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Clinical Evaluation-Radiographic Evaluation

Accurate radiographic evaluation of the fracture of the proximal humerus is essential for diagnosis and treatment. The trauma series is still the standard initial method for evaluating proximal humeral fracture. This consists of anteroposterior (AP) view of the scapula, a lateral, Y-view of the scapula, and axillary view. This series allows evaluation of the fracture pattern in three perpendicular planes.

It is not uncommon for inadequate radiographs to be done. The two most common problems include the AP view of the scapula with the arm internally rotated, and not doing an axillary view. Without an axillary view, it is almost impossible to determine the relationship between the humeral head and the glenoid.

To obtain a proper AP view of the scapula, the arm should be gently externally rotated about 20 degrees. This can be easily accomplished letting the patient hold onto IV pole or the edge of the table. A similar maneuver can be used to obtain abducted axillary view. Some surgeons prefer Velpau axillary view, in which arms stay in the sling, the patient leans back, and the beam is aimed down though the shoulder.

The role of CT in the evaluation of proximal humerus fractures remains controversial. Some orthopedists order CT scan only if pattern of the fracture cannot be clearly determined. Others argue that standard radiographs are not sufficient to appreciate subtle changes in rotation and positioning of the fragments and recommend CT scan as a part of standard radiographic evaluation of proximal humerus fractures. Moreover, CT images can be digitally manipulated to provide three-dimensional (3D) reconstruction of the fracture. Most recently, Edelson et al.

It reported their experience with 3D-CT reconstruction of the proximal humerus fractures. They suggest that 3D-CT reconstruction provides precise information about anatomy of bony fragments that not only help to better understand fracture pattern, but may lead to improved or better surgical procedures. Magnetic resonance imaging (MRI) is rarely needed.

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