What is the position of the c-arm relative to the patient when imaging the humerus

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Language: English Mature content filter: None

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Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always … More Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.

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  • Journal List
  • Arthrosc Tech
  • v.6(4); 2017 Aug
  • PMC5621472

Arthrosc Tech. 2017 Aug; 6(4): e1009–e1014.

Abstract

Proximal humeral fractures are common injuries with increasing incidence, particularly in the aging population. Nondisplaced or minimally displaced fractures can be treated conservatively whereas surgical fixation is usually indicated in the cases of displaced fractures. Various surgical options have been used for treatment of these fractures. Good outcomes have been reported with use of the Proximal Humeral Internal Locking System (PHILOS plate; Synthes, Zuchwil, Switzerland) as the implant of choice. However many complications have been reported, including varus malalignment, excessive retroversion of the articular part of the humerus, penetration of screws, and avascular necrosis of the humeral head. Therefore, we have hypothesized that an inadequate intraoperative fluoroscopic assessment may be an important factor contributing to these complications. We have described a step-by-step intraoperative fluoroscopic setup, including the proposal of a plate and screw view, focusing on the accuracy of reduction and proper placement of the PHILOS plate to prevent the complications previously described.

Proximal humeral fractures are the third most common fracture following hip and distal radius fractures in patients older than 65 years.1, 2 A majority of these fractures are either nondisplaced or minimally displaced and can be treated conservatively. Surgical fixation is usually indicated for displaced fractures.3, 4 Recently, an angular stable locking plate has been developed to assist with anatomic reduction and stronger anchorage. The Proximal Humeral Internal Locking System (PHILOS; Synthes, Zuchwil, Switzerland) is widely used as it provides a well-fitted precontoured shape and stable locking system, particularly for osteoporotic bone. Various articles have reported good functional outcomes after fixation using the PHILOS plate.5, 6 Nevertheless, many complications have been reported as well with the use of the PHILOS plate, such as varus malalignment, excessive retroversion of the articular part of the humerus, penetration of screws, and avascular necrosis of the humeral head.7 Surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures is usually difficult as it often involves the fixation of comminuted fractures in osteoporotic bone. The shoulder joint consists of complex anatomy that connects the upper extremity to the trunk. The thoracic cage obscures some part of the shoulder joint. We retrospectively reviewed cases that had postoperative complications and hypothesized that inadequate intraoperative fluoroscopic imaging may have been a factor contributing to these complications. To our knowledge, there is limited scientific evidence in the literature regarding fluoroscopic technique for ORIF of proximal humeral fractures. With an increasing incidence of proximal humeral fractures in the aging population, good understanding and proper use of the fluoroscopic techniques for ORIF of the proximal humeral fractures using PHILOS plate should be of great benefit. We have described a step-by-step intraoperative fluoroscopic setup, including the proposal of plate and screw views focusing on the accuracy of reduction and proper placement of the PHILOS plate to prevent complications that are related to inadequate intraoperative fluoroscopic assessment. These complications include varus malalignment, excessive retroversion, and screw penetration.

The Fluoroscopic Technique

Under general anesthesia, the patient is placed in the beach chair position (at 60°) with the entire limb prepped for free mobilization. The C-arm could be addressed in 2 positions, with the first position being from the contralateral side (Fig 1A) and the second position being over the head and parallel to the operating table (Fig 1B). Intraoperatively, we prefer to mobilize the patient's limb rather than reposition the C-arm for an adequate assessment (Video 1). Regarding basic anatomy, the articular surface of the humerus is retroverted approximately 20° to 30° relative to the humeral shaft (Fig 2A). Most surgeons acknowledge that the PHILOS plate has been designed for placement lateral to the bicipital groove. More importantly, the PHILOS plate must be placed opposite to the articular surface, which will allow the divergent locking screws to achieve maximum purchase at the humeral head (Fig 2B). The anteroposterior and lateral imaging views of the reduced fracture obtained intraoperatively should be in reference to the plate position, not according to the limb position as might be misconstrued.

What is the position of the c-arm relative to the patient when imaging the humerus

C-arm position. From the contralateral side (A), from over the head and parallel to the operating table (B).

