowledge and skills to function effectively in a medical practice. Multiple studies from different specialties surveying or testing graduating residents and young practicing physicians on their business management knowledge or specific business topics have shown severe deficiencies.^5-11 Unfortunately, graduating orthopedic surgery residents also appear inadequately prepared in PM. In a study of resident coding/billing knowledge, Gill and Schutt⁶ surveyed 2006 graduating orthopedic residents and found that only 13% felt confident in their coding ability. Our study results add to our understanding of multiple PM topics and demonstrate graduating orthopedic residents’ deficiencies throughout these topics.

 Increased efforts to develop business management training programs and curricula have helped improve both overall PM and business knowledge in other specialties.^12-15 ACGME now requires 100 hours of PM training among family medicine residency programs.¹⁶ A curriculum instituted in a general surgery residency focused on improving coding found that accuracy improved from 36% to 88% over 12 months.¹³ A family practice residency instituted a “simulated practice” model for its residents to improve practical PM learning and found statistically significant improvement over their prior didactic lectures.¹⁵ However, there continues to be significant variability in the topics and methods covered in business management curricula as programs struggle to determine how to most effectively use their limited time to prepare graduating residents.

In this study, we introduced the concept of FKD. With limited time available for teaching business knowledge and PM skills in residency, it has become imperative that training be efficient and effective. The FKD model can improve training efficiency by directing training to the topics that will produce the highest yield in preparing physicians for practice. As our results demonstrate, topics with the lowest levels of knowledge among surgeons often are not the same as the topics that are most needed to function effectively in practice (Table 3). The FKD model identifies deficiencies in practical, applicable knowledge rather than focusing on a general knowledge level. We suspect that focusing on topics with a high FKD would provide a higher yield in preparing physicians for practice. As such, our results suggest that training in business operations and coding/billing would likely provide the highest practical value, despite the fact that these were not the areas of least general knowledge.

Another finding of this study was the FKD difference based on type of practice. Compared with private practice physicians, hospital-employed or academic physicians had substantially lower overall FKDs and significantly lower FKDs in several specific topics. However, these FKD differences exist despite minimal differences in overall levels of knowledge. This would suggest that less business knowledge was needed by physicians to enter these types of practices compared with traditional private practice. We speculate that this may be one factor influencing the recent trend by graduating orthopedic residents to take hospital-employed positions, as these positions may appear less demanding in terms of learning the management aspects of the new practice.

Our results also showed slightly higher reported average business knowledge and lower FKD reported by those who had recently completed training (within 2-5 years) versus those in practice much longer. This is particularly interesting, as our institution has maintained the same lecture-based program for many years without significant changes. Although these differences may not be statistically significant, they may reflect an increased interest in and attention to learning PM skills while in training. However, we acknowledge this is only one of many possible explanations for these findings.

This study had several limitations. First, all respondents were graduates of a single institution. We were trying to limit the variability in business training, but this also limits the scope of the results. Second, self-ratings on surveys provide subjective measures of business knowledge and functional knowledge. Scores may vary based on individuals’ understanding of given topics, or they may inaccurately represent their level of understanding. This is especially true of respondents who graduated from residency, for example, 20 years earlier—their survey responses may reflect erroneous recollection of business training at time of graduation compared with respondents who graduated more recently. Conversely, more recent graduates may not have a fully formed or accurate picture of how much business knowledge is required to function in practice. Nevertheless, we found no significant differences in measured parameters based on graduation date, so we chose not to exclude older respondents, which also may have weakened our data pool. Further, FKDs are relative values used to compare subjective deficiencies rather than absolute scores of specific general knowledge. As such, subjectivity, including recollection of business training, is inherent in the model used in this study.

Conclusion

Graduating orthopedic surgeons currently appear inadequately prepared to effectively manage business issues in their practices, as evidenced by their low overall knowledge levels and high FKDs. The novel FKD model described in this study helps define FKD levels and identify topics that may provide the highest yield in improving effectiveness in practice. Residency curricula focused on improving business and PM knowledge, particularly in the topics with the highest FKDs (eg, business operations, coding/billing), may improve training efficiency in these areas. Further studies with larger numbers of physicians across multiple institutions are needed to confirm these findings and to validate the FKD concept.

With the increasing complexity of health care policy, significant changes in reimbursement and payer sources, and constant push to improve the cost-efficiency of care delivery, there has been a growing focus on the importance of business knowledge and practice management (PM) skills among physicians. Family medicine was the first specialty to require PM training during residency; other specialities have begun implementing business training into their residency curriculum.¹ In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 core competencies that should be included in resident training. One of these core competencies involves training in health care systems and PM.^2,3

 Residency program directors have also recognized the need for business training among residents. One study that surveyed general surgery program directors found that more than 87% agreed that residents should be trained in business and PM.⁴ Although these directors recognized the need for training, they also acknowledged the current deficiency: more than 70% thought their current trainees were inadequately trained in business and PM. Similarly, residents and physicians in multiple specialties have reported significant deficiencies in their training and knowledge of PM and business principles.^5-11 For example, in a recent survey of ophthalmologists who had been in practice less than 5 years, 70% reported being not very well or not at all trained in overall PM skills during residency.⁵ Yet, most respondents thought training in this area was the responsibility of the training program.

