Consensus on the Treatment of Midshaft Clavicular Fractures in Collegiate Football Players: A Delphi Approach of Sports Medicine Teams

Abstract

Background:

Optimal management of clavicular fractures in football players remains unclear.

Purpose:

To utilize the Delphi process to (1) identify factors used in decision-making for clavicular fractures in collegiate football players, (2) investigate the current use of bone stimulators, teriparatide, and specialized padding as adjuncts to treatment, and (3) determine areas of consensus for treatment.

Study Design:

Consensus statement.

Methods:

A total of 83 orthopaedic surgeons, nonsurgical sports medicine physicians, and athletic trainers from the Southeastern Conference were surveyed utilizing a 3-round Delphi process. The first 2 rounds identified the most important factors that influenced treatment. These factors were combined to create 48 clinical scenarios. In the third round, panelists were presented with 8 treatment options for each scenario. Treatment options were scored as “preferred treatment,”“acceptable treatment,”“not acceptable/contraindicated,” or “unsure/no opinion.” The threshold for consensus was set at 75%. Additional questions investigated panelists’ methods for measuring displacement and shortening as well as their use of bone stimulators, teriparatide, and specialized pads.

Results:

All 3 rounds were completed by 43 panelists (24 orthopaedic surgeons, 4 nonoperative sports medicine physicians, and 5 athletic trainers). The top 4 factors that influenced treatment in descending order were (mean score: 1, most important; 7, least important) amount of displacement (1.16), fracture location (3.60), player input (4.07), and return-to-play timeline (4.16). Bone stimulators and specialized pads were commonly used, but teriparatide was used less frequently. Consensus analysis in round 3 only analyzed results from orthopaedic surgeons because of low response rates from nonoperative sports medicine physicians (15.4%) and athletic trainers (22.7%) compared with orthopaedic surgeons (68.6%). Panelists were more likely to reach consensus on nonoperative treatment for nondisplaced fractures without shortening early in the year and were more likely to avoid nonoperative treatment for displaced fractures with shortening.

Conclusion:

The current study group considers multiple clinical factors in determining optimal treatment for collegiate football players with clavicular fractures, incorporates adjuncts to traditional management, and identified a limited set of scenarios that achieved consensus.

Clavicular fractures accounted for 2.6% to 5% of all reported fractures in emergency departments between 2015 and 2019 and are one of the most common orthopaedic injuries occurring during sports and recreational activities. ¹³ A total of 81% occur in the middle third, and almost half are displaced. ¹⁰ A recent descriptive epidemiology study of sports-related clavicular fractures found the highest percentage of clavicular fractures occurred in football, accounting for 27% of injuries. ¹³ Previous studies have investigated outcomes of operative and nonoperative management, including union rate, need for future surgery, and functional outcomes. ¹ Many researchers have attempted to identify patients and injury patterns best treated operatively or nonoperatively; however, due to conflicting data, there remains no clear consensus on which treatment is best for each patient and injury pattern. ⁴

Collegiate football players present different demands than does the general public. Some patient factors are unique to football players and are not commonly evaluated in standard medical literature on clavicular fracture management. These include (1) return-to-play timelines relative to athletic seasons, (2) athletic prowess and future career prospects, (3) return to contact sports, and (4) access to advanced rehabilitation. The influence of these factors on an individual physician's medical decision-making is largely unknown. Three adjuncts to treatment currently being used by some football team physicians are also not commonly evaluated in standard medical literature on clavicular fracture management. These include bone stimulators, teriparatide (Forteo; parathyroid hormone analog), and custom pads.^2,4

Because of the limited high-level scientific evidence on these topics, we decided to utilize a Delphi technique. The Delphi technique is a method for achieving consensus on controversial topics and typically involves conducting several rounds of surveys with a panel of experts. ⁴ The goal of the first round is to provide an open-ended or structured questionnaire to highlight key information about the chosen topic. The second round involves participants ranking identified features to weigh their importance, and the process is repeated until consensus regarding the topic is determined to be achieved.

The primary aim of this study was to use the Delphi technique to identify factors that are considered when making treatment decisions for football players with clavicular fractures. The secondary aim was to investigate the current use of bone stimulators, teriparatide, and pads as adjuncts to treatment. Our tertiary aim was to determine areas of consensus regarding the treatment of midshaft clavicular fractures in collegiate football players. Our primary hypothesis was that treatment decisions for clavicular fractures would be affected not only by standard factors already present in the medical literature such as fracture location and displacement, but also by factors unique to football players. Our secondary hypothesis was that bone stimulators, teriparatide, and specialized pads were currently being used as adjuncts to treatment for clavicular fractures. Our tertiary hypothesis was that consensus could be achieved for some but not all clinical scenarios.

Methods

SEC Study Group Members

Our multidisciplinary study group consisted of the Southeastern Conference (SEC) football nonsurgical sports medicine physicians, orthopaedic surgeons, and athletic trainers. Each of these medical professionals plays a critical role in the evaluation, treatment, and rehabilitation of collegiate football players.

This project was approved by the institutional review board of Baptist Health Care. The medical department of each SEC school and football team was reviewed to identify possible panel members, including 35 orthopaedic surgeons, 26 nonsurgical sports medicine physicians, and 22 athletic trainers for football. Panel members were contacted by email with a description of the project, an invitation to participate in the study, and a link to complete the first-round questionnaire. Individuals who were unable to be contacted by email or did not initially respond to the email invitation to participate were invited by phone if their contact information was available.

