Subject: Proximal humerus non-union
Date: Thu, 24 Apr 2003 20:36:31 -0400
From: Tom Kaplan
Please advise for the following situation...
64 yr old gentleman who lives independently. Drinks alcohol daily, chronically. He initially presented 1 month s/p fall complaining of persistent pain in his left shoulder. Radiographs at that time showed a 2-part left prox humerus fracture. Initial treatment with a sling full time.
On follow-up 4 wks later, patient states he wore the sling only 50% of the time. Still has pain in the shoulder. Has gross motion at the fx site on clinical exam. New x-rays attached.
My inclination is to perform ORIF with the Synthes locking prox hum plate with bone graft, but wonder about the amount of bone loss and excavation of the humeral head.
Thank you in advance for your recommendations.
Date: Thu, 24 Apr 2003 21:57:32 -0500
From: Obremskey, William T
I would agree w/ you about using the proximal humeral locking plate for this fx. Did this same case on 55yo last month and saw him in clinic today. It is still holding together. Always hard to judge version and head/neck angle. With 15 degrees of IR bicipital grove is directly anterior and head retroverted 15 degrees. It tends to fall into varus and shorten. Hold reduction with k-wires and use k-wire slot on plate attachment. K-wire in superior slot should just be superior to greater tuberosity. Try to put screws up to subchondral bone. Good Luck.
Date: Thu, 24 Apr 2003 23:00:15 -0500
From: Sciadini, Marcus
I agree with you and Dr. Obremskey regarding the implant of choice...the Synthes locking plate should work well. I would pack the defect in the proximal fragment with bone graft, but if bone quality and screw purchase is really poor, might consider cement augmentation.
Marcus F. Sciadini, M.D.
Date: Fri, 25 Apr 2003 08:31:05 -0700
From: Robert W Chandler
As an alternative, try the 90 degree blade plate:
Date: Sat, 26 Apr 2003 20:07 EST
From: Bill Burman
Note previous discussion of 90 degree blade plate and Bob Ostrum's OTA BFC talk on proximal humeral fx ORIF.
Date: Sun, 27 Apr 2003 11:49:00 -0700
From: John T. Ruth
This is a no win situation. Fixation and maintenance of fixation of this head fragment in this patient will be extremely difficult if not impossible even with locking plates. I have treated a similar patient with history of ETOH abuse. I discarded the head and did a hemiarthroplasty with repair of the tuberosities. He did well initially until he got arrested while intoxicated and was handcuffed. This produced a fracture at the tip of his stem. This did heal with a fracture brace. About 4 years later he re-appeared with gross loosening of the humeral component. He has little pain and poor function. I am not going to operate on him again. I usually do hemiarthroplasties for these types of fracture nonunions, however this patient will not do well with anything. I would consider doing nothing now.