What is the position of the c-arm relative to the patient when imaging the humerus

The articular surface of the humerus is retroverted approximately 20°-30° relative to the humeral shaft (A). The proper position of the PHILOS plate should be opposite to the articular surface that allows the divergent locking screws to achieve the maximum purchase at the humeral head (B). (B, long head biceps tendon; G, glenoid; GT, greater tuberosity; H, humeral head; LT, lesser tuberosity; PHILOS, Proximal Humeral Internal Locking System [Synthes].)

Screw View

In this view, the arm is positioned in 20° to 30° of external rotation (Fig 3A). This allows the articular surface of the humerus to be fully engaged in the glenoid fossa and corresponds with a retroversion of 20° to 30° in relation to the humeral shaft. As the name proposes, this view shows the maximum length of the inserted screws and only the edge of the PHILOS plate can be seen (Video 1). Two major pitfalls can be assessed and addressed in this view. First of all, the humeral head–shaft angle can be assessed to prevent varus malalignment (Fig 4A). Second, the appropriate level of the PHILOS plate placement can be assessed, which ideally should be 5 to 8 mm below the tip of the greater tuberosity to avoid secondary impingement (Fig 4B).

What is the position of the c-arm relative to the patient when imaging the humerus

Screw view: The arm is positioned at 20°-30° of external rotation. This view shows the maximum length of the inserted screws, and only the edge of the PHILOS plate can be seen (A). Plate view: The arm is internally rotated until the forearm is parallel to the coronal plane of the body. This view shows the full profile of the PHILOS plate, and only the distal portion of the locking screws spreading to the periphery can be seen (B). (B, long head biceps tendon; G, glenoid; GT, greater tuberosity; H, humeral head; LT, lesser tuberosity; PHILOS, Proximal Humeral Internal Locking System [Synthes].)

What is the position of the c-arm relative to the patient when imaging the humerus

Screw view: The humeral head–shaft angle (A). The appropriate level of the PHILOS plate placement is seen, which ideally should be 5-8 mm below the tip of the greater tuberosity (B). (PHILOS, Proximal Humeral Internal Locking System [Synthes].)

Plate View

In this view, the arm is internally rotated until the forearm is parallel to the coronal plane of the body (Fig 3B). As the name states, this view shows the full profile of the PHILOS plate. The PHILOS plate should be positioned opposite to the articular surface, at the center and over the humeral head and the shaft. The articular surface appears as a light bulb that is centered and over the PHILOS plate (Fig 5). Only the distal portion of the screws spreading to the periphery can be seen (Fig 5). However, if the classic light bulb is not seen in the appropriate position after placing the PHILOS plate lateral to the bicipital groove, malrotation of the humeral head should be suspected especially if excessive retroversion is seen. This should be of particular interest given that excessive retroversion often leads to 3-part fractures as a result of pull-out of the subscapularis tendon (Fig 6). When this malrotation occurs, there is risk of screw penetration.

What is the position of the c-arm relative to the patient when imaging the humerus

Plate view: This view shows the full profile of the PHILOS plate (A). The articular surface appears as a light bulb centered and over the plate (B). (PHILOS, Proximal Humeral Internal Locking System [Synthes].)

What is the position of the c-arm relative to the patient when imaging the humerus

The case where screw penetration could not be detected intraoperatively is shown. A postoperative radiograph of right shoulder, AP view, revealed acceptable head-shaft angle but screw penetration was seen (A). The light bulb location is not centered and over the plate (B), therefore excessive retroversion should be suspected. Incorrect plate placement was observed with screw penetration anteriorly. (AP, anteroposterior.)

The crucial steps of the fluoroscopic technique for ORIF proximal humeral fracture using the PHILOS plate is presented in Table 1. Summaries of the plate and screw views, their advantages/disadvantages, and pearls/pitfalls are presented in Table 2, Table 3, and 4, respectively. The rehabilitation protocol following ORIF of proximal humeral fracture using the PHILOS plate is presented in Table 5.

