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Humeral Anatomical neck fracture dislocation

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Hi .......
nice case posted in orthopod- unfortunately my reply not going through orthopod- and hence this personal mail
 
this gentleman sustained the injury ( open humerus- wound posterior/ olecranon/ulnar styloid/fracture dislocation shoulder) the day gonu hit Oman.
I could not transfer him to the higher centre as transport was not available.
 
I fixed his humerus first- to get leverage for the arm for attempted closed reduction of the shoulder, through posterior approach. turned him over, and attempted closed reduction. the shaft came off leaving the anatomical head inside as in ur case. I was successful previously in 3 cases to bring the head into glenoid closed with help of 3 mm schanz pin, but failed miserably here. so did open reduction and fixed with the buttress plate available to me. we dont have LCP or PHILOS. the tuberosities were attached with sutures to the plate. Elbow fixed with tbw, and so also the ulnar styloid.
patient has abduction 90 degrees at last follow up.
 
See the CT scan which shows the fracture of the anatomical neck- just waiting to be separated.
 
hope this helps.
 
SS Suresh
Head of Orthopaedic Services
Ibri Regional Referral Hospital
Sultanate of Oman

                            

sugesst open reduction and internal fixation using PHILOS ( proximal
humerus locked plate )  Best of luck RABENA YWAFK
Dr. Hazem AbdelAzeem

Hi
there are two options , both through open reduction and internal fixation  either with K wires or  proximal Humeral plate simillar to DHS with a screws passing through the neck and part of the head  .this plate is available in Egypt and I did not see in Saudi Arabia.

 

M. Khairy
 

الدكتور الكريم العلاج معروف ايها الطيب  

ORIF

CRIF صعب بس ممكن تحاول   Waleed Hammad

Dr .......
Dear brother
I would reccomend a CT scan 1st for planning to make sure where the head is from the glenoid, it should be anterior but how far anterior , we need to know as this would be very helpful for planning of your approach & if U would need a vascular surgeon with U or not , or a neurosurgeon
after that anterior approch (extended deltopectoral) then reduction of the head to the glenoid then reduction of the shaft to the head then fixation by plate or K wires (I prefer locked plate)
immopilize for 3-4 weeks then start gradual movement
at the end U may get lucky with no AVN or with AVN but menimal symptoms
\ if things get worse in the future we will have the chance to make a descision between arthrodesis & arthroplasty
thanks
Prof Dr Khaled Emara
Ain Shams University

Dr ......., whats hapening to you guys, no body will advice for Prosthetic replacemnt as primary in 28yrs old man. He just need to operated on urgent basis, reduced and fixed. Prosthetic replacemnt should be considered as seconday solution. People get your finger out from their and do some work.
.................................................................
Rgards to all.
 

Dr. Sowyleh Al-Rehaili 
MSc (Ortho), FRCS
Consultant Orthopaedic & Trauma Surgeon
Sallam
 
U need to do a 3D CT Scan first
 
ORIF by PHILLOS Locked Plate (Reduction of the Dislocation, Temporary fixation by K-Wire, Application of the Plate) .
 
Very difficult, nice challenge  .... El Zaher Hasan

Thank You
 
Based on the age I do strongly think that Open reduction then Fixation with 2 0r 3 Retrograde K wire from the metaphysis to the head without  penetrating the articular surface , It will heal with a better outcome than any prosthesis in the short and long term  even if he does require a prothesis after many years to come .
Regards
Shenouda 
 

hi .......

 

this is not only fracture but it is fracture and dislocation.

first relocate and then fix.

i think giving chance for fixation is better since this pt is young..

the risk of AVN is high.

pls check the type of dislocation u need to do CT, check forassociated findings..

 thanks

Khalid A. Al-Ismail,MD

Musculoskeletal Radiologist. 

Consultant Radiologist.

