Intraoperative imaging of the proximal humerus

Fluoroscopic visualization of anatomical fracture reduction and correct implant placement for the proximal humerus can be greatly facilitated using the following views:

• AP view of the shoulder
• Lateral (axial) view of the proximal humerus
• Scapular-Y (Neer’s) view (especially for nailing)

The axillary view is usually not necessary for the treatment of a proximal humeral fracture.

The following represents ideal imaging with the patient placed in the supine or various angles of beach chair position.

The orientation of the C-arm has to be adjusted.

The arm is in neutral position.

Position the beam centered over the humeral head.

It should be 20°–30° tilted inward in the axial plane, parallel to the glenoid joint surface.

The following lines and landmarks can be observed:

1. Glenoid fossa
2. Head of humerus
3. Anatomic neck
4. Calcar humerale
5. Greater tuberosity
6. Intertubercular groove
7. Lesser tubercle
8. Surgical neck
9. Lateral line
10. Medial line
11. Acromion
12. Coracoid

This image is taken with the patient in supine position. Images with the patient in the beach chair position should look the same.

The optimal view is obtained when:

• Minimal overlap of head and glenoid
• Head centered in the glenoid (depending on fracture)
• Visibility of greater tuberosity
• Head and shaft visible

This view is particularly useful for identifying:

• Glenohumeral dislocation and subluxation
• Varus and valgus displacement of the head
• Plate position
• Intraarticular screw

To obtain a lateral (axial) view, the arm needs to be externally rotated with abduction. This is only possible after the fracture is fixed preliminarily or definitively.

In other cases, the C-arm needs to be rotated (see Neer’s view below).

With the beam in the same position as for the AP view, rotate the arm externally (or internally) 90° from the neutral position.

The following lines and landmarks are seen:

1. Glenoid fossa
2. Head of humerus
3. Anatomic neck
4. Lesser tuberosity
5. Bicipital sulcus
6. Anterior line
7. Greater tuberosity
8. Posterior line

This image is taken with the patient in a beach chair position. Images with the patient in supine position should look the same.

The optimal view is obtained when the following is visible:

• Minimal overlap of head and glenoid
• Head centered in the glenoid (depending on fracture)
• Visibility of greater and lesser tuberosity
• Humeral head and neck are in axial alignment with the shaft

This view is particularly useful for identifying:

• Posterior displacement of the humeral head
• Plate malposition

This image shows slight residual posterior displacement of the humeral head.

With the beam set for an AP view, position the patient to allow arm rotation.

Continuously rotate the arm from neutral to 90° external rotation under fluoroscopy to obtain a range of views from correct AP to lateral (axial).

• Intraarticular screw (image)
• Relation of plate to shaft

Neer’s view is perpendicular to the AP view without manipulating the fractured arm. This necessitates repositioning the C-arm.

Position the patient and beam for the AP view. Swing the C-arm 90° around the shoulder to obtain a view perpendicular to the glenoid.

Before starting the surgery, ensure the patient and C-arm position allows this maneuver. A shoulder table (radiolucent) is necessary.

Left image: C-arm position for AP view

Right image: C-arm position for scapular-Y view

Note: Patient and arm position are not changed.

The following lines and landmarks are seen:

1. Coracoid
2. Scapular spine
3. Scapular body
4. Acromion
5. Lateral clavicle
6. Glenoid
7. Humeral shaft
8. Lesser tuberosity
9. Humeral head

The optimal view is obtained when the following is visible:

• Scapular body, coracoid, and spine form a Y-shape
• Humeral shaft and head are projected on the glenoid and scapular body

This view is particularly useful for identifying:

• Alignment of humeral head and shaft
• Signs of anterior or posterior subluxation/glenohumeral dislocation
• Correct implant placement
• Correct entry point for nailing

This AP view shows the guide wire for nail insertion pointing slightly lateral to the apex of the head for a bent nail.

These images show Neer’s view of the same case. The left image shows the guide wire too posteriorly. In the right image, this has been corrected with the wire in line with the medullary canal.

AP view of the above case with the nail inserted and fixed with screws to the humeral head, the insertion handle still in place.

Final lateral (axial) view of the nailing procedure

Final Neer’s view