This is a polyfragmentous, partially malunited fracture. Maybe some parts are necrotic ? What are the complaints? Pain, severely restricted ROM ? CT scan is needed. Probably, ORIF would be problematic. Maybe you should decide between Rehab leaving it like that or Hemiarthroplsty . I would do the latter.
I would recommend hemiarthroplasty if symptomatic. You might be surprised that some patients could be kept comfortable with no operative management. So just make sure that he needs something done before you pull the trigger on a surgery.
I did ORIF and bone grafting 31/2 months ago. There was a frank non union with osteoporosis. The # seemed to have united now
Hemi, Osteosynthese with this multifragm. will mostly lead to osteonecrosis.
It does look like it is uniting...but it also looks like osteonecrosis has begun. Good luck with this challenging patient.
In asymptomatic patients, I recommend a rehabilitation program. Hemiarthroplasty is the good choice for symptomatic patients.
ORIF after six months leads to AVN in many cases.
Hi to everyone. As I know the best treatment for preventing second pathologic fracture is using trip-parotid and as I know in this way there is no difference between patients with different ground disease (diabetics and non-diabetics). Bye now and good luck
He has got 90degrees of abduction and forward elevation at 31/2 months
My preference would be semi-arthroplasty, reverse shoulder in case of supplementary problems with the rotator cuff...
i think that if the humeral head vascularuty still good and no AVN i prefer locked plate with autograft
I am totally agree with Thierry for semi arthroplasty, and reverse shoulder.
1) Has it united? Do a CT if not sure
2) Does he have significant symptoms that would justify intervention?
I have no doubt that it has united and the pt was quite symptomatic to justify surgical intervention
If we have to answer the simple question of choosing a surgical intervention between the mentioned two, Hemiarthroplasty would be better than Internal Fixation.
If we have to answer the treatment of the patient we need to answer some simple initial questions.
1. What are the symptoms?
2. What are the expectations of the patient?
3. What is his occupation?
4. Is diabetes controlled or not?
5. What other comorbidities he has, if any?
6. What is the ROM?
When we establish the patient's condition, we need to ask the need of surgery.
- Can he do his daily activities without a great discomfort with the present picture (as the fracture is healed) and treat him with Physiotherapy?
In case of surgical intervention, the choice of Hemiarthroplasty versus Total Joint Replacement can be discussed according to his activities. If Hemiarthroplasty would be the answer, the type of it has to be questioned (regular or articulating with acromion - as diabetics' common risk is rotator calf rupture). In this particular patient as he is 6 months post-trauma, the muscles will be shorter due to immobilisation and lack of use and the joint maybe stiff.
I am sure that all this is questioned and answered, so Hemiarthroplasty will be the choice.
The main complaints are pain and inability to actively lift the shoulder. ROM : Abduction 70, ER 10. Diabetes reasonably controlled. No major co morbidity. Office clerk. Expect pain free ROM.
I'm confused. You say you think it has united ('I have no doubt that it has united') - if so, why are you wanting to fix or replace it?
The question then is, surely, is his cuff intact?
I am also sure that it has united. The keen arthroplasty surgeons are still interested to sacrifice the head
With the new information it will be better to have an examination/manipulation under anaesthetic to find the limits of the ROM. Then physiotherapy will be the answer and possibly review in 3 months to establish if there is any improvement. Surgery can be deferred.
I would love to see a CT scan.. I think that you still can reduce an nail this fracture. A total shoulder in a diabetic and maybe incompliant patient may end in a disaster
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