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Case conference

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

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Case conference

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

  2. 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

  3. 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

  4. 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

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

  6. Discussion • Proximal humeral fracture

  7. Deforming force displaced

  8. 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

  9. 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:

  10. Undisplaced • One-part fractures • nondisplaced • only minimally displaced • 1 cm other segments • angulated less than 45° • 47% to 85% prevalence of proximalhumeralfractures • conservative treatment

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

  12. Search • For old age, osteoporosis patient • With displaced fracture, anatomical fracture (surgical intervention) • Which is the best • Key wo1rd: • osteoporosis • Proximal humeral fracture

  13. Result • No 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

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

  15. 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

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

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

  18. 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

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

  20. 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

  21. 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。

  22. 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

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