Humeral Head Three-Part Posterior Fracture-Dislocation Reduced through a Posterior Approach and Fixed with Blocked Threaded Wires: A Consecutive Case Series.

Background and Objectives: Posterior fracture dislocations are rare. There is currently no uniformity regarding treatment. Therefore, outcomes are difficult to compare. We evaluated clinical and radiological outcomes of patients with humeral head posterior fracture dislocation treated with an open posterior reduction and then fixed with a biomechanically validated configuration of blocked threaded wires. Materials and Methods: 11 consecutive patients with humeral head three-part posterior fracture dislocation were treated by reduction through a posterior approach and fixed with blocked threaded wires. All patients were clinically and radiographically evaluated after a mean follow-up of 50 months. Results: The mean irCS was 86.1% (range: 70.5-95.3%). No significant difference was found between irCS at 6 and 12 months postoperatively and the final follow-up. Six patients noted their pain intensity as 0/10, three as 1/10, and two as 2/10. The postoperative reduction was considered as excellent in eight patients (Bahr's criteria) and good in the remaining three; at the final follow-up, reduction was excellent and good in seven and four patients, respectively. The mean neck-shaft angles at FU 0 and at the final FU were 137° and 132°, respectively. No signs of avascular necrosis, non-union, and arthritis progression were seen. No recurrence of dislocation or posterior instability symptoms were reported. Conclusions: We believe that our very satisfactory results stem from: (1) the manual reduction of the dislocation through a vertical posterior surgical approach, which does not produce further osteocartilaginous damage of the humeral head; (2) no multiple perforations of the humeral head are performed; (3) the threaded wires have a smaller diameter than the screws, therefore they preserve the bone tissue of the humeral head; (4) deperiostization or further detachment of soft tissues are not expected; (5) the adopted and validated system is stable and limits translation, torsion, and the collapse of the humeral head.

Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations.

INTRODUCTION: Proximal humeral fracture with associated glenohumeral dislocation (PHFD) is a challenging clinical problem. Outcomes of open reduction and internal fixation (ORIF) of these injuries have not been widely reported. The purpose of this analysis is to report our experience with ORIF of PHFD. METHODS: A retrospective review of our 2 institutions' shoulder surgery databases was conducted to identify all PHFDs that were treated with ORIF from 2008 through 2017. Radiographs were reviewed for fracture healing by 12 weeks postoperatively. All reoperations were recorded. Patient-reported outcomes using Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores at a minimum 2-year follow-up were recorded. RESULTS: There were 20 PHFDs identified: they were 50% male, 55.8 ± 10.3 years old (range 31.3-66.3), and had a body mass index of 29.3 ± 8.2 (15.2-47.8). Seven (35%) patients experienced varus collapse, nonunion, or avascular necrosis and 6 (30%) patients underwent reoperation. Of the 17 patients who did not go on to revision or arthroplasty, 14 (82.3%) had patient-reported outcomes at a mean follow-up of 4.9 ± 2.2 years (2.3-8.8). These patients had an average SST 8.0±4.0 yes responses (0-12) and ASES scores of 71.6 ± 20.4 (20.2-94.9). CONCLUSION: ORIF of PHFD carries a high rate of reoperation. In patients who achieve healing, functional scores are satisfactory. This information is important for proper patient counseling prior to surgery.

Using Teriparatide to Augment Healing in a Humeral Shaft Nonunion: A Case Report.

The occurrence of complications of fracture healing, such as delayed union and nonunion, is well known, but the use of pharmacotherapy for these delayed unions and nonunions has not been explored in detail. The authors describe a case of traumatic humeral shaft fracture successfully treated with once-daily administration of 20mcg of teriparatide for six months. The patient was a 22-year-old male who had been through a road traffic accident. The radiograph of the humerus shaft showed a fracture line and the displaced distal portion of the shaft of the humerus. Based on these features, the patient was diagnosed with a humeral shaft fracture. The patient underwent internal fixation with a dynamic compression plate. However, there were no signs of callus formation even after 12 weeks from the time of internal fixation. The patient was initiated with teriparatide administration and union was achieved after six months of a once-daily administration of teriparatide. Once-daily teriparatide treatment is shown to be beneficial for improving the healing of humeral shaft fractures showing delayed union.

A Case of Proximal Humerus Fracture Dislocation Presenting With Failed Primary Open Reduction and Internal Fixation Followed by Salvage Reverse Total Shoulder Arthroplasty.