First-Round Survey

The goal of the first-round survey was to identify and rank factors influencing the recommended treatment of closed clavicular fractures in an SEC football player. The questionnaire listed 27 factors; these factors were identified from a review of the literature and discussion between the authors, each of whom assisted with treatment of SEC football players at the time of the study. Panel members were asked to rank each factor on a 5-point scale (1 = not at all important to 5 = very important). The questionnaire also included a free-text response option for factors that were not listed among the 27 identified by the authors. The mean rank score for each factor was calculated, with a higher score denoting increased importance. We also evaluated and considered free-text factors for inclusion in future survey rounds. The top 7 factors were included in the second-round survey. We created a 1-paragraph literature review for each of the top 7 factors that was provided to panelists.

Second-Round Survey

Round 2 had 4 sections. The first section asked panelists to rank the importance of the top 7 factors identified in the first round. Although factors could have been ranked based on their scores in the first round, we aimed to mirror the Delphi technique of similar studies and provide panelists with a literature review to clarify importance, allowing them to be ranked more accurately. ¹²

The second section asked panelists about their use of standard and adjunct treatments for midshaft clavicular fractures. These treatments included nonoperative management alone, nonoperative management with a bone stimulator, nonoperative management with teriparatide, nonoperative management with a bone stimulator + teriparatide, operative management alone, operative management with a bone stimulator, operative management with teriparatide, and operative management with a bone stimulator + teriparatide. We asked the panelists whether they used each treatment frequently, sometimes, rarely, or did not use that treatment. They were also offered the option to submit a free-text response if a treatment they used regularly was not included.

The third section asked panelists about pad/cushion device use. They were asked how often they used soft padding, hard shield with soft padding, and 3-dimensional (3D) printed hard shield with padding over the fracture site as part of nonoperative or operative treatment.

The fourth section sought to provide clarity on methods used to calculate fracture displacement and shortening, as we noted discrepancies in the first-round responses. Several published methods exist for determining fracture displacement and shortening.^3,12 Our goal was to use this information to identify ranges of shortening and displacement commonly grouped clinically to be used in the round 3 survey.

Third-Round Survey

We reviewed the ranking scores of the top 7 factors and the responses on fracture displacement and shortening from the second round. The Delphi process grants moderators flexibility to adjust iterative rounds of surveys. This flexibility was used in this study to create a final round that would present the most useful information on the most common clinical scenarios. ⁴ As a result, the top 7 factors were adjusted into 4 final factors. We discarded the factor of fracture location and instead narrowed the scope of round 3 to only investigate midshaft clavicular fractures because this fracture location represented the most common fracture pattern. Narrowing the scope to include only midshaft clavicular fractures also allowed the survey to remain short enough that panelists were willing to complete all questions.

Fracture displacement was kept as a factor. We used the results of the second-round survey to group ranges of fracture displacement into 3 ranges for use in the third round. Rehabilitation timeline was rephrased as injury timing, which changed the factor from a dependent to an independent variable, making it more applicable for clinical use.

Fracture shortening was not listed explicitly in round 1 as a possible factor; however, it was listed as a free-response answer by a panelist in the first round and was identified in the literature as an important factor. ⁹ Because fracture shortening was not listed initially in the first round, it was also not listed in the ranking section of the second round but was investigated in a later section of the second round. Due to the importance of this factor in the literature, we decided to include shortening as a primary factor for investigation in the third round, despite not being included explicitly in the first round and only partially included in the second round.

Fracture angulation was discarded because most panelists included angulation as part of their understanding of fracture displacement.

The presence of additional pathology was also discarded. Clavicular fractures can occur in isolation; however, fractures resulting from high-energy mechanisms of injury can have associated head trauma, rib fractures, pneumothorax, or neurovascular injury. In Morgan et al’s ⁸ retrospective review of middle-third clavicular fractures in the National Football League (NFL), 19 clavicular fractures were identified. Among those, there were no open fractures and no concomitant injuries. ⁵ Because the goal of this survey was to offer recommendations for the most common clinical situations and to prevent round 3 from being prohibitively long to complete for panelists, we discarded this factor from future rounds.

The final 4 factors used for the third round, therefore, were injury timing, fracture displacement, fracture shortening, and player input. Each factor had 2 to 4 different possible values. Those factors were combined to create 48 unique clinical scenarios. For each clinical scenario, panelists were asked to score each of the 8 possible treatment options as “preferred treatment,”“acceptable treatment,”“not acceptable/contraindicated,” or “unsure/no opinion.” Panelists were only able to select preferred treatment for 1 treatment option for each clinical scenario. These treatment options included nonoperative management alone, nonoperative management with a bone stimulator, nonoperative management with teriparatide, nonoperative management with a bone stimulator + teriparatide, operative management alone, operative management with a bone stimulator, operative management with teriparatide, and operative management with a bone stimulator + teriparatide.

