Case conference Intern 8831122 Brief history Chief complaint

Case conference Intern 8831122 李政鴻 指導老師 劉耿彰醫師

Brief history Chief complaint n Rt shoulder pain following a fall Present illness n n n 88 -year-old female Falling down 10/24 Rt shoulder was hitting the ground directly Painful, disability, swelling and deformity no neurologic deficits, no open wound, nor other injury

Social History n Non-smoker, Non-drinker, chews no betel nuts. Past History n n n Peptic ulcer disease many years ago, patient underwent patial gastrectomy Iron deficiency anemia noted in recent years, was given Iron parenteral infusion with improvement in her Hemoglobulin level. hypertension but no DM history

PE Rt shoulder n n n 1. Limitation of right ROM due to pain, 2. local echymosis around right shoulder 3. Local tenderness and severe swelling near the shoulder 4. Distal circulation: intact 5. No neurologic deficits. Other extremities: normal

OP notes Two-part fracture of Rt proximal humerus over the surgical neck with extensive bone loss and osteoporosis clover-leaf plate

Discussion Proximal humeral fracture

n Deforming force displaced

Proximal humeral fracture Young group: n n Male, high energy trauma Good bone quality Old age group: n n Female, minor trauma Poor bone quality Poor understanding of outcome Rigid internal fixation : failure Nonprosthetic Management of Proximal Humeral Fractures 85: 1578 -1593, 2003. J Bone Joint Surg

Proximal humeral fractures classification - anatomic neck fracture: - one part fracture - two part fractures - two part surgical neck fracture - two part tuberosity fractures: - lesser tuberosity frx; - greater tuberosity frx; - three part fractures - four part fracture: - fracture dislocation:

Undisplaced One-part fractures nondisplaced n n n only minimally displaced 1 cm other segments angulated less than 45° 47% to 85% prevalence of proximal humeral fractures conservative treatment

Management Open procedures n n conventional plate cloverleaf, T-plate or blade plate, and tension band wires open screw techniques. Minimally invasive

Search For old age, osteoporosis patient With displaced fracture, anatomical fracture (surgical intervention) Which is the best Key wo 1 rd: n n osteoporosis Proximal humeral fracture

Result No comparative study Only cohort study, clinical trial, evaluation for one of those procedure Review paper n Nonprosthetic management of proximal humeral fractures n n THE JOURNAL OF BONE & JOINT SURGERY · JBJS. ORG VOLUME 85 -A · NUMBER 8 · AUGUST 2003 Minimal invasive procedure ( percutaneous pins): good for better bone Osteoporosis bone: still controverial

New device develop AO/ASIF Association for the Study of Internal Fixation

A New Locking Plate for Unstable Fractures of the Proximal Humerus Florian Fankhauser, MD; Christian Boldin, MD; Gert Schippinger, MD; Christian Haunschmid, MD; and Rudolf Szyszkowitz, MD CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 430, pp. 176– 181 January 2005

Following one year Complications n n Breakage of the plate : 1 Redislocation of the fracture in four patients Partial osteonecrosis in two patients, No non-unions

Acta Orthop Scand 2004; 75 (6): 741– 745

2 fractures failed to unite 3 patients developed an avascular necrosis of the humeral head. 2 implant failures were observed due to a technical error No impingement

Conclusion For proximal humeral fracture n n n Still controversial surgical treatment Individualize Surgeon prefer Need more extended study

For our patient Use clover-leaf plate May use new device n n n Formed by the anatomy of lateral proximal humerus Locking compression plates But expensive 50000