The call for more business and PM training during residency has been tempered by increasing demands on medical and surgical skills training and time limitations such as duty-hour restrictions. These limitations reinforce the need to find efficient and effective means of teaching necessary business knowledge and PM skills. Paramount to doing this is recognizing the difference between general knowledge and functional knowledge—essentially, what is specifically needed to function effectively in practice.

We conducted a study not only to determine the general level of knowledge that physicians have in different business and PM topics when they complete their residency, but also to evaluate the level of knowledge that graduating physicians need in different business and PM topics in order to function effectively in a medical practice. Toward this end, we developed a novel model that could help determine the level of the functional knowledge deficiency (FKD) of particular business topics. We thought this model would allow us to quantify how much knowledge physicians needed to acquire in a given topic in order to function effectively in practice. We hypothesized that graduating residents would report overall low levels of business knowledge and high FKDs.

Materials and Methods

To minimize variability in the specific type and amount of business training received, we focused this study on a single institution that had maintained a uniform business management curriculum over an extended period. The business training program provided to residents in the orthopedic surgery residency at this institution included 6 hours of didactic lectures on various business topics annually. This program has been in place for more than 15 years and has not undergone any significant changes during that time.

Using the program’s alumni directory, we emailed a cover letter and an 11-question survey to all 332 residents and fellows who had completed their residency or fellowship training at our institution between 1970 and 2008. Anyone who did not reply to the email was mailed a copy of the cover letter and the survey.

The first 4 survey questions involved the demographics of the surgeon and the surgeon’s practice. Subsequent questions focused on the surgeon’s understanding of 9 different general business and PM topics and their importance in the practice. The topics were marketing, business operations, human resources, contract negotiations, malpractice issues, coding/billing, medical records management, accounting, and economic analytical tools. The surgeon was asked to use a 10-point scale ranging from 1 (“knew nothing at all”) to 10 (“complete understanding”) to rate his or her understanding of each topic at the completion of residency. The surgeon was also asked to rate how important it was to understand that topic in the surgeon’s current practice. Again, a 10-point scale was used: 1 (“not important at all”) to 10 (“absolutely vital”) (Figure).

When the surveys were returned, their data were compiled and analyzed to determine the overall knowledge levels for each topic and the levels based on years in practice, type of practice, and level of involvement in PM. We also wanted to determine the amount of business knowledge that they needed in order to function effectively in practice (and that they lacked at time of graduation). We defined this as the FKD at graduation and calculated it as the difference between the surgeon’s reported importance of a topic in his or her current practice and his or her level of understanding of that topic at graduation. A larger FKD score represented greater deficiency, with a maximal possible FKD score of 9. A score of 0 would reflect an appropriate amount of knowledge to function effectively, and a negative score would reflect a knowledge surplus. Using the demographic information from the survey, we were then able to further analyze the levels of overall knowledge as well as the FKD for each topic with respect to length of time in practice, type of practice, and the surgeon’s involvement in PM.

We evaluated the reported levels of knowledge based on both type of practice (academic, hospital-employed, private practice) and who managed the practice (physician, nonphysician). Academic practices were defined as those associated with an academic medical center; hospital-employed practices were those in which the physician was an employee of a health system not associated with an academic medical center; and private practices were defined as physician-owned orthopedic practices not associated with an academic medical center. Regarding management, practices in which physicians were primarily responsible for the daily operations of the practice were considered physician-managed; conversely, practices in which operations were controlled by either employed or institutionally assigned administration were defined as nonphysician-managed.

Statistical analysis of the results for different practice types and levels of involvement in management was performed for both general knowledge and FKD. Means, medians, and standard deviations were calculated. One-way analysis of variance or t tests were then used to examine mean differences overall and within each business topic. When a difference was found, a post hoc Tukey multiple range test was performed to identify it. Differences at P < .05 were considered significant.

Results

One hundred eighty-two surgeons answered the survey, yielding a response rate of 55%. All had completed their training at our institution. Seven respondents were removed from the study because they had retired from practice (5) or had returned incomplete surveys (2).

The overall self-rated level of business knowledge of all responding surgeons at the conclusion of their training was 2.4 on the 10-point scale (Table 1). Specifically, physicians reported the lowest levels of business understanding in economic analytical tools (1.5), human resources (1.7), and contract negotiations (1.9), suggesting minimal knowledge of these topics generally. They reported the highest levels of knowledge in medical records management (3.8) and malpractice issues (3.3). Even these topics, however, still reflected overall low levels of knowledge.