Descriptive Reporting and Consensus Analysis

Because of the incomplete team representation from nonoperative sports medicine physicians and athletic trainers in round 3, the analysis of round 3 for consensus determination was conducted on the results from orthopaedic surgeons alone, as all SEC teams were represented with the 24 orthopaedic surgeons who responded to all surveys. This significantly changed the perspective and subject matter expertise of panelists; however, after careful deliberation with the key study stakeholders, it was determined that only the orthopaedic surgeons had the appropriate subject matter expertise to discern between the subtle differences in treatment recommendations listed in round 3. Round 3 was completed by 24 orthopaedic surgeons who scored 8 possible treatment options for 48 unique clinical scenarios, providing 9216 total determinations on the appropriateness of different treatments for closed midshaft clavicular fractures in SEC football players. For a treatment to reach consensus as the preferred treatment for a specific clinical scenario, 75% of panelists were required to have selected preferred treatment. For a treatment to reach consensus as acceptable treatment, 75% of panelists were required to have selected acceptable treatment or preferred treatment. For a treatment to reach consensus as not acceptable/contraindicated, 75% of panelists were required to have selected not acceptable/contraindicated.

Results

Characteristics of Respondents/Panelists

From the 16 schools in the SEC, we identified 35 orthopaedic surgeons for membership in the panel. The first-round survey was completed by 32 of 35 orthopaedic surgeons (91.4% response rate). The second-round survey was completed by 28 of 32 orthoapedic surgeons (87.5% response rate). The third-round survey was completed by 24 of 28 orthopaedic surgeons (85.7% response rate). Of the 35 initially identified orthopaedic surgeons affiliated with SEC football medical departments, 24 completed the entire survey, for a cumulative response rate of 68.6%.

The first-round survey was completed by 11 of 26 nonsurgical sports medicine physicians (42.3% response rate). The second-round survey was completed by 5 of 9 nonsurgical sports medicine physicians (55.6% response rate); 2 of the initial 11 were no longer with the football teams. The third-round survey was completed by 4 of 5 nonsurgical sports medicine physicians (80% response rate). Of the 26 initially identified nonsurgical sports medicine physicians affiliated with SEC football medical departments, 4 completed the entire survey, for a cumulative response rate of 15.4%.

The first-round survey was completed by 14 of 22 athletic trainers for football (63.6% response rate). The second-round survey was completed by 10 of 14 athletic trainers for football (71.4% response rate). The third-round survey was completed by 5 of 10 athletic trainers for football (50% response rate). Of the 22 initially identified athletic trainers for football affiliated with SEC football medical departments, 5 completed the entire survey, for a cumulative response rate of 22.7%.

Round 1: Ranking Factors for Treatment Determination

The top 7 factors identified were the presence of additional pathology, return-to-play timeline, rehabilitation timeline, fracture displacement, player input, fracture location, and fracture angulation, in descending order of importance. The 20 lowest factors were eliminated from future rounds. Other identified factors submitted by panelists included hand dominance (2), skin tenting/soft tissue envelope (2), nutrition/medical comorbidities (2), and fracture shortening (1). Some factors were combined or edited and included in the third round as we clarified definitions of the factors. Details of this process are outlined in the Methods section. Mean scores and standard deviations are listed in Table 1.

Table 1

Round 1 Results ^a

Factor	Orthopaedic Surgeon	PC	ATC	Overall
Additional pathology (ie, ligament tear, displacement of fracture)	4.66 ± 0.48	4.67 ± 0.50	4.57 ± 0.51	4.64 ± 0.49
Return-to-play timeline (ie, how quickly player is needed/wanted back on field)	4.59 ± 0.67	4.11 ± 0.60	4.36 ± 0.84	4.45 ± 0.72
Rehabilitation timeline (ie, projected duration of player recovery)	4.59 ± 0.56	4.56 ± 0.53	4.71 ± 0.47	4.62 ± 0.53
Amount of displacement of fracture	4.56 ± 0.62	4.67 ± 0.50	4.71 ± 0.47	4.62 ± 0.56
Player input (ie, taking player preferences into consideration)	4.53 ± 0.57	4.89 ± 0.33	4.43 ± 0.65	4.56 ± 0.57
Fracture location (ie, proximal, midshaft, distal)	4.47 ± 0.62	4.77 ± 0.44	4.64 ± 0.50	4.56 ± 0.57
Amount of angulation of fracture	4.44 ± 0.62	4.56 ± 0.53	4.64 ± 0.50	4.51 ± 0.57
Chance of reinjury	4.41 ± 0.80	4.44 ± 0.73	4.79 ± 0.43	4.51 ± 0.72
History of clavicular fractures (ie, ≥2 clavicular fractures)	4.41 ± 0.67	4.33 ± 0.50	4.64 ± 0.63	4.45 ± 0.63
Occurrence of injury (ie, preseason, midseason, postseason)	4.13 ± 0.83	3.89 ± 0.33	3.93 ± 0.92	4.03 ± 0.79
Need for follow-up care (ie, revision surgery, physical therapy)	3.91 ± 0.73	4.44 ± 0.52	4.28 ± 0.61	4.09 ± 0.70
Amount of activity in practice/games (eg, pushing, running, jumping)	3.91 ± 0.86	4.11 ± 0.60	4.29 ± 0.61	4.04 ± 0.77
Psychological effect (ie, player mental assessment/attitude)	3.75 ± 0.84	4.22 ± 0.67	4.00 ± 0.88	3.89 ± 0.83
Patient self-reported pain level	3.50 ± 0.88	4.11 ± 0.78	4.14 ± 0.53	3.76 ± 0.84
Neer classification	3.47 ± 0.72	4.11 ± 0.33	3.93 ± 0.73	3.69 ± 0.72
Position (eg, offense vs defense)	3.38 ± 1.07	3.67 ± 0.87	3.71 ± 0.47	3.51 ± 0.98
NFL draft prospect	3.34 ± 1.12	3.11 ± 0.60	3.36 ± 1.08	3.31 ± 1.03
AO classification	3.28 ± 0.77	4.00 ± 0.50	3.93 ± 0.73	3.56 ± 0.79
Starter status (eg, first string, second string)	3.09 ± 1.12	2.89 ± 0.78	3.43 ± 1.22	3.15 ± 1.10
Heisman potential (ie, star player vs unknown team member)	2.97 ± 1.15	2.78 ± 0.83	3.29 ± 1.27	3.02 ± 1.13
Year at university (eg, freshman, sophomore)	2.72 ± 1.25	2.56 ± 0.73	3.14 ± 1.02	2.80 ± 1.13
Method of injury (eg, blunt force tackle vs fall)	2.50 ± 1.14	3.67 ± 0.71	3.71 ± 0.83	3.00 ± 1.15
Scholarship status (ie, player on scholarship vs no scholarship)	2.28 ± 1.11	2.11 ± 0.78	2.29 ± 1.07	2.25 ± 1.04
Public awareness of injury (ie, injury seen on national television vs not televised)	1.78 ± 0.83	2.00 ± 0.71	2.14 ± 1.10	1.94 ± 0.88
Altitude (eg, low sea level, high sea level)	1.75 ± 0.72	2.56 ± 0.72	2.79 ± 0.97	2.15 ± 0.91
Circumstance of injury (ie, injured in game or practice)	1.72 ± 0.77	2.44 ± 0.88	2.57 ± 1.01	2.05 ± 0.93
Location of injury (ie, home game vs away game)	1.72 ± 0.81	2.11 ± 0.78	2.64 ± 1.28	2.02 ± 1.01

