Khoula Hospital Orthopedic rotation
Case write-up of:
Proximal humeral fracture
Prepared by: Name: Abdulnasser Al-Adawi ID: 42407
Name: Ahmed Said Al Barami Age: 48 years oldSex: Male Nationality: Omani
Place: Salalah
Patient ID: 625808 y
Presenting Complain: Right
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shoulder pain with difficulty in movement since 15 days
History of P/C: Ahmed had an electrical shock before 15 days while standing at chair fixing a fan socket, then he fall down on the floor directly on his right shoulder. But he didnt lose consciousness. He went to Salalah Hospital and x-ray was done where he diagnosed to have a posterior dislocation and proximal fracture of head of humerous. His shoulder reduced and sent home. After 2 weeks he came to Khoula Hospital through A & E because of shoulder pain.
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Systemic
Review:
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CNS: no headache, no dizziness, no fainting
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GI: no constipation, no diarrhea, no abdominal pain
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RS:
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CVS: no palpitation, no ankle swelling
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GUS: no dysuria,no haematuria, no genital swelling
no cough, no chest pain, no haemoptysis
PMH: -
No similar condition before or any previous fracture
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Not k/c/o HTN, DM or any chronic diseases
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No operation done previously
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No allergy to food or drugs
Family
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History:
No chronic diseases like HTN, DM
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Social
history:
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Retired
from work
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Married with 4 kids
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Ex-smoker
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Not alcoholic drinker
Examination:
- General: - Pt. alert and oriented - Seems to have little pain especially when moving - No signs of dehydration, cyanosis, clubbing, pallor, jaundice or lymphoadenopathy.
Vitals: Temp.: 37.3 Wt.: 90
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PR: 86 Ht.: 164
RR:
16
BP: 136/70 BMI: 33.47
Specific (right shoulder):
- LookNormal skin color with no scar Little
muscle wasting
Little
shoulder drop on affected side
- FeelNo local rise of temperature Sensation Very
intact
tender at the site of joint
- MoveVery difficult for the pt. because of severe pain but it shows limited movements like abduction and external rotation.
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Systemic:
* Musculoskeletal:
- Normal elbow and wrist joints of affected side - All other joints are intact and show normal range of movement - Normal movement of lower and upper limbs - Normal rip cage with no tenderness when breathing - Normal spine with no tenderness or any shape deformity - Normal GAIT
* Neurological: - General pt. with good mood, memory and oriented to place & people. No neck stiffness. - Glasgow coma scale= 15 - Cranial nerves all intact - Motor normal muscle tone, muscle power and reflexes of the whole body except right arm where muscle power obviously reduced (Grade 4) - Sensory intact
* Abdomen: - InspectionCentral obesity Centrally, No
inverted umbilicus
obvious mass
- Palpation Soft, non tender No
organomegaly or mass detected
- PercussionNormal tympanic sound - AuscultationNormal bowel sound No
bruits heard
- Rectal examination not done
*Chest: - Normal chest expansion - No scars or redness - No tenderness or tracheal deviation - Resonant percussion - Normal breathing sound, no crepitation
*CVS: - Normal S1 , S2sounds&no added murmur
- Normal pulse of arteries of both side (carotid, radial, posterior tibialis and dorsalis pedas)
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Investigations:
- AP view of right shoulder shows
a comminuted fracture at the posterior medial aspect of head of humerous. (Like this picture)
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Summary:
Ahmed, 48yr old Omani male from Salalah presented through A & E with Rt. Shoulder pain and difficulty in moving it since around 2 weeks. He had a direct injury to his right shoulder after an electrical shock without LOC. On examination, there were little muscle wasting, tenderness and limited ROM. X-ray showed comminuted fracture at posterior medial aspect of humeral head.
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Management (Surgery):
- Pre-operative: - Pre-operative diagnosis: comminuted fracture of post. medial aspect of humeral head
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Case Discussion:
- Proximal humeral fracture: Is a common injury to the shoulder(accounting for 47% of all fractures of the shoulder girdle). Especially common in elderly individuals due to osteoporosis, proximal humerous fractures are among the most common broken bones. While in adult its mainly due to direct trauma. The proximal humerous is part of the shoulder joint, and it also is the attachment of the important rotator cuff muscles. These muscles help with movement of the shoulder, and injury to the proximal humerous can affect the function of these muscles.
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C lassification:
1) By anatomical neck, epiphyseal or surgical neck. 2) By Neer classification: 1234-
Anatomical neck Greater tubersity Lesser tubersity Surgical neck
Displacement of a fracture fragment by 1 cm, or angulation between fracture fragments of 45° or greater, is what defines a fragment as being a "separate" part. Hence, a proximal humerousfractures may be called 2-part, 3-part or 4-part depending upon the amount of displacement and angulation seen on x -ray.
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Diagnosis:
Mainly done by x-ray
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T reatment:
Most often, proximal humerous fractures are not badly displaced, and will heal with simple management in sling and rest. 2-part fractures can usually be reduced closed; the arm is then bandaged to the chest for 3 or 4 weeks, after which shoulder exercises are commence. 3-part fractures in young, active individuals usually require open reduction and internal fixation with a plate and screw s. In elderly pt. with osteoporotic bone, the results are less certain and manipulative reduction followed by physiotherapy maybe equally satisfactory in the long term. 4-part fractures which carry additional risks of incomplete reduction, non-union and avascular necrosis of the humeral head, are best treated by prosthetic replacement, especially in elderly pt.
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C omplications:
1) Shoulder dislocation (depends on the direction of trauma) 2) Vascular and nerve injuries (need an urgent attention) 3) Stiffness (minimized by early exercise) 4) Malunion or non-union 5) Post-op infection 6) Loss of fixation or implant failure
References: (1) Apleys Concise System of O RTHOPAEDICS AND F RACTURES, 3 edition. Louis Solomon, David J. Warwick, SelvaduraiNayagam. (2) www.shouldersurgeon.com (3) www.emidicine.com (4) orthopedico.blogspot.com
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