There was no statistically significant difference between private practice and academic physicians. In addition, surgeons in physician-managed practices reported significantly (P = .045) higher levels of understanding of economic analytical tools than surgeons in nonphysician-managed practices (Table 1). There were no other statistically significant differences among groups.

The overall calculated FKD for all surgeons was 5.6. FKDs were calculated for all 9 business topics. The worst FKDs were in business operations (6.4) and coding/billing (6.3). The topic with the least deficiency (lowest FKD) was in medical records management (4.2) (Table 2).

Surgeons’ FKDs based on practice type (academic, hospital-employed, private practice) were compared to identify potentially significant differences. Hospital-employed physicians had the lowest overall FKD (4.0), followed by physicians in academic practices (5.1) and private practices (5.9). Hospital-employed physicians reported statistically significantly better (lower) FKDs in comparison with physicians in private practice in multiple topics, including human resources, contract negotiations, malpractice issues, coding/billing, and accounting (Table 2). Similarly, physicians in academic practices also had statistically significantly better FKDs than physicians in private practice in the topics of business operations, contract negotiations, and billing/coding. Compared with hospital-employed physicians, physicians in academic practices had significantly more knowledge about marketing, business operations, and accounting. Physicians in private practice did not have significantly better FKDs in any topic in comparison with hospital-employed or academic physicians. There was no significant difference in FKDs for medical records management or economic analytical tools based on practice type.

Comparisons based on PM involvement showed that physicians in practices with nonphysician management had only a slightly better FKD (5.6) at graduation than those in practices with physician involvement (5.7). None of the 9 topics was statistically significant different based on physician involvement in PM.

Discussion

Building a successful medical practice has become more difficult for graduating orthopedic surgery residents because of an increasingly complex health care system, shrinking reimbursement rates, and looming regulatory changes. These challenges have reinforced the importance of teaching residents the necessary PM knowledge and skills to function effectively in a medical practice. Multiple studies from different specialties surveying or testing graduating residents and young practicing physicians on their business management knowledge or specific business topics have shown severe deficiencies.^5-11 Unfortunately, graduating orthopedic surgery residents also appear inadequately prepared in PM. In a study of resident coding/billing knowledge, Gill and Schutt⁶ surveyed 2006 graduating orthopedic residents and found that only 13% felt confident in their coding ability. Our study results add to our understanding of multiple PM topics and demonstrate graduating orthopedic residents’ deficiencies throughout these topics.

 Increased efforts to develop business management training programs and curricula have helped improve both overall PM and business knowledge in other specialties.^12-15 ACGME now requires 100 hours of PM training among family medicine residency programs.¹⁶ A curriculum instituted in a general surgery residency focused on improving coding found that accuracy improved from 36% to 88% over 12 months.¹³ A family practice residency instituted a “simulated practice” model for its residents to improve practical PM learning and found statistically significant improvement over their prior didactic lectures.¹⁵ However, there continues to be significant variability in the topics and methods covered in business management curricula as programs struggle to determine how to most effectively use their limited time to prepare graduating residents.

In this study, we introduced the concept of FKD. With limited time available for teaching business knowledge and PM skills in residency, it has become imperative that training be efficient and effective. The FKD model can improve training efficiency by directing training to the topics that will produce the highest yield in preparing physicians for practice. As our results demonstrate, topics with the lowest levels of knowledge among surgeons often are not the same as the topics that are most needed to function effectively in practice (Table 3). The FKD model identifies deficiencies in practical, applicable knowledge rather than focusing on a general knowledge level. We suspect that focusing on topics with a high FKD would provide a higher yield in preparing physicians for practice. As such, our results suggest that training in business operations and coding/billing would likely provide the highest practical value, despite the fact that these were not the areas of least general knowledge.

Another finding of this study was the FKD difference based on type of practice. Compared with private practice physicians, hospital-employed or academic physicians had substantially lower overall FKDs and significantly lower FKDs in several specific topics. However, these FKD differences exist despite minimal differences in overall levels of knowledge. This would suggest that less business knowledge was needed by physicians to enter these types of practices compared with traditional private practice. We speculate that this may be one factor influencing the recent trend by graduating orthopedic residents to take hospital-employed positions, as these positions may appear less demanding in terms of learning the management aspects of the new practice.

Our results also showed slightly higher reported average business knowledge and lower FKD reported by those who had recently completed training (within 2-5 years) versus those in practice much longer. This is particularly interesting, as our institution has maintained the same lecture-based program for many years without significant changes. Although these differences may not be statistically significant, they may reflect an increased interest in and attention to learning PM skills while in training. However, we acknowledge this is only one of many possible explanations for these findings.