a

Data are presented as mean ± SD. Top factors were scored based on 1 = not at all important, 5 = very important. AO, Arbeitsgemeinschaft für Osteosynthesefragen; ATC, Athletic Trainer Certified; NFL, National Football League; PC, primary care sports medicine.

Round 2: Factor Additional Ranking and Investigation of Treatment Background Details

Panelists were provided with a brief literature review of the top 7 factors identified in the first round. We then asked panelists to rank those 7 factors (1 = most important to 7 = least important). The most important factors were the amount of displacement, followed by fracture location; player input; return-to-play timeline; fracture angulation; additional pathology (ie, ligament tear); and last, rehabilitation time. Mean scores and standard deviations are listed in Table 2.

Table 2

Round 2 Ranking of Top Factors With Literature Reviews ^a

Factor	Orthopaedic Surgeon	PC	ATC	Overall
Amount of displacement	1.21 ± 0.79	1.20 ± 0.45	1.00 ± 0.00	1.16 ± 0.65
Fracture location	3.82 ± 1.66	4.60 ± 0.89	4.40 ± 1.90	3.60 ± 1.73
Player input	3.82 ± 1.47	5.60 ± 1.67	5.30 ± 1.49	4.07 ± 1.52
Return-to-play timeline	4.11 ± 1.73	3.40 ± 1.52	3.10 ± 0.66	4.16 ± 1.73
Fracture angulation	4.68 ± 1.68	4.40 ± 1.83	4.64 ± 1.51	4.51 ± 0.57
Additional pathology	5.04 ± 2.12	5.20 ± 2.05	5.00 ± 1.25	4.84 ± 1.95
Rehabilitation time	5.32 ± 1.31	3.60 ± 2.30	4.60 ± 1.51	5.35 ± 1.36

a

Data are presented as mean ± SD. Top factors were scored based on 1 = most important, 7 = least important. ATC, Athletic Trainer Certified; PC, primary care sports medicine.

Round 2 also included questions for background on treatment modalities, pad utilization, and fracture measurement. Regarding the use of standard and adjunct treatments, panelists reported using all treatment combinations in some capacity. These combinations included nonoperative treatment alone; operative treatment alone; and nonoperative or operative treatments with the adjuncts of a bone stimulator, teriparatide, or both a bone stimulator and teriparatide (Table 3 shows standard and adjunct treatment options).

Table 3

Use of Standard and Adjunct Treatments ^a

Treatment Type	Yes: I Use This Treatment Frequently		Yes: I Use This Treatment Sometimes		Yes: I Use This Treatment but Rarely		No: I Do Not Use This Treatment
Nonoperative management alone	Ortho	1	Ortho	17	Ortho	5	Ortho	5
	PC	1	PC	3	PC	1	PC	0
	ATC	0	ATC	6	ATC	3	ATC	1
Nonoperative management with a bone stimulator	Ortho	2	Ortho	12	Ortho	8	Ortho	6
	PC	0	PC	2	PC	2	PC	1
	ATC	3	ATC	7	ATC	0	ATC	0
Nonoperative management with teriparatide b	Ortho	0	Ortho	7	Ortho	4	Ortho	17
	PC	0	PC	2	PC	1	PC	2
	ATC	1	ATC	4	ATC	1	ATC	4
Nonoperative management with a bone stimulator + teriparatide	Ortho	1	Ortho	6	Ortho	4	Ortho	17
	PC	0	PC	2	PC	1	PC	2
	ATC	2	ATC	4	ATC	0	ATC	4
Operative management alone	Ortho	10	Ortho	12	Ortho	3	Ortho	3
	PC	2	PC	2	PC	1	PC	0
	ATC	1	ATC	7	ATC	1	ATC	1
Operative management with a bone stimulator	Ortho	7	Ortho	9	Ortho	6	Ortho	6
	PC	0	PC	2	PC	2	PC	1
	ATC	2	ATC	7	ATC	1	ATC	0
Operative management with teriparatide	Ortho	0	Ortho	6	Ortho	2	Ortho	20
	PC	0	PC	2	PC	1	PC	2
	ATC	0	ATC	5	ATC	1	ATC	4
Operative management with a bone stimulator + teriparatide	Ortho	1	Ortho	5	Ortho	1	Ortho	21
	PC	0	PC	1	PC	2	PC	2
	ATC	2	ATC	4	ATC	0	ATC	4

