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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.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.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.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.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.

To compare radiographic and clinical outcomes of supination external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B2.1) treated with transsyndesmotic screw fixation with those treated with deltoid and posterior inferior tibiofibular ligament (PITFL) repair.Case series and single-surgeon retrospective analysis of a prospective database.Academic level I trauma center.Forty-five SER IV E ankle fractures fulfilled all inclusion/exclusion criteria with at least 12 months of radiographic follow-up.Deltoid and PITFL repair in addition to lateral malleolus fixation compared with transsyndesmotic screw fixation.Syndesmotic reduction compared with contralateral extremity on a postoperative computed tomography scan and maintenance of reduction based on final postoperative radiographs [medial clear space (MCS) and tibiofibular clear space (TCS)].There was no significant difference in mean postoperative TCS, MCS, or change in TCS or MCS between the cohorts. The anatomic treatment group had significantly better postoperative syndesmotic reduction compared with the transsyndesmotic cohort (7.4% vs. 33.3%; P = 0.02). Fourteen patients in the transsyndesmotic screw cohort underwent removal compared with 3 patients in the anatomic cohort who required secondary procedures. The transsyndesmotic screw cohort had statistically significant better mean dorsiflexion of ankle (mean 20 vs. 17 degrees; P = 0.02).This comparison of treatment strategies for SER IV E ankle fractures has shown an improvement in immediate postoperative syndesmotic reduction and the elimination of reoperation for removal of transsyndesmotic screws in patients treated with PITFL repair. Previous research has shown a good correlation between functional outcomes and syndesmotic reduction; however, further investigation into the functional outcomes of these patients is necessary to determine the future clinical impact of this anatomic fixation strategy.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The hyperplantarflexion variant ankle fracture is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. This infrequently reported injury pattern often includes an associated “spur sign” or double cortical density at the inferomedial tibial metaphysis. The objective of this study was to quantitatively establish the association of the ankle fracture spur sign with the hyperplantarflexion variant ankle fracture. Methods: Our clinical database of operative ankle fractures was retrospectively reviewed for the incidence of hyperplantarflexion variant and nonvariant ankle fractures as determined by assessment of injury radiographs, preoperative advanced imaging, and intraoperative observation. Injury radiographs were then evaluated for the presence of the spur sign, and association between the spur sign and variant fractures was analyzed. Results: The incidence of the hyperplantarflexion variant fracture among all ankle fractures was 6.7% (43/640). The spur sign was present in 79% (34/43) of variant fractures and absent in all nonvariant fractures, conferring a specificity of 100% in identifying variant fractures. Positive predictive value and negative predictive value were 100% and 99%, respectively. Conclusion: The ankle fracture spur sign was pathognomonic for the hyperplantarflexion variant ankle fracture. It is important to identify variant fractures preoperatively as patient positioning, operative approach, and fixation construct of variant fractures often differ from those employed for osteosynthesis of nonvariant fractures. Identification of the spur sign should prompt acquisition of advanced imaging to formulate an appropriate operative plan to address the variant fracture pattern. Level of Evidence: Level III, retrospective comparative study.