KFSH&RC (King faisal specialist hospital). 

mobile +966505842332  

P O Box 85232 Riyadh 11691. Saudi Arabia

sallam
there is high incidence of avn, patient should be forwarned
only open reduction and the best device would be philos  locking plate (synthes)  through deltopectoral approach (may be aided by a comined small lateral deltoid splitting approach or in the worst situation use perc threaded pins
amm attaching a paper, may be of help, i have a lot of current lit on the issue if u want to discuss any aspect of this fracture
 
regards

Mahran
This is a very unusual injury , but since you have to do what you have to do .... i would do an anterior deltopect. ap. >>>>> get the reduction >>>>> secure the fixation with an antegrade biodegradable pins >>>> immobilize for 4 weeks and then start passive ROM exc.
 
Abdulla S.  Al Zahrani ,
Dammam Medical Complex 
Saudi Arabia

Put it back!

I have had 2 cases that were similar, one is now 5 years down the line and one 2 years or so. Open reduction (delto-pectoral approach) fish out the head (not always easy) and fix with two AO partially threaded cancellous screws with washers (cannulated would be easier). 
Neither of my patients has significant problems, both fractures healed, no appreciable Avascular Necrosis. ROM about 80% normal. And sorry, I don't have the pictures to show, lost in a hard drive crash...  :-(
AVN is not inevitable after displaced subcapital fractures of Hip or Shoulder.  I recall a review of Italian experience in Garden III and IV, and only about 30% ahd AVN if I remember.

 
Gobinder Singh
Kuala Lumpur

You will not be able to get this reduced closed. The humeral head button holes thru the capsule and then everything collapses preventing a closed reduction.

Even if you had a hemiarthroplasty available in a 28 yo you should attempt open reduction internal fixation.

Locking plate vs nonlocking cloverleaf plate - there is no science that shows any advantage to a locking plate. The science out there suggests that the mechanism of failure is just different.

Keys
- Identify all the fragments on the way in. Use the biceps tendon as a landmark to help determine what is lesser tuberosity and what is greater tuberosity.
- Place sutures (#1 vicryl) into the GT and LT on the way in to allow control of the fragments
- You may need to incise the rotator interval to get adequate exposure and access to the humeral head fragment
- Leave rotator cuff attached to GT and LT fragment
- Get the humeral head out of the axilla
- If you are having a hard time controlling the humeral head fragment use a K wire as a joystick
- Place drill holes in the shaft laterally and anteriorly and then use sutures thru the GT and LT to reconstruct the tuberosities much like with a hemiarthroplasty
- Use K wires to obtain a temporary reduction
- I personally would use a cloverleaf plate and contour it a little into valgus to get a more stable configuration. Your goal is to save the humeral head and reconstruct bone stock not to obtain an anatomic reduction. I think if you try to get an anatomic reduction there will be so much bone loss that it will inevitably collapse.

Hope this is helpful

Regards

Christian

closed reduction under image intencifer guided and multiple threaded k wires and shoulder immobilsation for 6 weeks.open reduction will cause stiffness .
dr.ponraj.
 

Open reduction and internal fixation after a CT know if its anterior or posterior dislocation

Warn the patient of high chances of avascular necrosis

 

DR C CHERIAN KOVOOR

KOCHI

INDIA

under general anaesthesia

OPEN REDUCTION AND INTERNAL FIXATION BY A LOCKING PLATE

Dear
 I have similar cas , i did closed reduction and k. wire fixation .
and patient has full range of movement now .
regards
 

Only closed reduction and k.wire fixations

You have to try if not open and k.wire fixation .
 

DR EIAD SHAMSI BASHA
 

I don't want xrays I want to know how you get it reduced closed.
Manual traction won't work, do you manipulate with anterior pressure somehow and get the head back in.
 
Regards
 
CV

Please explain how you do a closed reduction for these cases.