a

Number in each cell represents the number of responses for each question. ATC, Athletic Trainer Certified; Ortho, orthopaedic surgeon; PC, primary care sports medicine.

b

Forteo; parathyroid hormone analog.

Panelists reported common use of pads over the clavicular fracture site. Both soft pads and hard shields with soft padding were used commonly, with some panelists reporting use of 3D-printed hard shields (Table 4).

Table 4

Padding Use ^a

Prompt	Always		Often		Sometimes		Rarely		Never		Not Sure
How often is soft padding over the fracture site used to supplement nonoperative or operative treatment?	Ortho	9	Ortho	11	Ortho	6	Ortho	2	Ortho	0	Ortho	0
	PC	1	PC	3	PC	1	PC	0	PC	0	PC	0
	ATC	2	ATC	3	ATC	3	ATC	2	ATC	0	ATC	0
How often is a hard shield with soft padding over the fracture site used to supplement nonoperative or operative treatment?	Ortho	3	Ortho	15	Ortho	8	Ortho	1	Ortho	0	Ortho	1
	PC	2	PC	2	PC	1	PC	0	PC	0	PC	0
	ATC	2	ATC	8	ATC	0	ATC	0	ATC	0	ATC	0
How often are you using a 3-dimensional printed hard shield with soft padding over the fracture site as part of nonoperative or operative treatment?	Ortho	3	Ortho	5	Ortho	6	Ortho	7	Ortho	5	Ortho	2
	PC	1	PC	0	PC	1	PC	3	PC	0	PC	0
	ATC	2	ATC	8	ATC	0	ATC	0	ATC	0	ATC	0

a

Number in each cell represents the number of responses for each parameter. ATC, Athletic Trainer Certified; Ortho, orthopaedic surgeon; PC, primary care sports medicine.

Panelists were asked about their methods for measuring fracture displacement, including superoinferior displacement and use of the distance between the apices of fracture fragments method (Table 5). Both techniques were used by panelists, with 21 using the superoinferior displacement method and 6 using the distance between apex method. One surgeon reported using an alternative method of measurement.

Table 5

Method for Measuring Fracture Displacement ^a

What Method Do You Use to Measure Fracture Displacement?	Ortho	PC	ATC
Superior/inferior displacement, cortical width, 100%	21	3	4
Distance between apex	6	2	2
Other	1	0	4

a

Data are presented as n. ATC, Athletic Trainer Certified; Ortho, orthopaedic surgeon; PC, primary care sports medicine.

Panelists were next asked if they considered fracture shortening as part of their decision-making on determining the treatment for their players and, if so, how they performed that measurement (Table 6). All panelists reported that fracture shortening affected their decision-making. Standard clavicular radiographs were used by 19 panelists to measure the shortening by measuring the overlap of fracture fragments. Bilateral acromioclavicular joint radiographs were used by 5 panelists to compare the distance from the sternoclavicular joint to the acromioclavicular joint between the uninjured and injured clavicle to determine fracture shortening. Four panelists reported that they estimated shortening as part of overall displacement.

Table 6

Methods for Measuring Fracture Shortening ^a

Do You Consider Fracture Shortening Part of Your Decision Making?	Ortho	PC	ATC
Yes: I measure shortening on the injury radiograph of the injured clavicle.	19	2	1
Yes: I obtain bilateral clavicular radiographs or bilateral AC joint views to compare shortening/distance from AC to SC joints.	5	1	3
Yes: I estimate shortening as part of overall displacement.	4	2	3
No	0	0	3

a

Data are presented as n. AC, acromioclavicular; ATC, Athletic Trainer Certified; Ortho, orthopaedic surgeon; PC, primary care sports medicine; SC, sternoclavicular.

In the final section of the second round, panelists were asked to choose between nonoperative and operative treatment, considering only the amount of superoinferior displacement (Table 7). These data were used to determine cutoffs for displacement categories for the round 3 survey (ie, 0%-25%, 25%-100%, >100%).

