Validation of a Novel Radiographic View for Evaluating Proximal Humerus Fractures: The Clear View

Abstract

Background: Orthogonal radiographs of the proximal humerus are challenging to obtain because the patient's body mass can impede a quality lateral view and positioning of the shoulder can cause fracture displacement and patient discomfort. We describe a novel radiograph, the Clear View, taken 90 degrees to the scapular Y (SY), developed with the goal to minimize pain and reduce radiation exposure. We evaluate the ability to accurately assess proximal humerus fracture displacement utilizing the Clear View in comparison to the standard available x-rays and assess pain score when obtaining the Clear View.Methods: Eleven independent observers at different levels of experience evaluated angulation and translation of three proximal humerus fractures: two cadaveric fractures and a third fracture in a 15-year-old to determine intraobserver correlation (ICC). Each fracture underwent the traditional radiographic series of anteroposterior (AP) in internal rotation (IR), AP in external rotation (ER), true axillary lateral (AX), SY, and transthoracic lateral (TRANS) plus computed tomography (CT). The Clear View was obtained on the two cadaver fractures. Pain scores based on the Wong-Baker FACES Pain Scale were assessed for individual radiographic projections in 13 patients with proximal humerus fractures.Results: ICC was >0.6 for all measures. True fracture angulation was underestimated a majority (>75%) of the time in all radiographic views; TRANS (p<0.001) and AX (p<0.049) views had the least amount of error. Moreover, measures of translation were both underestimated and overestimated in all views, but the most accurate measures of translation were obtained with IR, ER, and Clear Views. Pain scores ranged from 0-1.2 when the Clear View was obtained.Conclusions: Our study demonstrates that proximal humerus fracture angulation is often underestimated, and translation is difficult to measure regardless of view utilized. However, the Clear View, when combined with the AP view, offers an orthogonal, reproducible, valid measure of fracture translation and causes minimal patient discomfort.Level of Evidence: Level II, prospective cohort study Key Concepts•Proximal humerus fracture angulation is often underestimated, and translation is difficult to measure regardless of view utilized.•The newly described Clear View offers a reproducible, valid measure of fracture translation.•The Clear View is associated with low patient discomfort.•The Clear View may also reduce radiation exposure compared to standard transthoracic lateral imaging techniques.•A combination of an AP and the Clear View is recommended as a reproducible and comfortable method to obtain orthogonal views with the ability to measure fracture angulation and translation.