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Re: Prox humerus - перелом и вывых
Christian Veillette 26 Август 2007, 20:14
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Alex
What was his preinjury level of function? Prior to Aug 6 was he having recurrent episodes of instability or was this shoulder chronically dislocated?
I would recommend an initial attempted closed reduction in the OR with fluoroscopy. It is important that this is done in a controlled fashion to make sure you are not further displacing the head and leaving it behind. If
you can get it reduced then you will have a much better ability to understand the fracture and possible glenoid involvement. I think regardless
of getting the humeral head reduced this fracture should be managed operatively with plate fixation of the tuberosity fragment and a combination of lag screw and plate fixation of the proximal shaft extension. My concern is that treating it conservatively after closed reduction will lead to issues of instability and malunion given the size of the tuberosity fragment and past history.
I would also not be surprised if there was some glenoid issues related to the prior instability. It is difficult to tell on the provided xrays. Either a CT scan or an Axillary view should be done to assess this prior to definitive surgery.
If you were to get it reduced closed would you try to treat it nonoperatively?
As I mentioned above, my concern with this approach is that with the past history of instability and the current large tuberosity fragment you will likely end up with persistent issues with instability and likely malunion.
Thus, the only role of closed reduction is to improve the blood supply to the head (not as much an issue since it has been dislocated since Aug 6), allow better understanding of the fracture pattern, or stage definitive management until you have appropriate imaging/implants/personnel (not as much an issue because it is not acute).
Best regards
Christian
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