This study had several limitations. First, all respondents were graduates of a single institution. We were trying to limit the variability in business training, but this also limits the scope of the results. Second, self-ratings on surveys provide subjective measures of business knowledge and functional knowledge. Scores may vary based on individuals’ understanding of given topics, or they may inaccurately represent their level of understanding. This is especially true of respondents who graduated from residency, for example, 20 years earlier—their survey responses may reflect erroneous recollection of business training at time of graduation compared with respondents who graduated more recently. Conversely, more recent graduates may not have a fully formed or accurate picture of how much business knowledge is required to function in practice. Nevertheless, we found no significant differences in measured parameters based on graduation date, so we chose not to exclude older respondents, which also may have weakened our data pool. Further, FKDs are relative values used to compare subjective deficiencies rather than absolute scores of specific general knowledge. As such, subjectivity, including recollection of business training, is inherent in the model used in this study.

Conclusion

Graduating orthopedic surgeons currently appear inadequately prepared to effectively manage business issues in their practices, as evidenced by their low overall knowledge levels and high FKDs. The novel FKD model described in this study helps define FKD levels and identify topics that may provide the highest yield in improving effectiveness in practice. Residency curricula focused on improving business and PM knowledge, particularly in the topics with the highest FKDs (eg, business operations, coding/billing), may improve training efficiency in these areas. Further studies with larger numbers of physicians across multiple institutions are needed to confirm these findings and to validate the FKD concept.

With the increasing complexity of health care policy, significant changes in reimbursement and payer sources, and constant push to improve the cost-efficiency of care delivery, there has been a growing focus on the importance of business knowledge and practice management (PM) skills among physicians. Family medicine was the first specialty to require PM training during residency; other specialities have begun implementing business training into their residency curriculum.¹ In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 core competencies that should be included in resident training. One of these core competencies involves training in health care systems and PM.^2,3

 Residency program directors have also recognized the need for business training among residents. One study that surveyed general surgery program directors found that more than 87% agreed that residents should be trained in business and PM.⁴ Although these directors recognized the need for training, they also acknowledged the current deficiency: more than 70% thought their current trainees were inadequately trained in business and PM. Similarly, residents and physicians in multiple specialties have reported significant deficiencies in their training and knowledge of PM and business principles.^5-11 For example, in a recent survey of ophthalmologists who had been in practice less than 5 years, 70% reported being not very well or not at all trained in overall PM skills during residency.⁵ Yet, most respondents thought training in this area was the responsibility of the training program.

The call for more business and PM training during residency has been tempered by increasing demands on medical and surgical skills training and time limitations such as duty-hour restrictions. These limitations reinforce the need to find efficient and effective means of teaching necessary business knowledge and PM skills. Paramount to doing this is recognizing the difference between general knowledge and functional knowledge—essentially, what is specifically needed to function effectively in practice.

We conducted a study not only to determine the general level of knowledge that physicians have in different business and PM topics when they complete their residency, but also to evaluate the level of knowledge that graduating physicians need in different business and PM topics in order to function effectively in a medical practice. Toward this end, we developed a novel model that could help determine the level of the functional knowledge deficiency (FKD) of particular business topics. We thought this model would allow us to quantify how much knowledge physicians needed to acquire in a given topic in order to function effectively in practice. We hypothesized that graduating residents would report overall low levels of business knowledge and high FKDs.

Materials and Methods

To minimize variability in the specific type and amount of business training received, we focused this study on a single institution that had maintained a uniform business management curriculum over an extended period. The business training program provided to residents in the orthopedic surgery residency at this institution included 6 hours of didactic lectures on various business topics annually. This program has been in place for more than 15 years and has not undergone any significant changes during that time.

Using the program’s alumni directory, we emailed a cover letter and an 11-question survey to all 332 residents and fellows who had completed their residency or fellowship training at our institution between 1970 and 2008. Anyone who did not reply to the email was mailed a copy of the cover letter and the survey.

The first 4 survey questions involved the demographics of the surgeon and the surgeon’s practice. Subsequent questions focused on the surgeon’s understanding of 9 different general business and PM topics and their importance in the practice. The topics were marketing, business operations, human resources, contract negotiations, malpractice issues, coding/billing, medical records management, accounting, and economic analytical tools. The surgeon was asked to use a 10-point scale ranging from 1 (“knew nothing at all”) to 10 (“complete understanding”) to rate his or her understanding of each topic at the completion of residency. The surgeon was also asked to rate how important it was to understand that topic in the surgeon’s current practice. Again, a 10-point scale was used: 1 (“not important at all”) to 10 (“absolutely vital”) (Figure).

When the surveys were returned, their data were compiled and analyzed to determine the overall knowledge levels for each topic and the levels based on years in practice, type of practice, and level of involvement in PM. We also wanted to determine the amount of business knowledge that they needed in order to function effectively in practice (and that they lacked at time of graduation). We defined this as the FKD at graduation and calculated it as the difference between the surgeon’s reported importance of a topic in his or her current practice and his or her level of understanding of that topic at graduation. A larger FKD score represented greater deficiency, with a maximal possible FKD score of 9. A score of 0 would reflect an appropriate amount of knowledge to function effectively, and a negative score would reflect a knowledge surplus. Using the demographic information from the survey, we were then able to further analyze the levels of overall knowledge as well as the FKD for each topic with respect to length of time in practice, type of practice, and the surgeon’s involvement in PM.

