The Axillary View Typically Does Not Contribute to Decision Making in Care for Proximal Humeral Fractures

HSS Journal Online First Article

Marschall B. Berkes, MD
Landstuhl Regional Medical Center, Landstuhl, Germany

Jacqueline F. Birnbaum, BA
Hospital for Special Surgery, New York, NY

Lionel E. Lazaro, MD
Hospital for Special Surgery, New York, NY

Milton T. M. Little, MD
Hospital for Special Surgery, New York, NY

Joseph T. Nguyen, MPH
Hospital for Special Surgery, New York, NY

Joshua S. Dines, MD
Joshua S. Dines, MD

Associate Attending Sports Medicine and Shoulder Service, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

Dean G. Lorich, MD
Dean G. Lorich, MD
Associate Director of Orthopaedic Trauma Service, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

Abstract

Background
Convention dictates that an axillary view be obtained when evaluating proximal humerus fractures (PHF). However, the axillary view is frequently omitted because of pain and technical considerations. Furthermore, its diagnostic utility is unclear in this setting.

Questions/Purposes
The purpose of this study was to (1) determine the rate of obtaining an adequate axillary X-ray and complete shoulder series at a level I trauma center, (2) understand the cost of ordering and attempting an axillary radiograph, and (3) determine if axillary radiographs influence the management of PHF.

Patients and Methods
PHF treated between 2009 and 2011 that were ordered for an AP, scapular Y, and axillary view was identified. The types of radiographs actually obtained were recorded. The cost of obtaining three views and a single view of the shoulder with X-ray was determined. Lastly, three surgeons reviewed 42 PHF, both with and without an axillary view (AV), and treatment recommendations were compared.

Results
30% of PHF in this series had an adequate axillary view, and 14% received a complete trauma series. No factors could be identified that were associated with successfully obtaining an axillary view. Reviewers demonstrated substantial intraobserver reliability (κ = 0.759–0.808) regarding treatment recommendations for PHF with and without the axillary view. The addition of the AV had minimal influence on treatment recommendations.

Conclusion
Considering that the axillary view for PHF is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value, orthopedic surgeons can consider foregoing the use of the axillary view when evaluating and treating PHF, particularly if other advanced imaging is utilized.

This Online First article was published on SpringerLink in June 2015.
View the full HSS Journal article at springerlink.com.

About the HSS Journal

HSS Journal, an academic peer-reviewed journal published three times a year, February, July and October. The Journal accepts and publishes peer reviewed articles from around the world that contribute to the advancement of the knowledge of musculoskeletal diseases and disorders.

 

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