Imaging of patients with suspected proximal humeral fractures should include anteroposterior (AP), scapular Y, and axillary projections. The last may be difficult for some patients. Therefore, a transthoracic radiograph provides a lateral view and is excellent for evaluation of humeral head rotation (see Fig. 9-5). CT with coronal and sagittal reformatting or three-dimensional reconstruction is optimal for evaluating fragment displacement and angulation (see Fig. 9-6). Three-dimensional reconstructions may also improve the consistency for classification.

Treatment of proximal humeral fractures is based on the fracture classification, patient age, comorbidities, activity, and bone quality. Treatment options include closed reduction, open reduction and internal fixation, and arthroplasty. Hemiarthroplasty is usually performed unless there is significant glenoid articular disease.

One- and two-part fractures (Fig. 9-6) may be treated conservatively with closed reduction. Greater tuberosity fractures displaced 5 mm or more should be internally fixed to avoid loss of function and axillary nerve injury. Lesser tuberosity fractures tend to displace medially, but can usually be treated with closed reduction.

Three- and four-part fractures (Fig. 9-5) are more complex. In elderly patients with significant comorbidities, fractures may be treated with closed reduction. Significant loss of motion is
common. Valgus-impacted head fragments are at less risk for avascular necrosis so results may be satisfactory with closed reduction. Open reduction may be accomplished with plate and screw fixation (see Fig. 9-7), intramedullary nails (see Fig. 9-8), or tension band constructs (see Fig. 9-9). Hemiarthroplasty is also an option. This approach is commonly performed on elderly patients with osteoporotic bone because internal fixation is more complex in this setting (see Fig. 9-10).

Complications following repair of proximal humeral fractures may be related to the initial injury or surgical approaches. Proximal humeral fractures are associated with neurovascular injuries in 21% to 36% of cases. The axillary nerve is most frequently injured and this may result in permanent motor dysfunction. Nerve injury is most common following anterior fracture dislocations. Most vascular injuries (84%) occur in elderly patients and more than half are associated with brachial plexus injuries. Diagnosis may be accomplished clinically (loss of sensation over the lateral deltoid with axillary nerve injury) or magnetic resonance imaging (MRI). Vascular injuries can be clarified with angiography because magnetic resonance (MR) angiography can be difficult following acute trauma. The rotator cuff and biceps are typically involved. Interposition

of the biceps tendon between tuberosity fragments will prevent healing. Rotator cuff disruptions and tendon interposition can be evaluated with CT, MRI, or conventional arthrograms (see Fig. 9-11).

Arthrosis and loss of range of motion occur with both closed and open treatment approaches (see Fig. 9-12). Adhesive capsulitis is also fairly common following proximal humeral fractures. This may be difficult to detect unless conventional arthrography is performed and the actual capsular volume measured. Mild to moderate (5 to 10 mL) capsulitis may respond to distention arthrography.

Avascular necrosis occurs in up to 14% of three-part fractures treated with closed reduction and the incidence is higher with four-part fractures. Imaging may be hindered with internal fixation devices. However, aggressive approaches in treatment approaches for three- and four-part fractures (internal fixation or hemiarthroplasty) reduce the need to image patients following treatment. Patients treated with closed reduction or minimal internal fixation hardware can be evaluated with MRI.

Implant failure, malunion, and nonunion may be evident on serial radiographs (see Fig. 9-13). Evaluation of nonunion is most easily accomplished with CT with reformatting in the coronal and sagittal planes in the presence of orthopaedic hardware. In patients treated with closed reduction, MRI may also be helpful. The fracture margins will have low signal
intensity with high signal intensity between the fragments on T2-weighted sequences.

Imaging of patients with suspected clavicular injuries should include AP and angled AP (15 degrees normally or 40 degrees cephalad for subtle injuries) projections to include the entire clavicle and acromioclavicular and sternoclavicular articulations (see Fig. 9-15). The mid and distal aspects of the clavicle are easily evaluated on these views. The medial clavicle and its articulation are more difficult to visualize due to bony overlap. Although there are several techniques that can be used to better visualize the medial clavicle, CT is most often performed to better define this region (see Fig. 9-16).

Stress views can be performed on patients with suspected ligament injury and acromioclavicular separation. However, this approach is usually reserved for stable injuries to avoid further displacement of the clavicle fracture.

Conservative treatment is most often employed for treatment of clavicle fractures, specifically medial and mid-clavicle fractures. A sling or figure-of-eight brace is typically used for approximately 6 weeks with early shoulder, elbow, and hand range of motion exercises when tolerated by the patient.

Operative intervention is considered for cosmetic deformity, shortening of mid clavicle fractures >2 cm, and distal fractures. The incidence of nonunion is highest with shortening and displaced distal clavicular fractures (see Fig. 9-17). Treatment of distal third fractures has been controversial. Group II type II fractures are at the level of the coracoclavicular ligaments. Type IIA fractures are proximal to the ligaments and the ligaments remain intact. Type IIB injuries have significant displacement of the fracture fragments due to the loss of downward restraint of the coracoclavicular ligaments (see Fig. 9-18). Excellent surgical results have been reported with intramedullary pin or wire fixation and ligament repair. Plate and screw fixation is also an option (see Figs. 9-19 and 9-20).

Complications may be related to the type of injury or treatment. In the past, the incidence of malunion and nonunion was considered to be insignificant. However, in recent years nonunion in displaced midshaft fractures has been reported to be 15% with unsatisfactory patient outcomes in up to 32% of cases. Distal third fractures are less frequent compared to midshaft fractures, but they account for half of nonunions. Imaging of nonunion can be accomplished with serial radiographs (Fig. 9-19). However, if callus and healing potential need to be better defined it is best to evaluate the fracture with CT with reformatted images in the appropriate image planes. The incidence of nonunion in displaced midshaft and distal clavicle fractures can be reduced significantly (2.2%) with operative intervention. Surgical treatment is not without complications. Migration of wires and pins has been described. Hardware removal for pain and irritation may also be necessary in up to 8% of patients. Other complications related to operative intervention include wound infection (4.8%) and transient brachial plexus neuropathy (13%). Other reported complications regardless of treatment include complex regional pain syndrome and thoracic outlet syndrome. The latter may require conventional or MR angiography for diagnosis.

Instability or residual symptoms in the acromioclavicular joint can be evaluated with stress views once the fracture is considered healed clinically.

AP, lateral or scapular Y and axillary views should be obtained. The latter two projections may provide the only clear images of the coracoid and acromion (see Fig. 9-30). The most difficult problem is defining the complexity of the injury to the body and neck of the scapula and, more importantly, the articular involvement. This is difficult to assess on radiographs. When there is a question about the extent of injury, CT with reformatting or three-dimensional reconstruction should be obtained (see Fig. 9-31).

Most scapular fractures can be treated with closed reduction. This is due to the extensive muscle support about the scapula that reduces displacement. Most fractures treated with closed reduction (90%) heal within 6 to 8 weeks. Shoulder motion should be initiated as soon as possible.

Glenoid articular fractures can be internally fixed with screws, K-wires, or reconstruction plates and screws. Similar fixation devices can be used for glenoid neck, scapular spine, and coracoid fractures.