We evaluated the reported levels of knowledge based on both type of practice (academic, hospital-employed, private practice) and who managed the practice (physician, nonphysician). Academic practices were defined as those associated with an academic medical center; hospital-employed practices were those in which the physician was an employee of a health system not associated with an academic medical center; and private practices were defined as physician-owned orthopedic practices not associated with an academic medical center. Regarding management, practices in which physicians were primarily responsible for the daily operations of the practice were considered physician-managed; conversely, practices in which operations were controlled by either employed or institutionally assigned administration were defined as nonphysician-managed.

Statistical analysis of the results for different practice types and levels of involvement in management was performed for both general knowledge and FKD. Means, medians, and standard deviations were calculated. One-way analysis of variance or t tests were then used to examine mean differences overall and within each business topic. When a difference was found, a post hoc Tukey multiple range test was performed to identify it. Differences at P < .05 were considered significant.

Results

One hundred eighty-two surgeons answered the survey, yielding a response rate of 55%. All had completed their training at our institution. Seven respondents were removed from the study because they had retired from practice (5) or had returned incomplete surveys (2).

The overall self-rated level of business knowledge of all responding surgeons at the conclusion of their training was 2.4 on the 10-point scale (Table 1). Specifically, physicians reported the lowest levels of business understanding in economic analytical tools (1.5), human resources (1.7), and contract negotiations (1.9), suggesting minimal knowledge of these topics generally. They reported the highest levels of knowledge in medical records management (3.8) and malpractice issues (3.3). Even these topics, however, still reflected overall low levels of knowledge.

There was no statistically significant difference between private practice and academic physicians. In addition, surgeons in physician-managed practices reported significantly (P = .045) higher levels of understanding of economic analytical tools than surgeons in nonphysician-managed practices (Table 1). There were no other statistically significant differences among groups.

The overall calculated FKD for all surgeons was 5.6. FKDs were calculated for all 9 business topics. The worst FKDs were in business operations (6.4) and coding/billing (6.3). The topic with the least deficiency (lowest FKD) was in medical records management (4.2) (Table 2).

Surgeons’ FKDs based on practice type (academic, hospital-employed, private practice) were compared to identify potentially significant differences. Hospital-employed physicians had the lowest overall FKD (4.0), followed by physicians in academic practices (5.1) and private practices (5.9). Hospital-employed physicians reported statistically significantly better (lower) FKDs in comparison with physicians in private practice in multiple topics, including human resources, contract negotiations, malpractice issues, coding/billing, and accounting (Table 2). Similarly, physicians in academic practices also had statistically significantly better FKDs than physicians in private practice in the topics of business operations, contract negotiations, and billing/coding. Compared with hospital-employed physicians, physicians in academic practices had significantly more knowledge about marketing, business operations, and accounting. Physicians in private practice did not have significantly better FKDs in any topic in comparison with hospital-employed or academic physicians. There was no significant difference in FKDs for medical records management or economic analytical tools based on practice type.

Comparisons based on PM involvement showed that physicians in practices with nonphysician management had only a slightly better FKD (5.6) at graduation than those in practices with physician involvement (5.7). None of the 9 topics was statistically significant different based on physician involvement in PM.

Discussion

Building a successful medical practice has become more difficult for graduating orthopedic surgery residents because of an increasingly complex health care system, shrinking reimbursement rates, and looming regulatory changes. These challenges have reinforced the importance of teaching residents the necessary PM knowledge and skills to function effectively in a medical practice. Multiple studies from different specialties surveying or testing graduating residents and young practicing physicians on their business management knowledge or specific business topics have shown severe deficiencies.^5-11 Unfortunately, graduating orthopedic surgery residents also appear inadequately prepared in PM. In a study of resident coding/billing knowledge, Gill and Schutt⁶ surveyed 2006 graduating orthopedic residents and found that only 13% felt confident in their coding ability. Our study results add to our understanding of multiple PM topics and demonstrate graduating orthopedic residents’ deficiencies throughout these topics.

 Increased efforts to develop business management training programs and curricula have helped improve both overall PM and business knowledge in other specialties.^12-15 ACGME now requires 100 hours of PM training among family medicine residency programs.¹⁶ A curriculum instituted in a general surgery residency focused on improving coding found that accuracy improved from 36% to 88% over 12 months.¹³ A family practice residency instituted a “simulated practice” model for its residents to improve practical PM learning and found statistically significant improvement over their prior didactic lectures.¹⁵ However, there continues to be significant variability in the topics and methods covered in business management curricula as programs struggle to determine how to most effectively use their limited time to prepare graduating residents.

