• Malposition of the greater or lesser tuberosity ( e.g. >1 cm from native anatomical position)
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Average 3.9 of 10 Ratings
A 69-year-old male sustained a proximal humerus fracture that underwent open reduction and internal fixation nine months ago. He complains of constant pain and weakness; repeat radiographs are shown in Figures A and B. What is the most appropriate surgical treatment at this time?
Revision open reduction and internal fixation
Valgus corrective osteotomy of proximal humerus
Humeral head resection
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Figures A and B show loss of fixation of a proximal humerus fracture. The most appropriate treatment for this scenario is a humeral arthroplasty, as the tenuous blood supply of the proximal humerus is likely chronically disrupted, leading to osteonecrosis and poor healing potential of the proximal humerus. Traditionally, hemiarthroplasty was performed for these presentations, but reverse total shoulder arthroplasty has emerged as a potentially better treatment method, especially if the rotator cuff function/status is unknown or poor.
According to the referenced article by Norris et al, delayed shoulder hemiarthroplasty decreased shoulder pain in 95% of patients but warned of technical difficulties and limited postoperative range of motion. A total shoulder arthroplasty is needed if glenoid erosion from the screw(s) or bone occurs.
Norris TR, Green A, McGuigan FX.
J Shoulder Elbow Surg. 1995 Jul-Aug;4(4):271-80. PMID: 8542370 (Link to Abstract)
Norris, JSES 1995
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Average 4.0 of 19 Ratings
A 24-year-old female sustains a surgical neck proximal humerus fracture in a motor-vehicle collision. She undergoes open reduction and internal fixation but heals in 45 degrees of varus and has significant limitation of shoulder range of motion despite 9 months of conservative treatments. What is the most appropriate treatment at this time?
Manipulation under anesthesia
Humeral head resurfacing
Revision open reduction internal fixation with osteotomy
Reverse total shoulder arthroplasty
Malunions of the proximal humerus typically result in significant restrictions in range of motion. This young patient has sustained a proximal humeral malunion, and treatment should include a corrective osteotomy for improved outcomes, as she has failed conservative treatment.
The cited reference by Williams et al as well as the referenced article by Siegel et al explain various techniques in management of proximal humerus malunions. They state that the two primary indications for surgical management of proximal humerus malunion include 1) pain and 2) diminished function resulting from limited range of motion. Because this patient is young, you would attempt revision ORIF/osteotomy as opposed to humeral head arthroplasty.
Williams GR Jr, Copley LA, Iannotti JP, Lisser SP.
J Shoulder Elbow Surg. 1997 Sep-Oct;6(5):423-8. PMID: 9356930 (Link to Abstract)
Williams, JSES 1997
Siegel JA, Dines DM.
Orthop Clin North Am. 2000 Jan;31(1):35-50. PMID: 10629331 (Link to Abstract)
Average 3.0 of 22 Ratings
HPI - Proximal humerus fracture 6 months ago, operated on overseas (open reduction, internal fixation) Progressive pain and disability after initial improvement. Complete skin closure, no history of wound complications or infection. Normal WBC, ESR, and CRP.
What additional imaging, if any, would you order?
HPI - Operated 4 months ago of proximal humerus fracture.
What do you think is the most likely cause for lack of active motion?