60 yrs healthy male
sustained
RTA
Confused what to do
Kindly shower ur opinion
sustained
RTA
Confused what to do
Kindly shower ur opinion
Jagan Mohan Open reduction and fixation. Biceps tendon may impede the reduction . Sometimes it becomes necessary to cut the long head and do a tenodesis distally
Sarathkanth Gudipati make note of neurovascular status, do immediate ORIF through extended deltopectoral approach, cuff repair maybe required and yes biceps tendon is a problem.
- Sarathkanth Gudipati from the X ray it looks like a 3 part # ,max it can be a 4 part ,whatever it is u have to go and do same procedure.
- Sarathkanth Gudipati 3D CT not available in many places kareem thats why its better to expect a 4 part fracture and get ur philos plate, cortical screws and no.2 ethibond ready. wat do u say
Manoharan Muthulingam What ever the proximal humerus plate please hold the rotators with ethibond sutures and tie over the plate.
U should achieve medial cortical contact, valgus reduction.
- Sarathkanth Gudipati i 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 Almarwanya Thank 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.
Abdulmajeed Hail I did three cases looks like same. Better to start open fixation with plat and screws as it is then do a shoulder reduction
Tushar Mankad Dr 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.
- Baskar Chockalingam Feel soo good when getting immense very useful suggestions like from drabdulla n dr tushore
- Sanjay Joseph I 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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