In this study, we introduced the concept of FKD. With limited time available for teaching business knowledge and PM skills in residency, it has become imperative that training be efficient and effective. The FKD model can improve training efficiency by directing training to the topics that will produce the highest yield in preparing physicians for practice. As our results demonstrate, topics with the lowest levels of knowledge among surgeons often are not the same as the topics that are most needed to function effectively in practice (Table 3). The FKD model identifies deficiencies in practical, applicable knowledge rather than focusing on a general knowledge level. We suspect that focusing on topics with a high FKD would provide a higher yield in preparing physicians for practice. As such, our results suggest that training in business operations and coding/billing would likely provide the highest practical value, despite the fact that these were not the areas of least general knowledge.

Another finding of this study was the FKD difference based on type of practice. Compared with private practice physicians, hospital-employed or academic physicians had substantially lower overall FKDs and significantly lower FKDs in several specific topics. However, these FKD differences exist despite minimal differences in overall levels of knowledge. This would suggest that less business knowledge was needed by physicians to enter these types of practices compared with traditional private practice. We speculate that this may be one factor influencing the recent trend by graduating orthopedic residents to take hospital-employed positions, as these positions may appear less demanding in terms of learning the management aspects of the new practice.

Our results also showed slightly higher reported average business knowledge and lower FKD reported by those who had recently completed training (within 2-5 years) versus those in practice much longer. This is particularly interesting, as our institution has maintained the same lecture-based program for many years without significant changes. Although these differences may not be statistically significant, they may reflect an increased interest in and attention to learning PM skills while in training. However, we acknowledge this is only one of many possible explanations for these findings.

This study had several limitations. First, all respondents were graduates of a single institution. We were trying to limit the variability in business training, but this also limits the scope of the results. Second, self-ratings on surveys provide subjective measures of business knowledge and functional knowledge. Scores may vary based on individuals’ understanding of given topics, or they may inaccurately represent their level of understanding. This is especially true of respondents who graduated from residency, for example, 20 years earlier—their survey responses may reflect erroneous recollection of business training at time of graduation compared with respondents who graduated more recently. Conversely, more recent graduates may not have a fully formed or accurate picture of how much business knowledge is required to function in practice. Nevertheless, we found no significant differences in measured parameters based on graduation date, so we chose not to exclude older respondents, which also may have weakened our data pool. Further, FKDs are relative values used to compare subjective deficiencies rather than absolute scores of specific general knowledge. As such, subjectivity, including recollection of business training, is inherent in the model used in this study.

Conclusion

Graduating orthopedic surgeons currently appear inadequately prepared to effectively manage business issues in their practices, as evidenced by their low overall knowledge levels and high FKDs. The novel FKD model described in this study helps define FKD levels and identify topics that may provide the highest yield in improving effectiveness in practice. Residency curricula focused on improving business and PM knowledge, particularly in the topics with the highest FKDs (eg, business operations, coding/billing), may improve training efficiency in these areas. Further studies with larger numbers of physicians across multiple institutions are needed to confirm these findings and to validate the FKD concept.

Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.^1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.^3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.^5,6

Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,⁷ are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening^8,9; no study has determined the best radiographic view for evaluating fracture displacement.

We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.

Patients and Methods

Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.

Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.

The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.

After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.

The Orthopaedic Trauma Association classification system⁸ was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).

Results

Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).

Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.

Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).

Discussion

Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.

Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues⁹ used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed¹⁰ studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues⁹ and Sharr and Mohammed¹⁰ recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.

Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues¹¹ investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues¹² studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues¹³ found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.

Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.^14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society¹⁴ randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.

Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.

There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.

This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.

There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.

Conclusion

Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.

Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.^1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.^3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.^5,6

Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,⁷ are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening^8,9; no study has determined the best radiographic view for evaluating fracture displacement.

We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.

Patients and Methods

Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.

Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.

The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.

After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.

The Orthopaedic Trauma Association classification system⁸ was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).

Results

Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).

Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.

Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).

Discussion

Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.

Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues⁹ used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed¹⁰ studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues⁹ and Sharr and Mohammed¹⁰ recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.

Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues¹¹ investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues¹² studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues¹³ found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.

Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.^14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society¹⁴ randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.

Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.

There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.

This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.

There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.

Conclusion

Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.

Clavicle fractures are common injuries, accounting for 2.6% to 5% of all adult fractures.^1,2 Most clavicle fractures (69%-82%) occur in the middle third or midshaft.^3,4 Midshaft clavicle fractures are often treated successfully with nonoperative means consisting of shoulder immobilization with either a sling or a figure-of-8 brace. Operative indications historically have been limited to open or impending open injuries and to patients with underlying neurovascular compromise. However, recent clinical studies have found that fractures with particular characteristics may benefit from surgical fixation. Important relative indications for open reduction and internal fixation of midshaft clavicle fractures are complete fracture fragment displacement with no cortical contact, and fractures with axial shortening of more than 20 mm.^5,6

Accurately determining the extent of displacement and shortening can therefore be important in guiding treatment recommendations. The standard radiographic view for a clavicle fracture is upright or supine anteroposterior (AP). Typically, an AP radiograph with cephalic tilt of about 20° is obtained as well. On occasion, other supplemental radiographs, such as a 45° angulated view, as originally described by Quesada,⁷ are obtained. To our knowledge, the literature includes only 2 reports of studies that have compared different radiographic views and their accuracy in measuring fracture shortening^8,9; no study has determined the best radiographic view for evaluating fracture displacement.