Table 7

Treatment Based Only on Superior/Inferior Displacement ^a

Question	Nonoperative Management		Operative Management
When superior/inferior fracture displacement alone is considered, if a fracture is nondisplaced, which management would you recommend as your primary treatment?	Ortho	25	Ortho	3
	PC	5	PC	0
	ATC	7	ATC	3
When superior/inferior fracture displacement alone is considered, if a fracture is 25% displaced (1/4 cortical width displaced), which management would you recommend as your primary treatment?	Ortho	20	Ortho	8
	PC	4	PC	1
	ATC	4	ATC	6
When superior/inferior fracture displacement alone is considered, if a fracture is 50% displaced (1/2 cortical width displaced), which management would you recommend as your primary treatment?	Ortho	14	Ortho	13
	PC	3	PC	2
	ATC	2	ATC	8
When superior/inferior fracture displacement alone is considered, if a fracture is 75% displaced (3/4 cortical width displaced), which management would you recommend as your primary treatment?	Ortho	7	Ortho	20
	PC	2	PC	3
	ATC	1	ATC	9
When superior/inferior fracture displacement alone is considered, if a fracture is 100% displaced (1 full cortical width), which management would you recommend as your primary treatment?	Ortho	1	Ortho	27
	PC	0	PC	5
	ATC	0	ATC	10
When superior/inferior fracture displacement alone is considered, if a fracture is >100% displaced (>1 full cortical width), which management would you recommend as your primary treatment?	Ortho	0	Ortho	28
	PC	0	PC	5
	ATC	0	ATC	10

a

Data are presented as n. ATC, Athletic Trainer Certified; Ortho, orthopaedic surgeon; PC, primary care sports medicine.

Round 3: Consensus Scoring for Clinical Scenarios and Treatment Options

The 48 different clinical scenarios are listed in Table 8. Data for all 9216 treatment determinations and groupings of consensus are visualized in the Appendix. Fracture displacement and shortening were the most powerful drivers for deciding on the acceptability of treatment options; therefore, summaries on the consensus below are grouped by the amount of displacement and shortening to aid in interpretation of the data. Overall, player input had less of an impact on recommendations than fracture displacement and shortening. Injury timing affected whether consensus was reached in 8 of the 48 clinical scenarios.

Table 8

Clinic Scenarios Matrix ^a

Question	Timing	Displacement	Shortening	Player Input
Q01	Spring Practice	0% to 25% (1/4 cortical width)	<2 cm	Prefers Operative Tx
Q02	Spring Practice	0% to 25% (1/4 cortical width)	<2 cm	Prefers Nonoperative Tx
Q03	Spring Practice	0% to 25% (1/4 cortical width)	2+ cm	Prefers Operative Tx
Q04	Spring Practice	0% to 25% (1/4 cortical width)	2+ cm	Prefers Nonoperative Tx
Q05	Spring Practice	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Operative Tx
Q06	Spring Practice	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q07	Spring Practice	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Operative Tx
Q08	Spring Practice	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q09	Spring Practice	>100% (>1 cortical width)	<2 cm	Prefers Operative Tx
Q10	Spring Practice	>100% (>1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q11	Spring Practice	>100% (>1 cortical width)	2+ cm	Prefers Operative Tx
Q12	Spring Practice	>100% (>1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q13	Fall Camp	0% to 25% (1/4 cortical width)	<2 cm	Prefers Operative Tx
Q14	Fall Camp	0% to 25% (1/4 cortical width)	<2 cm	Prefers Nonoperative Tx
Q15	Fall Camp	0% to 25% (1/4 cortical width)	2+ cm	Prefers Operative Tx
Q16	Fall Camp	0% to 25% (1/4 cortical width)	2+ cm	Prefers Nonoperative Tx
Q17	Fall Camp	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Operative Tx
Q18	Fall Camp	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q19	Fall Camp	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Operative Tx
Q20	Fall Camp	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q21	Fall Camp	>100% (>1 cortical width)	<2 cm	Prefers Operative Tx
Q22	Fall Camp	>100% (>1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q23	Fall Camp	>100% (>1 cortical width)	2+ cm	Prefers Operative Tx
Q24	Fall Camp	>100% (>1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q25	Early Season	0% to 25% (1/4 cortical width)	<2 cm	Prefers Operative Tx
Q26	Early Season	0% to 25% (1/4 cortical width)	<2 cm	Prefers Nonoperative Tx
Q27	Early Season	0% to 25% (1/4 cortical width)	2+ cm	Prefers Operative Tx
Q28	Early Season	0% to 25% (1/4 cortical width)	2+ cm	Prefers Nonoperative Tx
Q29	Early Season	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Operative Tx
Q30	Early Season	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q31	Early Season	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Operative Tx
Q32	Early Season	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q33	Early Season	>100% (>1 cortical width)	<2 cm	Prefers Operative Tx
Q34	Early Season	>100% (>1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q35	Early Season	>100% (>1 cortical width)	2+ cm	Prefers Operative Tx
Q36	Early Season	>100% (>1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q37	Late Season	0% to 25% (1/4 cortical width)	<2 cm	Prefers Operative Tx
Q38	Late Season	0% to 25% (1/4 cortical width)	<2 cm	Prefers Nonoperative Tx
Q39	Late Season	0% to 25% (1/4 cortical width)	2+ cm	Prefers Operative Tx
Q40	Late Season	0% to 25% (1/4 cortical width)	2+ cm	Prefers Nonoperative Tx
Q41	Late Season	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Operative Tx
Q42	Late Season	25% (1/4 cortical width) to 100% (1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q43	Late Season	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Operative Tx
Q44	Late Season	25% (1/4 cortical width) to 100% (1 cortical width)	2+ cm	Prefers Nonoperative Tx
Q45	Late Season	>100% (>1 cortical width)	<2 cm	Prefers Operative Tx
Q46	Late Season	>100% (>1 cortical width)	<2 cm	Prefers Nonoperative Tx
Q47	Late Season	>100% (>1 cortical width)	2+ cm	Prefers Operative Tx
Q48	Late Season	>100% (>1 cortical width)	2+ cm	Prefers Nonoperative Tx

a

Tx, treatment.

