title: Upright versus supine radiographs of clavicle fractures: does positioning matter?
abstract: OBJECTIVE
  To determine whether clavicle fracture displacement and shortening are different between upright and supine radiographic examinations.
  
  
  METHODS
  Combined retrospective and prospective comparative study.
  
  
  METHODS
  Level I Trauma Center.
  
  
  METHODS
  Forty-six patients (mean age, 49 years; range, 24-89 years) with an acute clavicle fracture were evaluated.
  
  
  METHODS
  Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the 2 positions.
  
  
  METHODS
  One resident and 3 traumatologists classified the fractures and measured displacement and shortening. Data were aggregated and compared to ensure reliability with a 2-way mixed intraclass correlation.
  
  
  RESULTS
  Fracture displacement was significantly greater when measured from upright radiographs (15.9 ± 8.9 mm) than from supine radiographs (8.4 ± 6.6 mm, P < 0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright but not on supine radiographs. Compared with the uninjured side, 3.0 ± 10.7 mm of shortening was noted on upright radiographs and 1.3 ± 9.5 mm of lengthening on supine radiographs (P < 0.001). The intraclass correlation was 0.82 [95% confidence interval (CI), 0.73-0.89] for OTA fracture classification, 0.81 (95% CI, 0.75-0.87) for vertical displacement, and 0.92 (95% CI, 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators.
  
  
  CONCLUSIONS
  Increased fracture displacement and shortening was observed on upright compared with supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.
authors.affiliation: *Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO; †Mercy Clinic Orthopedic Trauma - Surgery Center, Springfield, MO; and ‡Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.
authors.forename: Jonathon D
authors.initials: JD
authors.lastname: Backus
authors.forename: David J
authors.initials: DJ
authors.lastname: Merriman
authors.forename: Christopher M
authors.initials: CM
authors.lastname: McAndrew
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Gardner
authors.forename: William M
authors.initials: WM
authors.lastname: Ricci
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002968:Clavicle / Q000000981:diagnostic imaging* / Q000293:injuries*; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D056888:Patient Positioning / Q000379:methods*; D011856:Radiographic Image Enhancement / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016683:Supine Position; D055815:Young Adult
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