We conducted a study to determine which radiographic view best captures the most fracture fragment displacement. Acute midshaft clavicle fractures were assessed with simulated angled radiographs created from preoperative upright 3-dimensional (3-D) fluoroscopy scans. Our hypothesis was that a radiographic view with 20° of cephalic tilt would most often detect the most fracture displacement. In addition, we retrospectively reviewed our study patients’ initial AP injury radiographs to determine if obtaining a different view at maximum displacement would have helped identify a larger number of completely displaced midshaft clavicle fractures.

Patients and Methods

Institutional review board approval was obtained. Using our institution’s trauma registry database, we retrospectively identified 10 cases of patients who had undergone preoperative 3-D fluoroscopy for midshaft clavicle fractures. Study inclusion criteria were age 18 years or older, acute midshaft clavicle fracture, and preoperative 3-D fluoroscopy scan of clavicle available. Pediatric patients, nonacute injuries, and clavicle fractures of the lateral or medial third were excluded.

Three-dimensional fluoroscopy was used when the treating surgeon deemed it necessary for preoperative planning. All imaging was performed with a Philips MultiDiagnost Eleva 3-D fluoroscopy imager with patients in the upright standing position. (Informed patient consent was obtained.) Software bundled with the imager was used to create representative radiographs of differing angulation.

The common practice at most institutions is to obtain 2 radiographic views as part of a standard clavicle series. The additional AP angulated radiograph typically is obtained with 20° to 45° cephalic tilt from the horizontal axis. Therefore, simulated radiographs ranging from 15° to 50° of angulation in 5° increments were created, and the amount of superior displacement of the medial fragment was measured. As the simulated views were constructed from a 3-D composite image, there was none of the magnification error that occurs with AP or posteroanterior (PA) views. The stated degree of angulation mimics a radiograph’s AP cephalic tilt or PA caudal tilt (Figures 1A, 1B). For all radiographic images, displacement between fracture fragments was determined by measuring the distance between the superior cortices at the fracture site of the medial and lateral fragments. Each simulated radiograph was measured by 2 readers using standard computerized radiographic measurement tools. Final displacement was taken as the mean of the 2 measurements.

After determining which radiographic angulation demonstrated the largest number of maximally displaced fractures, we compared the simulated radiographs at that angulation with the injury AP images for all patients. Total number of patients with a completely displaced midshaft clavicle fracture and no cortical contact was recorded for the 2 radiographic views.

The Orthopaedic Trauma Association classification system⁸ was used to classify the clavicle fractures. Statistical analysis was performed with the Fisher exact test and a regression model, using SPSS Version 19.0 (IBM SPSS Statistics).

Results

Ten patients met the study inclusion criteria. Mean age was 32.9 years (range, 18-65 years). Seven of the 10 patients were male. Six patients had right-side clavicle fractures. Of the 10 patients, 5 had the comminuted wedge fracture pattern (15-B2.3), 2 had the simple spiral pattern (15-B1.1), 2 had the spiral wedge pattern (15-B2.1), and 1 had the oblique pattern (15-B1.2).

Table 1 summarizes the fracture displacement measurements obtained with the different radiographic views. Of the 10 cases, 5 showed the most displacement with the 15° tilted view (P = .004), and the other 5 showed maximum displacement with different radiographic angulations. In addition, 6 patients showed the least displacement with the 50° angulated view (P < .001). Results of the regression analysis are summarized in Tables 2 and 3.

Initial horizontal AP imaging showed completely displaced midshaft clavicle fractures in 9 of the 10 patients, and 15° simulated radiographs showed completely displaced fractures in all 10 patients (P = .50).

Discussion

Our study results demonstrated that an upright 15° radiographic tilt (AP cephalad or PA caudal) identified the most fracture displacement in the most patients with acute midshaft clavicle fractures. To our knowledge, this is the first study to identify the radiographic angulation that best shows the most clavicle fracture fragment displacement.

Other investigators have studied the accuracy of different radiographic views in the assessment of midshaft clavicle fractures, but they concentrated on fracture shortening. Smekal and colleagues⁹ used computed tomography (CT) and 3 different radiographic views to evaluate malunited midshaft clavicle fractures. Comparing the horizontal clavicular length measurements obtained with radiographs and CT scans, they determined that PA thoracic radiographs were in highest agreement with the CT scans. The results, however, were not statistically significant. In their study, supine CT was successful because the fractures were healed, and the displacement and shortening amounts were not affected by patient position. Sharr and Mohammed¹⁰ studied the accuracy of different views in the assessment of clavicle length in an articulated cadaver specimen. They obtained multiple AP and PA radiographs of different horizontal (medial, lateral) and vertical (cephalad, caudal) angulations. Actual clavicle length was then directly measured and compared with the length measured on the different views. The authors concluded that a PA 15° caudal radiograph was most accurate in assessing clavicular length. Both Smekal and colleagues⁹ and Sharr and Mohammed¹⁰ recommended the PA radiograph because it decreases the degree of magnification on AP radiographs by minimizing the film-to-object distance.