No clinical scenario and treatment combination reached a 75% consensus for a preferred treatment. Five combinations reached 40% to 45% consensus for a preferred treatment. All others reached <40% consensus as the sole preferred treatment.

A total of 127 clinical scenarios and treatment combinations reached the minimal 75% consensus as acceptable treatment, including treatments selected as acceptable or preferred for each clinical scenario.

For fracture displacement 0% to 25% and <2 cm of shortening, there was consensus that nonoperative management alone or nonoperative management with a bone stimulator was acceptable with all player input or injury timing options. There was no consensus that nonoperative management with teriparatide or nonoperative management with a bone stimulator + teriparatide was acceptable with any player input or injury timing option.

For fractures with 0% to 25% displacement and ≥2 cm of shortening, there was consensus that nonoperative management alone was acceptable only for a player who preferred nonoperative treatment and sustained an injury during spring practice.

For fractures with 25% to 100% displacement and shortening <2 cm, there was consensus that nonoperative management alone or nonoperative management with a bone stimulator was acceptable for players who preferred nonoperative treatment at any injury time point.

For fractures with >100% displacement and <2 cm of shortening, there was consensus that the recommendation of operative management alone or operative management with a bone stimulator was acceptable for all player input or injury timing options. There was no consensus that operative management with teriparatide or operative management with a bone stimulator + teriparatide was acceptable for any player input or injury timing option.

For fractures with >100% displacement and ≥2 cm of shortening, there was consensus that recommending operative management alone or operative management with a bone stimulator was acceptable for all player input and injury timing options. There was no consensus that operative management with teriparatide or operative management with a bone stimulator + teriparatide was acceptable for any player input or injury timing option.

Three clinical scenario and treatment combinations reached the 75% consensus threshold for unacceptable/contraindicated. These combinations all included fractures with >100% displacement, ≥2 cm of shortening and nonoperative treatment with Forteo.

Discussion

The primary aim of this study was to use the Delphi technique to investigate patient factors that are unique to football players that affect clavicular fracture management. The top 4 factors in decision making when treating clavicular fractures in college football players were determined by our study group in descending order to be (mean score: 1 = most important; 7 = least important) amount of displacement (1.16), fracture location (3.60), player input (4.07), and return-to-play timeline (4.16).

The secondary aim was to investigate the current use of bone stimulators, teriparatide, and specialized padding as adjuncts to treatment among our study group. Bone stimulators and specialized pads were commonly used in clavicular fracture management while teriparatide was used by a minority of clinicians.

The tertiary aim was to determine areas of consensus regarding the treatment of midshaft clavicular fractures in collegiate football players. No clinical scenario nor treatment option combinations reached the 75% consensus threshold for preferred treatment. However, 127 clinical scenarios and treatment combinations reached the 75% consensus threshold for acceptable treatment. Three clinical scenarios and treatment combinations reached the 75% threshold for unacceptable/contraindicated. Panelists were more likely to reach consensus on nonoperative treatment for nondisplaced fractures without shortening early in the year and were more likely to avoid nonoperative treatment for displaced fractures with shortening.

Previous studies on clavicular fractures in football players have been retrospective case series and cohort studies. Morgan and colleagues ⁸ performed a retrospective review of the NFL Injury Surveillance System over a 5-season period, beginning with the 2003 training camp, and sent a detailed questionnaire to the medical staff of all 32 NFL teams. Their review found that 19 players had sustained a middle-third clavicular fracture. Six fractures were nondisplaced or minimally displaced and were treated nonoperatively; these healed at a mean time of 7.3 weeks. Thirteen fractures were 100% displaced, with 6 treated with acute surgical fixation and 7 treated nonoperatively. The displaced fractures treated surgically healed without complication at 8.8 weeks. Three of 7 displaced fractures treated nonoperatively healed clinically without sequela at a mean of 13.3 weeks. Four of 7 displaced fractures treated nonoperatively sustained a refracture within 1 year of the initial injury. The authors concluded that for NFL athletes, nondisplaced clavicular fractures heal consistently with nonoperative management while displaced clavicular fractures heal more predictably with operative management.

There are 3 retrospective cohort studies on clavicular fractures in NFL athletes that provide descriptive analysis of how these injuries heal with both nonoperative and operative treatment.^6,7,14 None of these studies report on adjunct treatments nor clinician decision making.^6,7,14 In 2017, Jack et al^6,7 published 2 studies: a cohort study evaluating performance and return-to-sport rates/timing after nonoperative treatment of clavicular fractures in NFL athletes and a cohort study after open reduction and internal fixation of clavicular fractures in NFL athletes. In the nonoperative study, 30 players with 32 fractures were identified, including 2 players who fractured their contralateral clavicle. ⁷ With nonoperative treatment, 96.9% were able to return to sport at a mean of 244.6 ± 119.6 days. Players with nonoperative treatment had career lengths similar to those of controls (P > .05). ⁷ In the operative study, 17 surgeries in 16 players were analyzed. ⁶ Fifteen players (93.8%) were able to return to sport in the NFL at a mean 211.3 ± 144.7 days postsurgery. The mean return to sport was 53.4 days for players who returned during the same season. Players who underwent clavicular fracture open reduction and internal fixation played in a similar number of games per season and had similar career lengths in the NFL as controls. ⁶ A third retrospective cohort study evaluated published NFL injury reports and subsequent postinjury performance from 1998 to 2015. ¹⁴ Seventeen players were used in their analysis. Athletes returned to competition after a median of 3.47 months and missed a median of 8 games. The mean return-to-play timeline for operative treatment was 3.4 months compared with 5.2 months for nonoperative treatment. ¹⁴ Athletes with clavicular fractures had no statistically significant impact on athletic performance after the fracture. ¹⁴