Table 1

Crucial Steps of the Fluoroscopic Technique for ORIF of Proximal Humeral Fracture Using the PHILOS Plate

Patient position
 Beach chair position (at 60°) with entire limb prepped for free mobilization. The original beach chair provides better fluoroscopic image of the shoulder region as it lacks back support.
C-arm position
 Contralateral side or
 Over the head and parallel to the operating table
 Ipsilateral side: obstructs assessment of the surgical field
Techniques
 Mobilize the patient's limb rather than repositioning the C-arm
 Use the technique of plate and screw views in reference to the position of the plate, not the patient's position

Table 2

Summary of Plate and Screw Views

Screw view
 Shows the maximum length of the screws being inserted
 Articular surface of the humerus is fully engaged to the glenoid fossa
 Arm position externally rotated 20°-30°
 Only the edge of the PHILOS plate can be seen
 Assessment of the head-shaft angle and proper level of the PHILOS plate
Plate view
 Shows the full profile of the PHILOS plate
 Articular surface of the humerus overlaps with the PHILOS plate and appears as a light bulb centered and over the plate
 Arm position is internally rotated until the forearm is parallel to the coronal plane of the body
 Only the distal portion of the screws spreading to periphery can be seen
 Assessment of malrotation and screw penetration particularly if there is incorrect placement of the PHILOS plate

Table 3

The Advantages and Disadvantages

Advantages
 Beach chair position allows better fluoroscopic image.
 The plate and screw views are 2 orthogonal views that provide adequate details of fixation.
 Forearm reposition for different fluoroscopic views is easier
Disadvantages
 Supine position makes it difficult for fluoroscopic assessment.
 Two orthogonal views in reference to patient's position provide inadequate details of fixation.
 Reposition of the C-arm for different fluoroscopic views is difficult and takes more time.

Table 4

Pearls and Pitfalls of the Fluoroscopic Technique Using Plate and Screw Views

Pearls
 • The use of an original beach chair provides better fluoroscopic image intensification of the shoulder region as it lacks back support
 • The intraoperative fluoroscopic images taken should be referenced from the position of the PHILOS plate rather than the position of the patient
 • The C-arm should be positioned contralateral to the surgical field or over the head of the operating table parallel to the patient to assess the surgical field more efficiently
 • The screw view detects malalignment of the reduction (particularly varus)
 • The plate view detects screw penetration, especially when there is excessive retroversion of the humeral head
 • Forearm repositioning without disruption of the C-arm position for different fluoroscopic views results in quick assessment
Pitfalls
 • The use of a standard operating table set up in beach chair position may not provide adequate fluoroscopic image of the shoulder region as usually there are still radiopaque side bars present
 • Imaging of the anteroposterior and lateral views that is referenced from the position of the patient rather than the position of the PHILOS plate can result in undetected complications such as screw penetration or malalignment
 • The C-arm positioned ipsilateral to the surgical field obstructs assessment the surgical field
 • Repositioning of the C-arm for different fluoroscopic views results in a prolonged operation time

Table 5

Rehabilitation Protocol Following ORIF of Proximal Humeral Fracture Using PHILOS

1. Arm sling for 4-6 weeks
2. Passive ROM exercise is allowed 48-72 hours postoperation
3. Active assisted ROM exercise is allowed 3-4 weeks postoperation

Discussion

When an unstable displaced proximal humeral fracture is encountered, an angular stable locking plate, known as the PHILOS plate, is a widely preferred implant. It allows stable fixation of the fracture, particularly in osteoporotic bone. Various articles have reported successful outcomes using this angular stable device. Nevertheless, Sudkamp et al.8 reported a relatively high complication rate of 34% in a prospective, multicenter, observational study. These complications included screw penetration, malreduction, loss of reduction, and avascular necrosis. The greater number of complications were associated with incorrect surgical technique, with 40% of complications already presented at the end of the procedure.9

Therefore, this indicates that correct surgical technique as well as an adequate intraoperative fluoroscopic assessment will lead to stable fixation and allow the surgeon to avoid these particular complications. This article describes a step-by-step fluoroscopic technique for ORIF of proximal humeral fracture, including the use of plate and screw views. It focuses on the accuracy of reduction and the precise placement of the PHILOS plate, which has rarely been mentioned in the existing literature. This technique is of great value to achieve successful outcomes.

