Case conference

Intern 8831122 李政鴻指導老師 劉耿彰醫師

Brief history

Chief complaint Rt shoulder pain following a fall

Present illness 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 Non-smoker, Non-drinker, chews no betel

nuts.

Past History 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 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

Two-part fracture of Rt proximal humerus over the surgical neck with extensive bone loss and osteoporosis

OP notes

clover-leaf plate

Discussion

Proximal humeral fracture

Deforming force

displaced

Proximal humeral fracture

Young group: Male, high energy trauma Good bone quality

Old age group: 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 fracturesnondisplaced only minimally displaced 1 cm other segments angulated less than 45°

47% to 85% prevalence of proximal humeral fracturesconservative treatment

ManagementOpen procedures conventional plate cloverleaf, T-plate or

blade plate, and tension band wires open screw techniques.

Minimally invasive

Search

For old age, osteoporosis patientWith displaced fracture, anatomical fracture (surgical intervention)Which is the best

Key wo1rd: osteoporosis Proximal humeral fracture

ResultNo comparative study

Only cohort study, clinical trial, evaluation for one of those procedure

Review paper Nonprosthetic management of proximal humeral

fractures 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, MDCLINICAL ORTHOPAEDICS AND RELATED

RESEARCH

Number 430, pp. 176–181 January 2005

Following one yearComplications 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 unite3 patients developed an avascular necrosis of the humeral head.2 implant failures were observed due to a technical errorNo impingement

Conclusion

For proximal humeral fracture Still controversial surgical treatment Individualize Surgeon prefer

Need more extended study

For our patient

Use clover-leaf plate

May use new device Formed by the anatomy of lateral proximal

humerus Locking compression plates But expensive 50000

評論

Dr. 李宜恭雖然目前找不到有 Ramdomized trial 的研究 只有一些小的 cohort study針對 EBM 來說，這也是它目前的實證也應該要把它列出來 看看裡面人員選取是如何，怎樣的開刀方式才好，也能夠給予聽眾對於各方面術式的了解。

評論

Dr. 劉耿彰現在你讀了那麼多的文章，如果你是臨床的醫師，你要怎樣處理病人雖然新的工具很不錯 ，不過也要individualize, 更要醫師自己選擇熟悉的方式來處理，如果不熟悉而硬要去做反而會得不到預期的效果