Sarathkanth Gudipatii havent seen any recurrent dislocation of shoulder as a post op complication after such fractures which are fixed. dont think we need a bankart repair. instead cuff repair might be necessary.
DrAbdullrab AlmarwanyaThank you for presenting this case : This AP X-Ray films of a 60 y old ,male , patient (mostly of the right shoulder (dominance?)), shows fracture dislocation of the proximal humerus (3 part?? ), ,the glenoid appeared to be notched in its inferior aspect and there is diffuse thinning of the bones cortex (osteoporosis?) .This single view provide inadequate information about the fracture plane (can not accurately delineate the degree of displacement and rotation of the fracture fragments( the tuberosities and humeral head)),direction of dislocation ,state of rotator cuff and the congruity of the glenoid . For planning the management of such difficult case in a RTA victim after following the ATLS guide lines (ABCDE)and from the available information I would suggest :to ask about the time since the accident .Next: to Examine for any associated injury in cervical spine, elbow ,Neurovascular bundle , position and movement of the shoulder . Then to do a complete trauma series imaging (true AP,scapular Y, axillary).to determine the direction of dislocation (can alter the approach ) CT scan ,MRI, as indicated .
When we reach to a good evaluation of this complex injury through the above mentioned steps the decision making regarding the ideal treatment plan can be outlined .
But generally speaking in 3 part fracture dislocation Open reduction and internal fixation can be an option but Prosthetic replacement is indicated when secure fixation cannot be obtained, usually in elderly patients with osteoporotic bone (like in this patient).prosthetic replacement include : hemiarthroplasty (if there is rotator cuff compromise and the glenoid surface is intact and healthy) total shoulder arthroplasty when the rotator cuff is intact and the glenoid surface is compromised (arthritis, trauma) reverse shoulder arthroplasty in elderly individuals with nonreconstructible tuberosities. THANKS.
Tushar MankadDr Baskar You have posted a difficult case. Your’s truly has had the opportunity to operate upon such injuries- by now quite a few times. The comment made by Dr Abdullrub above merits attention. Now the other important points: Document neurovascular status preop especially Deltoid/Axillary Nerve. Explain that even if intact at present, postop deficit is possible. Make not a single attempt to reduce it closed-just not done-even under GA. For reducing the head use finger manipulation or blunt instruments like a spatula covered with mop. Be prepared to fix /reconstruct glenoid/Capsule:keep suture anchors ready-do it before head fixation if possible. Fix the head fragment in nearly anatomical position as possible. Use suture fixation (Ethibond No 5) for tuberosities in addition to implant on humeral side. Before final fixation make sure all major fragments are accounted for and secured with strong traction sutures. Take consent for and keep it ready: hemiarthroplasty, again fixing tuberosities properly, if you do a hemi. Use bicipital groove for deciding version. If this is a surgeon’s first such case, it is best to have a senior or someone who has done a case or two before. If you fix it, don’t bother about type of implant as long as you get good stable fixation. Do not hurry for mobilisation in postop period. Expect functional ranges at best. Long term physio will be needed. Best wishes.
Sanjay JosephI have done two cases of fracture dislocation just like this with ORIF. Always repair Bankart lesion, because without it, both were dislocating easily on table even before opening anterior shoulder restraints.
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