Footnotes

The authors report that they have no conflicts of interest in the authorship and publication of this article.

Supplementary Data

Video 1:

Clip showing the fluoroscopic technique of an unstable displaced 3-part proximal humeral fracture of the left shoulder in a 70-year-old woman who underwent ORIF using the PHILOS plate. This video presentation describes how to use fluoroscopy for ORIF of the proximal humeral fracture using a PHILOS plate in beach chair position. The patient was administered general anesthesia and placed in the beach chair position at 60°. The C-arm can be approached in 2 ways, from the contralateral side or from over the head and parallel to the operating table. As we know, the humeral articular surface is retroverted 20°-30° relative to the humeral shaft. The PHILOS plate has been designed to be placed just lateral to the bicipital groove, which actually is the location opposite to the articular surface. So, the AP and lateral views of the plate should be obtained in the intraoperative fluoroscopic assessment. This is done by forearm manipulation rather than C-arm repositioning. After reduction, temporary fixation, and plate placement, a C-arm is used to check the reduction and correct the plate position. The 2 orthogonal fluoroscopic views including AP and lateral view of the plate will be referred to as the Screw and Plate views, respectively. Screw view: It is known that normal humeral head is in 20°-30° retroversion. Therefore, in case of correct rotational alignment, the arm position should externally rotate approximately 20°-30° in Screw view. This view is used to assess the humeral head-shaft angle to prevent varus mal-alignment. In addition, this view is used to evaluate the level of plate position to prevent subacromial impingement. The appropriate level should be below the tip of the greater tuberosity about 5-8 mm. Plate view: In case of correct rotational alignment, in Plate view, the arm position should internally rotate until the forearm is parallel to the body plane. The plate position should be at the center of the humeral head, implying that the plate is directly opposite to the articular surface. Moreover, the plate should be parallel to the humeral shaft. The humeral head should demonstrate light bulb appearance.

An example radiograph shows excessive retroversion of the humeral head after reduction as assessed on a plate view. The plate appears en face but the humeral head does not show a light bulb appearance. After achieving correct reduction and plate position, all additional locking head screws can be inserted in the humeral head and shaft fragments. (AP, anteroposterior; ORIF, open reduction and internal fixation; PHILOS, Proximal Humeral Internal Locking System [Synthes].)

References

1. Palvanen M., Kannus P., Niemi S., Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92. [PubMed] [Google Scholar]

2. Bergdahl C., Ekholm C., Wennergren D., Nilsson F., Moller M. Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: Data from the Swedish Fracture Register. BMC Musculoskelet Disord. 2016;17:159. [PMC free article] [PubMed] [Google Scholar]

3. Murray I.R., Amin A.K., White T.O., Robinson C.M. Proximal humeral fractures: Current concepts in classification, treatment and outcomes. J Bone Joint Surg Br. 2011;93:1–11. [PubMed] [Google Scholar]

4. Jawa A., Burnikel D. Treatment of proximal humeral fractures: A critical analysis review. JBJS Rev. 2016;4 [PubMed] [Google Scholar]

5. Geiger E.V., Maier M., Kelm A., Wutzler S., Seebach C., Marzi I. Functional outcome and complications following PHILOS plate fixation in proximal humeral fractures. Acta Orthop Traumatol Turc. 2010;44:1–6. [PubMed] [Google Scholar]

6. Aksu N., Gogus A., Kara A.N., Isiklar Z.U. Complications encountered in proximal humerus fractures treated with locking plate fixation. Acta Orthop Traumatol Turc. 2010;44:89–96. [PubMed] [Google Scholar]

7. Clavert P., Adam P., Bevort A., Bonnomet F., Kempf J.F. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg. 2010;19:489–494. [PubMed] [Google Scholar]

8. Sudkamp N., Bayer J., Hepp P. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91:1320–1328. [PubMed] [Google Scholar]

9. Miyazaki A.N., Estelles J.R., Fregoneze M. Evaluation of the complications of surgical treatment of fractures of the proximal extremity of the humerus using a locking plate. Rev Bras Ortop. 2012;47:568–574. [PMC free article] [PubMed] [Google Scholar]


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