In our study, the first round identified 7 factors as most influential. Although only the top 7 factors were selected for continuation in the Delphi process, 19 factors had a mean score of ≥3 (1 = not at all important to 5 = very important). These scores demonstrate that many factors are considered by the sports medicine team, and the weight of these factors may be different for each athlete and clinician. The second round of the Delphi approach primarily ranked the top factors identified from the first round. These factors generally matched what has been identified in prior research as critical factors. ¹¹

Round 2 also included background questions on treatment modalities, pad use, and fracture measurement. The standard treatments of nonoperative management alone and operative management alone were both common. Using a bone stimulator was also common for supplementing nonoperative and operative treatment. Teriparatide was used by approximately 25% of the panelists as an adjunct for both operative and nonoperative treatment, occasionally also while using a bone stimulator; however, the adjunct of teriparatide was listed more often as “not used" than bone stimulators. This result may reflect a new area of investigation as an opportunity for treatment. Panelists commonly used pads to supplement nonoperative and operative treatment. Although soft pads were used, many panelists reported using both off-the-shelf and 3D-printed hard shells for additional protection of the fracture site.

In round 3, no clinical scenario and treatment option combinations reached the threshold for preferred treatment. In fact, the highest level of consensus as preferred treatment only reached 45%. This finding most likely mirrors the success seen clinically with nonoperative and operative treatment of both nondisplaced and displaced fractures.

There was some consensus on scenario and treatment combinations as acceptable treatment. Nondisplaced and minimally displaced fractures with shortening <2 cm generally reached consensus that it was acceptable to treat nonoperatively or operatively with or without a bone stimulator. As fracture displacement and shortening increased, there was less consensus on the acceptability of nonoperative treatment and sustained consensus on the acceptability of operative treatment. For the majority of the clinical scenarios, the presence or absence of a bone stimulator as an adjunct to nonoperative or operative intervention did not change whether the scenario reached consensus. There were no treatment options that included teriparatide alone or teriparatide with a bone stimulator that reached consensus for preferred or acceptable treatment. This finding may demonstrate an increased familiarity and comfort with bone stimulator use than teriparatide as an adjunct. No scenario included a bone stimulator that reached consensus as not acceptable/contraindicated. Most scenarios that included teriparatide also did not reach consensus as not acceptable/contraindicated. This finding may demonstrate either that respondents were hesitant to label colleagues’ use of teriparatide as not acceptable/contraindicated or found that it is permissible in many clinical situations, save for a select few.

Only 3 clinical scenario and treatment option combinations reached the threshold for not acceptable/contraindicated. These combinations all included fractures with >100% displacement and shortening ≥2 cm. Although it was expected that these fractures would trend toward operative rather than nonoperative management, it is unclear why nonoperative management with teriparatide met the 75% threshold for consensus as unacceptable/contraindicated but nonoperative management alone, nonoperative management with a bone stimulator, and nonoperative management with a bone stimulator + teriparatide did not.

The timing of a player's injury was an important factor for panelists; for instance, a fracture sustained during spring practice or fall camp has more time to heal before the start of the season. Therefore, players and providers may be more likely to consider treatment options that take longer to heal but carry low risk of complications. During the early season, a fast recovery may allow the player to return for the end of the season. During the late season, there is little time for recovery and return to play during the same season. This consideration was mirrored in the responses. Shared decision making between surgeon and patient can increase the chances of treatment success and patient satisfaction. ¹¹

Limitations

This study had several limitations. First, there was some panelist attrition after each round, most likely due to the time commitment required to complete the surveys—especially the longer third-round survey. The attrition was highest in the primary care sports medicine physicians and the certified athletic trainers, suggesting a level of delegation of these decisions to the orthopaedic surgeons by the sports medicine team.

Another limitation is that many of the 27 initial factors on the first round were dropped in future rounds. Many dropped factors were scored as moderately important, with no clear dropoff in score between the top 7 factors and the bottom 20 factors. However, if we retained too many factors, the survey would have become prohibitively long for panelists to complete. The mean scores for factors were also close to each other, making the ranking list fragile to small changes in scoring by a small number of panelists.

In addition to removing the bottom 20 factors, we had to make significant changes to the top 7 factors. These changes could have been avoided by identifying more ideal factors at the beginning of the study. However, the benefit of performing multiple rounds of the study is that Delphi process leaders can leverage the panel's expertise to identify topics and provide expert opinions. Finally, some combinations for clinical scenarios and treatment options reached consensus, whereas other similar and more aligned treatment options did not. This finding could be the result of true differences in opinion; however, fatigue could have resulted in some confusing results in round 3, as we asked respondents to score 8 treatment options for 48 scenarios.

A final consideration is that this survey included caregivers in the southeastern United States. As practice patterns can differ based on geography, these findings may be limited in their broader generalizability and medical providers must always ensure they are following appropriate standards of care.

Conclusion

The current study group considers multiple clinical factors in determining optimal treatment for collegiate football players with clavicular fractures, incorporates adjuncts to traditional management, and identified a limited set of scenarios that achieved consensus.