[Ortho] Prox humerus - перелом и вывых

[Christian Veillette]

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