Proximal Humerus Fractures Workup
- Author: Mark A Frankle, MD; Chief Editor: S Ashfaq Hasan, MD more...
Routine preoperative laboratory studies for proximal humerus fractures include the following:
Complete blood count (CBC)
Basic metabolic panel
Type and cross-match
Radiographic evaluation is the most important diagnostic tool for proximal humerus fractures. Incorrect views or poor quality radiographs can lead to errors in prognosticating outcome and an inappropriate choice of treatment.
The initial series for evaluating a patient with a suspected proximal humerus fracture is the trauma series, which consists of anteroposterior (AP) and lateral views in the scapular plane and an axillary view.
The scapula sits obliquely to the chest wall. Therefore, to achieve a true AP view, the x-ray beam must be tilted approximately 40° to plane of the thorax. Similarly, in the lateral view, the x-ray beam will parallel the scapular spine when the body is tilted 40°. The axillary view can be obtained with the use of the Velpeau view, allowing the arm to stay within the sling. In this view, the patient is seated and tilted backwards approximately 45°.
Use the AP projection to assess fracture displacements of the surgical neck (varus or valgus), the greater tuberosity (superior displacement), and the lesser tuberosity (medial displacement). The glenohumeral joint should be clearly visible. If overlap is seen, suspect dislocation. The lateral view is helpful in assessing flexion or extension of the surgical neck and posterior displacement of the greater tuberosity fragment.
The axillary view helps to assess tuberosity fragments, with anteromedial displacement of the lesser tuberosity fragment and posterior displacement of the greater tuberosity fragment. This view is critical in assessing the greater tuberosity fragment, as superior displacement may be absent and the infraspinatus can be completely avulsed with a posteriorly displaced fragment. Furthermore, dislocation of the head can be defined clearly on this view.
Linear tomography can help to assess nonunions of the surgical neck. However, it has been replaced by computed tomography (CT). In addition to surgical neck assessment, CT can provide information on articular involvement in head splitting fractures, impression fractures, chronic fracture dislocations, and glenoid rim fractures. Tuberosity displacement can also be assessed.
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