Open Reduction and Internal Fixation of Posterior Fracture Dislocation of the Shoulder Made Easy!

What to Learn from this Article?

Posterior dislocated humeral fracture can be reduced by schanz screw through deltopectoral approach without increasing risk to remaining blood supply.


Case Report | Volume 7 | Issue 6 | JOCR Nov – Dec 2017 | Page 24-26| Waqar Saadat, Puneet Monga. DOI: 10.13107/jocr.2250-0685.934


Authors: Waqar Saadat [1], Puneet Monga [2]

[1] Department Trauma and Orthopaedic, Furness General Hospital, Barrow-in-Furness. UK.
[2] Department Trauma and Orthopaedic, Wrigthington, Wigan and Leigh NHS Trust, UK.

Address of Correspondence:
Dr. Waqar Saadat,
Furness General Hospital, Barrow-in-Furness, UK.
E-mail: waqar.saadat@yahoo.co.uk


Abstract

Introduction: Posteriorly dislocated humeral head fracture has a great implication, as it is associated with high risk of avascular necrosis, limited access through the deltopectoral approach, and posterior approach to the posteriorly dislocated humeral fracture increases the risk to the remaining blood supply.
Technical Tip: Posteriorly dislocated humeral fracture is approached through deltopectoral approach. Schanz pin is inserted into the humeral head to achieve purchase in the humeral head. Applying laterally directed force the humeral head is disengaged from the lateral margin of glenoid. A rotatory force then repositions the humeral head into a congruous position. Open reduction internal fixation is then carried out in a standard fashion.
Conclusion: Retrieving the humeral head from the posteriorly dislocated position in patients with posterior fracture dislocation of the shoulder can be challenge to a trauma surgeon. With this novel technique, humeral head is reduced through deltopectoral approach without increasing the risk to the remaining blood supply.
Keywords: Posterior shoulder dislocation, avascular necrosis, deltopectoral approach, Schanz screw.


Introduction
Proximal humeral fractures rank as second most common fractures of the upper extremity accounting for 4–5% of all fractures [1]. About 20% of displaced proximal humeral fractures require surgery [2]. However, functional outcome mainly depends on the age of the patient and less on the deformity [3, 4]. In fractures where adequate reduction and stable fixation cannot be achieved, and the vascularity of the head fragment is impaired or at risk, primary arthroplasty has to consider. Using anterograde, intramedullary nailing for complex fractures has considerable disadvantage of affecting rotator cuff function. For fractures where there is no significant displacement of the tuberosities, intramedullary locking nails are best option to consider in displaced two-part fractures or three- and four-part fractures [5]. Locking plate fixation has proved to be the gold standard, especially when the displacement of the tuberosities is present. Retrieving locked posteriorly dislocated humeral head can be a challenge from an anterior deltopectoral approach [6]. Insertion of rotator cuff, biceps tendon and neighboring neurovascular structures, and extramedullary fixation of proximal humeral fractures mainly has to be approached from lateral aspect [7, 8]. Only way to achieve reduction of the medial fracture zone is through indirect manipulation or across the fracture line [9]. Fluoroscopy is mandatory as direct visual control is not possible [9]. Posteriorly dislocated humeral head fracture and associated comminution has a great implication as it is associated with high risk of avascular necrosis [10]. The standard deltopectoral approach provides limited access to the posterior aspect of the proximal humerus [11] and posterior approach to the posteriorly dislocated humeral fracture increases the risk to the remaining blood supply. This poses a dilemma for the operating surgeon. We suggest a technical tip to help reduce the humeral head without increasing the risk to the remaining blood supply.

Technical Tip
Posteriorly dislocated humeral fracture (Fig. 1 and 2) is approached through deltopectoral approach. Schanz screws are intended for use with external fixator system. With the help of universal drill chuck with a T-handle, Schanz screw is manually screwed into the middle of the fracture surface the posteriorly dislocated humeral head to achieve purchase in the humeral head (Fig. 3). Applying laterally directed force, the humeral head is disengaged from the lateral margin of the glenoid (Fig. 4). A rotatory force then repositions the humeral head into a congruous position. Open reduction internal fixation is then carried out in a standard fashion.

Discussion
Undisplaced proximal humerus fractures which can be treated and managed non-operatively with favorable outcome, fractures with intra-articular extension and severe comminution require surgical fixation [2, 12]. Fracture reduction is of paramount importance in orthopedic surgery which holds true even for proximal humerus fracture [13].

Conclusion
During the deltopectoral approach, soft-tissue stripping damage the local blood supply and integrity of deltoid, which may increase the risk of avascular necrosis and delay post-operative functional recovery [14, 15, 16]. Retrieving the humeral head from the posteriorly dislocated position in patients with posterior fracture dislocation of the shoulder can be challenge to a trauma surgeon.

Clinical Message
With this novel technique, the humeral head is reduced via deltopectoral approach without increasing the risk to the remaining blood supply.

References
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Dr. Waqar Saadat Dr. Puneet Monga

How to Cite This Article: Saadat W, Monga P. Open Reduction and Internal Fixation of Posterior Fracture Dislocation of the Shoulder Made Easy. Journal of Orthopaedic Case Reports 2017 Nov-Dec; 7(6): 24-26

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