LIMITED RECOMMENDATION Two low quality studies were reviewed demonstrating more displacement of midshaft clavicle fractures with upright compared to supine radiographs (Herman 2019, Malik 2017). Herman et al. found a higher proportion of displacement greater than 100% in the group with upright radiographs (52.1% vs 33.5%). Malik (2017) specifically measured the change in vertical and horizontal displacement on supine and upright radiographs taken within 2 weeks and found significantly more displacement in both planes in the upright group. The mean displacement ranged from 3.34 to 6.3 mm with use of upright films when compared to supine radiographs. Additionally, Herman et al. noted upright films more frequently lead to a change in treatment as a result of displacement when compared to supine imaging. Upright clavicle radiographs may provide more information regarding displacement compared to supine radiographs alone.
Benefits/Harms of Implementation
Patient positioning for upright versus supine radiographs is unlikely to cause notable harm or benefit to the patient. Upright radiographs are likely to show more displacement and may lead to changes in treatment secondary to displacement compared to supine radiographs.
Outcome Importance
Understanding the impact of positioning on displacement is important for the treating surgeon so that appropriate treatment and injury stratification can be determined.
Cost Effectiveness/Resource Utilization
No evidence related to cost or resource utilization is available on this topic. It is unlikely that there is a substantial difference between upright and supine radiographs as this is only a difference in patient positioning.
Acceptability
Little needed change in practice pattern makes this recommendation likely to be acceptable to most.
Feasibility
Alterations in position are feasible in most x-ray settings. Obtaining upright radiographs, once patient is able, can be performed in a subacute manner without clinically relevant changes in treatment.
Future Research
Continued understanding of the impact of displacement on clinical outcomes is necessary.
- Herman, A., Whitesell, R., Stewart, R. L., Lowe, J. A. The impact of upright radiographs of midshaft clavicle fractures on treatment recommendations. Acta Orthopaedica Belgica 2019; 3: 289-296
- Malik, A., Jazini, E., Song, X., Johal, H., O'Hara, N., Slobogean, G., Abzug, J. M. Positional Change in Displacement of Midshaft Clavicle Fractures: An Aid to Initial Evaluation. Journal of Orthopaedic Trauma 2017; 1: e9-e12