Regards

Christian

We were tow me and my assistant, you have to do it as urgent as possible, and I was not sure that it will come so I prepaid the patient for open reduction if not will succeed, but in our plan only K.Wire  fixation,

So under G A i ask my assitat to do axial traction and i felt the head under my hand and with gentil pushing the head we get the reduction , and we were very happy for us and for the patient ,   Once the head reduiced you did extenal or internal the get better reduction, and i fixed by K.WIRE,

REGARDS

ESB

Very interesting.
I have never been able to get these reduced closed and do not even try any more.
That being said, I cannot argue with the reduction you obtained. If you can maintain it with K wires and not get a pin tract infection the outcome will be fine - likely as good or better than ORIF

Regards

CV

THANK YOU MY FREIND
ESB

You did a great job. Marvelous reduction.

 Dino Aguilar, M.D.daguilar@cablenet.com.ni

Mobile (505) 8832132  Of.      (505) 255-6898   Fax (505) 249-3277  Blackberry Pin:  20644E88

PO Box 2261  Hospital Metropolitano Suite 306

Managua, Nicaragua

 

the Pt. is too young for prosthesis, you can do open reduction and fixation with 2 6.5 mm cancellous screws.
 

you can not do it closed, the reduction is defficult even by open reduction, I did recently similar case, you have to dissect more
medially to reache the head.    Zeitony
 
The head appears very too radioopaque. I think an MRI to confirm the viabilty of the head is needed. Then how old is this injury?
If the duration of injury is more than six weeks and the head is shown to viable then open reduction will be the only option as closed reduction under C arm will difficult.
Whatever method of fixation adopted clover leaf plate or locked plate the chance of AVN is high hence the patient should be warned of this.
good luck
DR Anthony Olasinde
Federal Medical Centre Owo
Nigeria 
 

Dr Madgy, I would suggest Open reduction with distal to proximal 4mm partially threaded screw entering below the level of the axillary nerve, Regards.

Dear Dr. .......
thanks for your letter, the only treatment for anatomical neck 
fracture is shoulder hemiarthroplasty, because of AVN of the humeral 
head which is inevitable because of deprivation of blood supply of the 
head, this treatment is valid whatever the age is. So my opinion is to 
transfer the case for any hospital has shoulder arthroplasty.
Thanks
Amr Abdelhady
prof of orthop.
Ain Shams University
Consultant of shoulder surgery

One month ago, I had a similar case, SUBHAN ALLAH, and it went good by fixation via 2 k wires and tension band. 
The most important step in such cases is the perfect reduction of the dislocated head.
You will find it as a cap that's stripped of all attached soft tissue cuff.
You might need anchors for reattachment of rotator cuff back into place.
You might use cancellous lag screws with washer for fixation augmentation.
Best of luck 
Dr. Mohammed M Kotb, MD Ortho
Lecturer Orthopedics, Assiut University Hospital,
Egypt
Currently, director of Reconstructive Microsurgery
Unit, Saudi German Hospital, Jeddah, Saudi Arabia
PO box; 2550, Jeddah 21461
Tel. 00966-2 6829000/6394000
Fax. 00966-2 6835874/6905038
Mob. 00966-558543389
e.mail, mkotborth@yahoo.com,
mkotborth@hotmail.com,
mkotborth@gmail.com
ortho6.jed@sghgroup.net

Dear Dr. ..

I think the only soultion is ORIF with the new Locked plate PHILOS from AO with good repair of the Rotator cuff muscle.

Please tell me the end results for this patient.

Thanks for sharing this case

Dr. Mohamed ElSalamouny
Trauma Surgeon AOAA
Prince Abdulrahman AlSedary Central Hospital
Sakaka - AlJouf
Mobile 0551854858
Fax 046242065

Assalam o Alaikum Dear Brothers,
I hope You all are keeping well. This patient requires Open reduction and fixation by T2 Proximal Humeral Nail, Short , 8mm diameter( Stryker). It can also be fixed by Polaris Humeral Nail.
Masalam
Dr Khurshid Shah
Orthopeadic Surgeon, Lancashire Teaching Hospitals UK

 

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