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Proximal Humerus Fractures
Posted: Sep 27 2021 #(C101799)
A

Proximal Humerus Fracture in 21M

HPI

A 21-year-old male with a history of right upper extremity brachial plexus tractional injury (1 year prior) presents after a motor vehicle collision. He does not have normal sensation in the right arm but notes that the arm is floppy and feels that it is broken. He has baseline decreased sensation and weakness in the right arm. Other injuries include multiple left-sided rib fractures and a small pneumothorax.

PMH

PMH: Right upper extremity brachial plexopathy (1 year prior) PSH: ORIF right clavicle (1 year prior)

PE

Focused physical examination of the right upper extremity reveals an obvious deformity of the right arm without any open wounds. There is a well-healed scar over the right clavicle. He has 3/5 wrist extensors/flexors, 3/5 FDS/FDP, 3/5 I/O, 3/5 EPL, and 1/5 elbow flexion/extension. There is diffusely decreased sensation to light touch from C5-T1. He has 2+ RP and warm and well-perfused fingers.

Poll
1 of 9
1. In addition to an AP, Scapular Y, and Axillary shoulder radiographs, would you obtain any further imaging to guide your management?
No - AP, Scapular Y, and Axillary radiographs are Sufficient
62%
704/1128
Yes - additional radiographic views (aXR)
3%
41/1128
Yes - CT scan (CT)
26%
297/1128
Yes - MRI
2%
24/1128
Yes - aXR + CT
1%
18/1128
Yes - aXR + MRI
0%
4/1128
Yes - CT + MRI
1%
13/1128
Yes - aXR + CT + MRI
0%
9/1128
Outside my area of expertise - best if I don't vote
1%
18/1128
2. Would you use a classification system to guide the management of the initial treatment?
No - a classification system would not help me
55%
602/1077
Yes - AO/OTA
25%
277/1077
Yes - Neer classification
7%
84/1077
Yes - Descriptive
6%
72/1077
Yes - Other
0%
2/1077
Outside my area of expertise - best if I don't vote
3%
40/1077
3. If you choose Operative management, what is your primary indication for operative management in this patient?
I would not choose Operative management
13%
140/1074
Poly-trauma (i.e multiple rib fractures, pneumothorax)
13%
146/1074
History of ipsilateral brachial plexopathy
22%
247/1074
Fracture location
11%
126/1074
Fracture morphology
22%
237/1074
Other (patient age, return to function, pain control)
14%
157/1074
Outside my area of expertise - best if I don't vote
1%
21/1074
4. If you choose Operative management, what procedure would you perform?
I would not choose Operative management
7%
82/1070
Open Reduction & Internal Fixation (ORIF)
50%
542/1070
Intramedullary nail fixation (IMN)
35%
384/1070
ORIF + IMN
3%
36/1070
Arthroplasty
0%
1/1070
External Fixation (ExFix)
0%
7/1070
Outside my area of expertise - best if I don't vote
1%
18/1070
5. If you choose Open Reduction & Internal fixation (ORIF), how would you position the patient?
I would not choose ORIF
9%
95/1033
Supine
20%
215/1033
Beach-chair
58%
608/1033
Lateral decubitus
7%
73/1033
Prone
2%
21/1033
Outside my area of expertise - best if I don't vote
2%
21/1033
6. If you choose Open Reduction & Internal fixation (ORIF), what approach would you use?
I would not choose ORIF
6%
63/1016
Deltoid-splitting (acromial, anterolateral)
15%
159/1016
Deltopectoral (with anterolateral approach to humeral shaft if needed)
70%
719/1016
Posterior
3%
40/1016
Other
0%
6/1016
Outside my area of expertise - best if I don't vote
2%
29/1016
7. If you choose Open Reduction & Internal fixation (ORIF), what construct would you choose?
I would not choose ORIF
6%
60/993
Lag screw(s) + neutralization plate(s)
43%
427/993
Cerclage wire(s) + neutralization plate(s)
3%
38/993
Compression plate(s) only
15%
151/993
Bridge plate(s) only
14%
148/993
Intramedullary nail (IMN)
13%
139/993
Other
0%
3/993
Outside my area of expertise - best if I don't vote
2%
27/993
8. If you choose Operative management and obtained the construct shown, what would be your immediate postoperative weight-bearing status?
I would not choose Operative management
4%
42/925
Non-weight bearing (NWB)
46%
427/925
Partial weight bearing (PWB) less than 5 lbs
30%
283/925
Weight bearing as tolerated (WBAT)
16%
157/925
Outside my area of expertise - best if I don't vote
1%
16/925
9. If you choose Operative management and obtained the construct shown, when would you allow unrestricted shoulder active range of motion?
I would not choose Operative management
4%
38/929
Immediately
18%
174/929
< 2 weeks
8%
76/929
2-4 weeks
22%
208/929
5-6 weeks
29%
278/929
7-8 weeks
8%
83/929
9-10 weeks
2%
21/929
11-12 weeks
2%
19/929
> 12 weeks
1%
18/929
Outside my area of expertise - best if I don't vote
1%
14/929
PROCEDURE #1 DOP: 9/27/2021

ORIF right humerus (supine, deltopectoral approach, Proximal humerus locking plate)

POLL#
Surgeon's Choices
1
In addition to an AP, Scapular Y, and Axillary shoulder radiographs, would you obtain any further imaging to guide your management?
No - AP, Scapular Y, and Axillary radiographs are Sufficient
2
Would you use a classification system to guide the management of the initial treatment?
No - a classification system would not help me
3
If you choose Operative management, what is your primary indication for operative management in this patient?
History of ipsilateral brachial plexopathy
4
If you choose Operative management, what procedure would you perform?
Open Reduction & Internal Fixation (ORIF)
5
If you choose Open Reduction & Internal fixation (ORIF), how would you position the patient?
Supine
6
If you choose Open Reduction & Internal fixation (ORIF), what approach would you use?
Deltopectoral (with anterolateral approach to humeral shaft if needed)
7
If you choose Open Reduction & Internal fixation (ORIF), what construct would you choose?
Lag screw(s) + neutralization plate(s)
8
If you choose Operative management and obtained the construct shown, what would be your immediate postoperative weight-bearing status?
Non-weight bearing (NWB)
9
If you choose Operative management and obtained the construct shown, when would you allow unrestricted shoulder active range of motion?
< 2 weeks
icon
OUTCOMES
Post-procedure P1
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