Our findings are important because more accurate determination of fracture displacement in patients with midshaft clavicle fractures may change clinical management. Nowak and colleagues¹¹ investigated various patient and clavicle fracture characteristics that were predictive of a higher rate of long-term sequelae. They found that complete fracture displacement was the strongest radiographic predictor of patients’ beliefs that they were fully recovered from injury at final follow-up. The authors concluded that fractures with no bony contact should receive more “active” management. Robinson and colleagues¹² studied a cohort of patients with nonoperatively managed midshaft clavicle fractures and concluded that complete fracture displacement significantly increased risk for nonunion (this risk was 2.3 times higher in patients with displaced fractures than in patients with nondisplaced fractures). Last, McKee and colleagues¹³ found that shoulder strength and endurance were significantly decreased in nonoperatively treated displaced midshaft clavicle fractures than in the same patients’ uninjured shoulders.

Extending the results of these studies, recent prospective randomized control trials and a meta-analysis have compared the clinical outcomes of nonoperatively and operatively managed displaced midshaft clavicle fractures.^14-18 With few exceptions, these studies found improved clinical results with operative fixation. In one such study, the Canadian Orthopaedic Trauma Society¹⁴ randomized patients with displaced midshaft clavicle fractures to either operative plate fixation or sling immobilization. The operative group was found to have improved Disability of the Arm, Shoulder, and Hand scores, improved Constant shoulder scores, increased patient satisfaction, faster mean time to bony fracture union, higher satisfaction with shoulder appearance, and lower rates of nonunion and malunion. Given the results of these studies, accurate identification of a displaced midshaft clavicle fracture with no cortical contact is fundamental in deciding whether to recommend operative fixation.

Retrospective review of our cohort’s initial radiographs revealed 1 case in which the patient’s completely displaced midshaft clavicle fracture would not have been diagnosed solely with an AP horizontal image. Cortical contact was seen on a standard AP clavicle radiograph (Figures 2A, 2B), and a 15° tilt radiograph created from 3-D fluoroscopy scan showed complete fracture fragment displacement (Figure 3). A change in fracture classification from partially displaced to fully displaced could alter the type of management used by a treating surgeon.

There were obvious weaknesses to this study. First, its sample size was small (10 patients). Nevertheless, we had sufficient numbers to find a statistically significant angulation. Second, a wider range of radiographic angles could have been studied. Our intent, however, was to investigate the accuracy of the 2 most common supplementary clavicle views (20° and 45° cephalic tilt). Therefore, we selected a range of simulated radiographs that began 5° outside these angulations. Third, we measured only the degree of fracture displacement; we were unable to accurately access fracture shortening, as the 3-D fluoroscopic images were limited to the injured clavicles. A potential solution to this problem is to widen the exposure field in order to include the entire chest and allow clavicular length comparison against the uninjured side. Doing this would have been possible, but at the expense of increasing the patient’s radiation exposure.

This innovative study used 3-D fluoroscopy to capture clavicle fracture images with patients in an upright position. Unlike standard CT, in which patients are supine, this 3-D imaging technology better emulates the patient positioning used for upright radiographs, thereby avoiding potential fracture fragment alignment changes caused by shifts in body position. In addition, 3-D fluoroscopy allows us to create multiple precise simulated radiographic angulations without the magnification error of AP radiographs and, to a lesser extent, PA radiographs. Having a standing PA 15° caudal tilt radiograph obviates the need for CT with 3-D reconstruction. More fine detail may be revealed by CT with 3-D reconstruction than by a standing PA 15° caudal tilt radiograph, but the patient faces less radiation risk and cost with the radiograph.

There is no consensus as to what constitutes the standard radiographic series for clavicle fractures. Radiographic technique can vary with respect to supplemental view angulation, supine or upright patient positioning, and AP or PA radiographic views. Although our study did not address the effect of supine versus upright patient positioning on acute midshaft clavicle fracture displacement, we think that, for all clinical and research purposes, upright 15° caudal PA radiographs should be obtained for patients with acute midshaft clavicle fractures.

Conclusion

Our retrospective study of 10 patients with acute midshaft clavicle fractures and preoperative upright 3-D fluoroscopy scans found that a 15° angulated radiograph most often demonstrated the most fracture fragment displacement. Given these findings, we recommend obtaining an additional PA 15° caudal radiograph in the upright position for patients with midshaft clavicle fractures to best assess the extent of fracture displacement. Accurately identifying the degree of fracture displacement is important, as operative management of completely displaced fractures has been shown to improve clinical outcomes.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.