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Prox humerus - перелом и вывых
Ортопедия и травматология Отправлено Alexander Chelnokov 26 Август 2007, 03:21
Дорогие коллеги,Мужчина 44 л. упал с крыши дачи 6 августа. Картинки в приложении.
Лет 5 назад нде-то оперирован по поводу привычного вывихв этого же плеча.После операции не вывихивал до этой травмы.Как тут лечить? Есть ли шансы на закрытое вправление? Чем лучше фиксировать? Какие меры принять с учетом бывшего и нынешнего вывиха? Заранее спасибо.
Dear colleagues,
A male 44 y.o. admitted to our unit. Injured at Aug. 6 - fall from 3 m. Images attached. Five years ago was operated somewhere else for recurrent dislocation of thу same shoulder, no data what was done.
What would be optimal treatment option? Any chance of closed reduction? What should be done to address the current and past dislocations? THX.

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    Re: Prox humerus - перелом и вывых
    Christian Veillette 26 Август 2007, 20:14
    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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    • Re: Prox humerus - перелом и вывых
      Отправитель: Alexander Chelnokov 27 Август 2007, 14:28
      CV> recurrent episodes of instability or was this shoulder chronically

      No.

      CV> I would recommend an initial attempted closed reduction in the OR with

      Well, we'll try to insert a wire with olive and manipulate the head.

      CV> If you were to get it reduced closed would you try to treat it
      CV> nonoperatively?


      My dream was to perform closed reduction and intramedullary nailing.
      But i am becoming more and more sceptic about success of the closed manipulation.

      [ Ответить ]
      • Re: Prox humerus - перелом и вывых
        Отправитель: Christian Veillette 27 Август 2007, 16:54
        A nail would not be my first choice of implant in this particular fracture pattern but I have seen it done.

        Locking plate or cloverleaf plate thru a standard deltopectoral approach.

        Let us know how it turns out.

        Regards

        Christian

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        • Re: Prox humerus - перелом и вывых
          Отправитель: rohit shah 29 Август 2007, 20:03
          >Locking plate or cloverleaf plate thru a standard deltopectoral approach.

          I AGREE WITH CHRISTIAN VEILLETTE


          rbs
          jtj
          bharat patel
          A.G.O.T.

          [ Ответить ]
    Re: Prox humerus - перелом и вывых
    DR Tim Bray 27 Август 2007, 09:13
    This is an anterior fracture/dislocation with shaft extension-no chance for closed reduction-probably contraindicated, especially since the injury is now 19 days old. We do these supine on a radiolucent table with an arm board extension-you now have an unobstructed radiographic view of the entire upper extremity both AP and lateral with excellent axillary views of the glenohumeral joint to assess your reduction and screw placement. This is the perfect indication for a locking plate via the traditional deltopectoral approach. Use the biceps tendon to stay anatomically oriented during the approach and be sure to check the rotation post plate application. In general, we have not performed any soft tissue stabilization procedures during the fixation, may stay away from external rotation past neutral during rehab and early motion protocol. This one should do fine.
    Bray, Althausen, O'mara- Reno
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    Re: Prox humerus - перелом и вывых
    Alexander Chelnokov 28 Август 2007, 23:48
    Попытка закрыто изменить положение не удалась. Передним доступом сделали открытую репозицию, гленоид без особенностей. Временно фиксировали спицами и остроконечным костедержателем. Фиксировали гвоздем T2 PHN (Stryker). Для профилактики вывихов после введения проксимальных винтов ротировали дистальный отдел кнаружи на 30
    градусов как аналог остеотомии по Weber. Снимки в приложении. Комментарии и критика привествуются.



    Attempt of closed reduction failed. Open reduction via anterior approach. The head was temporarily fixed by wires and sharp clamps. Fixation by a nail - T2 PHN (Stryker). The distal fragment has been rotated 30 degrees externally after proximal locking for dislocation prevention as "virtual" Weber osteotomy. Images attached.
    Comments/critics are welcome.
    [ Ответить ]

    • Re: Prox humerus - перелом и вывых
      Отправитель: Christian Veillette 29 Август 2007, 20:04
      I have never used that particular implant.

      Is there only a single screw in the head?

      What was the status of the cuff?

      Did you do any sort of anterior capsular repair?

      Interesting idea regarding the Weber rotation.

      Please let me know how this patient does in 6 weeks/6 months.

      Great case.

      Regards
      CV

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      • Re: Prox humerus - перелом и вывых
        Отправитель: Alexander Chelnokov 29 Август 2007, 22:32
        > I have never used that particular implant.

        To my mind it was most suitable for this injury because of long shaft extension.

        > Is there only a single screw in the head?

        All 3 screws are in the head. The feature of the nail is that it has four holes oriented not 45 degrees to frontal or sagittal planr, but anatomically to the head and both tubercles. The holes in the nail are threaded so angular stability is perfect, and contain a nylon bushing
        preventing any screw rotation/back out.

        > What was the status of the cuff?

        I've seen only subscapularis - was in place.

        > Did you do any sort of anterior capsular repair?

        Just suture.

        > Interesting idea regarding the Weber rotation.

        Frankly speaking I am not sure about over-rotation. I requested the
        patient to check these days if the shoulder feels comfortable. If not we are able to remove the distal screw, change rotation and re-lock the
        nail.

        > Please let me know how this patient does in 6 weeks/6 months.

        ok.
        THX for your input.


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    • Re: Prox humerus - перелом и вывых
      Отправитель: rohit shah 29 Август 2007, 20:05
      WILL U PLEASE TELL IN DETAIL ABT WEBER ROTATION

      ROHIT
      JAWAHAR
      AND BHARAT
      A.G.O.T.

      [ Ответить ]
    • Re: Prox humerus - перелом и вывых
      Отправитель: samsnow 30 Август 2007, 20:11
      Ув. Александр Николаевич! Какая может быть здесь критика? Операция выполнена на все100! А элемент деротационных деяний а-ля Вебер в данном случае,учитывая анамнез,позволяет выразить уверенность а отсутствии релюксаций а будущем,поскольку это,наверное,единственный действительно радикальный (он же в целом ряде случаев этиологический) метод лечения привычного вывиха плеча. А объяснять или нет суть его коллеге из Индии-Ваше дело.
      С-Петербург,Елизаветинская б-ца,1 травм.отделение,Сергей Самсонов.

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      • Re: Prox humerus - перелом и вывых
        Отправитель: Alexander Chelnokov 30 Август 2007, 21:45
        > метод лечения привычного вывиха плеча.

        Спасибо на добром слове.

        > А объяснять или нет суть его коллеге из Индии-Ваше дело.

        Спасибо, что напомнили. Полный текст статьи про остеотомию Weber можно взять тут (pdf, 1,5 Mb).



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