<html><head><meta http-equiv="Content-Type" content="text/html charset=koi8-r"></head><body style="word-wrap: break-word; -webkit-nbsp-mode: space; -webkit-line-break: after-white-space; ">1) This a chronic, 4-part anterior fracture dislocation. How do I know it is anterior, and not posterior, only with a plain AP X-ray ??<br><br>Because posterior dislocations do not behave this way, radiographically, believe me. Also, there MAY be an A-C TYPE V dislocation in this shoulder ... But. let's forget that, now ...<br><br>2) What is the "personality" of the fracture ????<br><br>Well, the patient is a young female, 26 years, who, unfortunately, had this severe problem NOT properly diagnosed. <br><br>So, she is young, very young. She needs the best we can give. <br><br>3) Do we need more exams to establish the diagnosis ??? NO. <br><br><br>4) Do we need more exams to better comprehend the lesion, and to better elaborate our surgical plan ??? SURE. <br><br>A CT would be very nice, to better understand the fracture, now. <br><br>An MRI is mandatory . WHY ???<br><br>for us to see the state of the cuff <br>for us to to see the viability (AVN) of the humeral head <br><br>5) But, regardless of all the "disgraces", I would try to reconstruct that. An arthroplasty in such a young patient is already a "disgrace" itself, so I would try to mount that. <br><br>6) There is a lot of "heterotopic ossification" around GT, to get things more difficult ...<br><br>7) How to operate ????<br><br><br>beach chair position <br>a classical delto-pec approach (axillary approach), extended as needed - NO COSMETIC ISSUES, here, in spite of patient being a young female <br>opening of delto-pec interval <br>identification of humeral head - at this point, surgeon must remember that some neurovascular structures may be close to head, so A LOT OF CARE is needed, to dissect at that part. <br>before reducting humeral head, surgeon must identify GT and LT, and perform strong N 5 Ethibond whipstitches in GT and in LT - a lot of scary tissue shall be there...<br>with LT and GT well identified and isolated, then surgeon must reduce head <br>I would, for sure, use a tricortical iliac graft, between diaphysis and head<br>With a good PHILOS, surgeon must re-establish the best cephalic-diaphyseal angle (head-shaft relation) he can, and fix that<br>GT and LT shall be fixed with bony sutures, in usual fashion <br>a biceps tenodesis MUST be done, here<br><br>8) What about prognosis ???? Well, quite unpredictable, regardless of a hard, long lasting surgery.<br><br>What about AVN ???? Well, technically, 100 % chance, but some patients adapt to that, because shoulder is not a hip ...<br><br><br>9) I would try to do that, and I would prepare my mind for the good and the bad ... <br><br><br><br>Here are some photos, of chronic, locked, 4 part posterior dislocation, 2 months old, that I did September/2011. Patient is 67, very, very active - had a really reasonable, honest clinical result ... <br><br>Photos attached ...<br><br><br>Dr Sergio Rowinski<br>Orthopedic Surgeon<br>Shoulder & Elbow Surgery<br>S&#227;o Paulo, Brazil<br><img height="696" width="522" apple-width="yes" apple-height="yes" id="2ee88d37-839b-47f4-95cd-bb2c0cf72fbb" src="cid:368245DD-CDF0-4DFD-80E5-5126A528A0BB"><img height="650" width="544" apple-width="yes" apple-height="yes" id="c29fc44a-a800-4138-adf0-c99b757eaf3e" src="cid:F19862BE-7F3E-4DF5-9A9A-FBA74D9DE331"><img height="696" width="522" apple-width="yes" apple-height="yes" id="8c46bc7d-50e7-4eb7-bf3f-d6f07bb47f9f" src="cid:BAA68238-DE0D-4D6E-BDF9-31175267A514"><img height="575" width="766" apple-width="yes" apple-height="yes" id="3caa929c-5615-46ea-ab7d-727518da8091" src="cid:10D226A3-D25A-4BFA-AB64-E6B70FADF95B"><img height="769" width="577" apple-width="yes" apple-height="yes" id="fd7b51ff-db8a-470d-aae6-6aa468b76197" src="cid:B60A2C89-9738-4A81-AB3C-BE461AEE7F4A"><img height="724" width="543" apple-width="yes" apple-height="yes" id="ed9b69e3-db54-4b3b-b541-132bef6013c2" src="cid:CFFEA25A-5B12-4E46-A9B6-0668377C2808"><img height="534" width="712" apple-width="yes" apple-height="yes" id="89f4af98-66e2-4cb2-aa09-a617ce259aeb" src="cid:DE48F67F-3BA3-4279-8A6B-76ACBDA8C6CF"><img height="558" width="744" apple-width="yes" apple-height="yes" id="79e8cb2f-c578-4753-876a-dbba55f66f93" src="cid:24AFF434-F5C7-4657-916E-EFF944166C42"><img height="859" width="653" apple-width="yes" apple-height="yes" id="ec41c679-a9f1-46e5-a935-8da5c3968924" src="cid:4A569EEE-7E22-4BE3-B22D-7CE6333AB52E"><img height="739" width="554" apple-width="yes" apple-height="yes" id="5ac63eac-a36d-4025-bb63-58966601d99a" src="cid:1FED2ACA-6168-46BD-8268-B63069E0352B"><img height="589" width="655" apple-width="yes" apple-height="yes" id="c1021f2e-701b-472a-b6d2-1b432b13d23a" src="cid:288FD034-AAB0-416B-8CA7-9087D75A6D51"><img height="533" width="655" apple-width="yes" apple-height="yes" id="58d479ea-d7ee-4414-b228-48ab1be58294" src="cid:4F08DD79-12D3-4F71-B7AD-FB764C0DECC1"></body></html>