The treatment of proximal humerus fractures is complex. Factors like fracture pattern, patient age, pre-injury activity level, soft tissue status, and comorbidities play a role in decision-making for non-operative versus operative management. Complications of non-operative vs operative management of proximal humerus fractures include but are not limited to arthrofibrosis, fracture nonunion, and avascular necrosis. We report an unusual case of a 64-year-old female presenting with a three-part proximal humerus fracture dislocation. The patient underwent primary open reduction internal fixation. Twenty-four weeks after open reduction and internal fixation, the patient experienced collapse of the humeral head with intraarticular hardware migration, and she underwent hardware removal. Fifty-two weeks after hardware removal, the patient experienced avascular necrosis of the humeral head, and she underwent salvage reverse total shoulder arthroplasty. There is debate in the current literature on the best management of multi-part proximal humerus fracture-dislocations.

An Irreducible Posterior Fracture-Dislocation of the Shoulder: A Case Report.

Posterior fracture-dislocations of the shoulder are exceedingly rare orthopedic injuries. The management of these rare and complex injuries can be challenging from initial presentation through definitive management. Timely diagnosis of these injuries is critical to prevent devastating complications, yet the diagnosis is often delayed. Delays in surgery and poor fracture reduction are associated with a high risk of complications such as avascular necrosis. Additionally, these injuries have the potential to be irreducible. This may occur secondary to osteochondral humeral defects, soft tissue interposition, or entrapment. The long head of the biceps tendon incarceration is one potential block to reduction. Definitive surgical treatment options include open reduction and internal fixation (ORIF) and shoulder arthroplasty. While reoperation rates are higher in patients undergoing ORIF, arthroplasty longevity is a concern among young, active patients with high functional demands. Fibular strut allograft is a useful adjunct when reconstructing complex proximal humerus fractures. We present a case of a 28-year-old male who sustained a significantly comminuted four-part left proximal humerus fracture with an irreducible posterior humeral head dislocation requiring urgent ORIF following a motor vehicle accident.

Bilateral Posterior Four-Part Fracture-Dislocation of the Proximal Humerus After First-Time Seizure.

This report presents a previously undescribed case and treatment of bilateral four-part proximal humerus (PH) fracture-dislocations presented in a 61-year-old Caucasian male patient following a first-time seizure episode. The patient was treated with bilateral reverse total shoulder arthroplasty due to pre-existing glenohumeral arthritis and rotator cuff atrophy. The surgery was successful, and the patient's postoperative recovery was uneventful. Fractures of the proximal humerus are a relatively common adult osteoporotic fracture; however, posterior fracture-dislocations of the PH, frequently related to motor vehicle accidents, seizures, or electrical shock, are remarkably scarce. A treatment algorithm for these injuries is lacking.

Humeral Head Replacement and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fracturesm.

Acute proximal humeral fractures in the elderly are generally treated non-operatively if alignment is acceptable and in stable fracture patterns. When operative treatment is indicated, surgical fixation is often difficult or impossible to obtain. Hemiarthroplasty has long been the standard of care. However, with its reliance on tuberosity healing, functional outcomes and patient satisfaction are often poor. Reverse shoulder arthroplasty has emerged as a new technology for treating proximal humeral fractures but the indications for its use remain uncertain. While not conclusive, the evidence suggests that reverse shoulder arthroplasty yields more consistent results, with improved forward elevation and higher functional outcome scores. The primary advantages of hemiarthroplasty are improved shoulder rotation and shorter operative time. Complication rates do not vary significantly between the two options. Although higher quality trials are needed to further define the role of reverse shoulder arthroplasty, current evidence suggests that this is a reasonable option for surgeons who are highly familiar with its use.

Fracture of Proximal Humerus with dislocation of Glenohumeral joint in a 3 year old child: A case report.

INTRODUCTION: Though proximal humeral physeal injuries are common in children, reports of proximal humeral physeal injuries with disruption of glenohumeral joint are exceedingly rare. We here report such a case. CASE REPORT: A three year old male patient presented to us with proximal humeral physeal separation along with glenohumeral dislocation. Under general anaesthesia, closed reduction could be achieved. Thereafter, three Kirschner wires were used to fix the physeal injury. Wires were removed at six weeks and physiotherapy was started. Good range of motion was achieved, and follow up radiographs demonstrated no evidence of growth arrest at one year. CONCLUSION: In spite of significant displacement in cases of proximal humeral physeal injury with glenohumeral dislocation in children, closed reduction can be achieved and should be attempted.