Intraoperative Imaging in Proximal Humerus Fractures

Ladies and gentlemen, dear colleagues, I would like to extend a warm welcome to everybody at the screen today. We're talking about intraoperative imaging in treatment of proximal humerus fractures. What can you expect from our talk? We will start with the standard projections. We will explain you the radiological anatomical landmarks in these projections and then we will show you how you can perform these standard projections in two different patient positions, first in supine position and after that in beach chair position. I would like to introduce the faculty to you. This is my colleague Eric Mandelker. Mine. My name is John Franco. We are trauma surgeons at the big trauma center in Ludwigshafen, Germany. And now I want to explain. The radiological. Anatomical landmarks with this symbol model to you. In this so-called AP view you can see the humeral head. You can see the greater tubercle you will see later. And the image the lesser tubercle 2 you will see the intertubercular crove where the biceps tendon is located. We have the so-called anatomical net neck and we have the so-called surgical neck. This is the lateral line and this is the medial line. In the lateral or axial view, you can see the humeral head as well you have. The greater tubercle. The lesser. Tubercle. The intertubercular crove. This is the anatomical neck, the surgical neck. This is the anterior line and this is the posterior line. Now we move over to the specimen and we will perform these two D standard views and try. To find these anatomical landmarks in the images. We start with the patient in supine position. The advantage of this position is that you don't have to move the arm for the two standard projections, you move the C arm. We will show it to you. This is an advantage if you have an unstable situation. During your procedure while treating an approximate humerus fracture. As I said, supine position of the patient. The C arm comes from the head of the patient. I recommend 90 degrees abduction in the shoulder, 90 degrees flexion in the elbow. The hand points toward the ceiling. And then X-ray, please. This is a good AP view. What you can see here. Is. The humeral head. The creator tubercle. This is the lesser tubercle this is. The Intertubercular crove, lateral line and medial line and we have and this is one of the criterias for good image we have. A minimum of overlap. Between the glenoid and the humeral head. OK. What I want to show you now is how to move the C arm to get a good lateral or axial fuel. Please move the C arm. And as you can see now you don't have to move the arm, it's always in the same position. And then one shot, please. This is a good axial view. You see a minimal overlap between the glenoid and the humoral head. This is the humoral head. This is the. Crater. Tubercle. This is the lesser tubercle. This is the anterior line. This is the posture line. Surgical neck, anatomical neck. Now we will place the patient in a beach chair position and explain to you how the two views are made in this position and what is the advantage of beach chair or the disadvantage of beach chair. In contrast to supine position, the advantage of beach share position is that gravity can help you to reduce the fracture. As you can see here, the disadvantage is you have to move the arm to achieve. Your standard projections. Again the CM comes from the head of the patient and then you need a forward tilt or rotation. Orbital rotation of about 25 to 30 degrees and due to the fact that the glenoid. Is in the 3D space now with an angulation of 20 degrees or if the shoulder is hanging down on the deck that like that maybe 15 to 10 degrees. You should tilt the C arm so that you have later a minimal overlap between the glenoid and the humeral head. We prepared this for you. One feature of the CMS is that you can store positions. And. Press a button and then the store precision will be reached by itself. So you see this is the orbital rotation and then. This is. The angulation of the C arm. So I take the arm and for an A view. Parallel to the detector. And um. The hand is in neutral position or the forearm. Image. Now you see, it's very easy. To achieve. This. AP view. We have a minimal overlap of the glenoid and the humeral head. We have a good insight into the joint space. This is the creator to burkel, this is the lesser tubercle. This. Is the intertubercular groove where the byte substation is located. This is. The anatomical neck, surgical neck, medial line, lateral line. Now I will show you how you can achieve a good lateral view. Again you start with the same position. The Army's power level to the proximal humerus is parallel to the detector, and then you rotate. 90 degrees image please. One more. One more, please. Fluoro. Stop. And this is a good axial or lateral view? You have. Your. When we're ahead. You have a minimal overlap between the glenoid and the humeral head. This is the crater. To Berkel, this is the lesser tubercle. This is the anterior line and this is the posterior line. And in all these views you have a good insight between the acromion and the humeral head. Now we learned how to achieve the two standard projections in supine position and beach chair position, AP and lateral or axial, but I want to add. One very important thing, if we're talking about the treatment of proximal humerus fractures, we fixed these fractures after reduction. With a plate or with a nail, if we fix it, we have to bring in screws into the humeral head or bolts for fixation of the nail. And if you place several screws, for example at the humeral head. The highest complication rate that we have is an intra articular joint misplacement or joint penetration. And in a lot of cases you cannot detect this penetration with a 2 standard fuse wire. The humeral head has a convex. Totally convex joint surface. And if I place a screw that comes out for example here for 2 millimeters. And I have my AP view. The screw is covered by the humeral head, and it seems to me that the screw is inside the bone, not outside. And if I make a lateral view, the same problem again. I think the screws in the bone, but it's not in the bones in the joint, the screw tip, and therefore if we're talking about. Humor fractures. I recommend at the end of your procedure do a dynamic fluoroscopy, or maybe pulse if you want. I do it with dynamic fluoroscopy. And check every tip of your screw, or every tip of of the screws so that you can be pretty sure that you don't have a screw penetration into the joint. Now we come to the end of our presentation. I want to summarize the take home messages for you. What have we learned at the proximal humerus? We have two standard projections. It's the AP view or the axial or so-called letter view. We have different landmarks that we can assess in these views and we have in general two positions of the patient to achieve these fuse. It is the so-called beach chair position and some minutes ago we saw the supine position. The advantage of the beach position is that gravity can help you to reduce the fracture. The disadvantage is you have to move the arm for the two standard. Projections. The advantage of the supine position is that you don't have. To move the arm. The disadvantages. Gravity cannot help you and the range of movement is more limited than in the beach chair position. And. One very important point. Always think about or remember that you have to check. Due to the convex joint surface of the proximal humerus, you have to check the tip of your screws or your implants so that you can be sure that you don't have an intra articular implant misplacement. Thank you very much for your attention.

06 Intraoperative imaging in proximal humerus fractures With the 2D/3D C-arm Cios Spin PD Dr. med. Jochen Franke BGU clinic, Ludwigshafen, Germany SIEMENS 2D imaging in supine in supine position 3D 2D imaging in the beach chair position Take-home messages Please note that the learning material is for training purposes only. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively "Operator Manual") issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Please note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively "Functionality') may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Siemens Healthcare GmbH 2022 Healthineers