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European Journal of Orthopaedic Surgery... Apr 2017Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture-dislocations. Impression fractures of the articular... (Review)
Review
Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture-dislocations. Impression fractures of the articular surface of the humeral head, followed by humeral neck fractures and fractures of the lesser and grater tuberosity, are the more common associated fractures. Multiple mechanisms have been implicated in the etiology of this traumatic entity most commonly resulting from forced muscle contraction as in epileptic seizures, electric shock or electroconvulsive therapy, major trauma such as motor vehicle accidents or other injuries involving axial loading of the arm, in an adducted, flexed and internally rotated position. Despite its' scarce appearance in daily clinical practice, posterior shoulder dislocation is of significant diagnostic and therapeutic interest because of its predilection for age groups of high functional demands (35-55 years old), in addition to high incidence of missed initial diagnosis ranging up to 79 % in some studies. Several treatment options have also been proposed to address this type of injury, ranging from non-surgical methods to humeral head reconstruction procedures or arthroplasty with no clear consensus over definitive treatment guidelines, reflecting the complexity of this injury in addition to the limited evidence provided by the literature. To enhance the literature, this article aims to present the current concepts for the diagnosis, evaluation and treatment of the patients with posterior fracture-dislocation shoulder, and to present a treatment algorithm based on the literature review and our own experience.
Topics: Algorithms; Arthroplasty, Replacement, Shoulder; Arthroscopy; Bone Transplantation; Closed Fracture Reduction; Humans; Immobilization; Open Fracture Reduction; Osteotomy; Shoulder Dislocation; Shoulder Fractures; Tendon Transfer
PubMed: 27562590
DOI: 10.1007/s00590-016-1840-5 -
Health Technology Assessment... Mar 2015Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced... (Comparative Study)
Comparative Study Randomized Controlled Trial
The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults.
BACKGROUND
Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck.
OBJECTIVE
To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults.
DESIGN
A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years.
SETTING
Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation.
PARTICIPANTS
Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck.
INTERVENTIONS
The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups.
MAIN OUTCOME MEASURES
The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected.
RESULTS
The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses.
CONCLUSIONS
Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care.
TRIAL REGISTRATION
Current Controlled Trials ISRCTN50850043.
FUNDING
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.
Topics: Aged; Casts, Surgical; Cost-Benefit Analysis; Female; Humans; Male; Middle Aged; Orthopedic Procedures; Outcome Assessment, Health Care; Radiography; Shoulder Fractures; Surveys and Questionnaires; United Kingdom
PubMed: 25822598
DOI: 10.3310/hta19240 -
The Pan African Medical Journal 2020Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9% of shoulder fracture-dislocations and often misdiagnosed during the initial... (Review)
Review
Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9% of shoulder fracture-dislocations and often misdiagnosed during the initial presentation to a physician. Though the reverse Hill-Sachs lesion is a common injury associated with posterior shoulder dislocation, the associated scapula fracture represents only 6% of the lesions associated with a posterior dislocation of the shoulder. We report the case of a neglected posterior shoulder dislocation with a reverse Hill-Sachs lesion treated by filling with an autologous graft associated with an extra articular fracture of the scapula fixed by a plate and a posterior bone end-stop because of the posterior instability. After two years of follow-up, the patient has no episode of dislocation and is satisfied with the functional result with a constant score of 68/100 points.
Topics: Autografts; Female; Follow-Up Studies; Fracture Dislocation; Humans; Joint Instability; Middle Aged; Patient Satisfaction; Scapula; Shoulder Dislocation; Shoulder Fractures
PubMed: 33088404
DOI: 10.11604/pamj.2020.36.275.25046 -
The Journal of Bone and Joint Surgery.... Mar 2005Posterior shoulder dislocations and fracture-dislocations are uncommon injuries that most often occur during seizures or as a result of high-energy trauma. Despite... (Review)
Review
Posterior shoulder dislocations and fracture-dislocations are uncommon injuries that most often occur during seizures or as a result of high-energy trauma. Despite advances in imaging, they are frequently diagnosed late. Detection is facilitated by heightened clinical suspicion of the injury in high-risk individuals together with appropriate radiographic investigation. A wide variety of operative techniques, ranging from simple closed reduction to soft-tissue and bone stabilization procedures to prosthetic arthroplasty, are available to treat these injuries. Selection of the most appropriate treatment option is complex and multifactorial. Because of the rarity of these injuries, evidence-based treatment protocols are difficult to devise. Good functional outcomes are associated with early detection and treatment of isolated posterior dislocations that are associated with a small osseous defect and are stable following closed reduction. Poor prognostic factors include late diagnosis, a large anterior defect in the humeral head, deformity or arthrosis of the humeral head, an associated fracture of the proximal part of the humerus, and the need for an arthroplasty.
Topics: Humans; Shoulder Dislocation; Shoulder Fractures
PubMed: 15741636
DOI: 10.2106/JBJS.D.02371 -
Medicine Dec 2017Proximal humerus fracture occuring simultaneously with dislocation of a shoulder in children is extremely rare, with only a few recent reports of on such cases having... (Review)
Review
RATIONALE
Proximal humerus fracture occuring simultaneously with dislocation of a shoulder in children is extremely rare, with only a few recent reports of on such cases having been reported.
PATIENT CONCERNS
A 6-year-old girl fell from a ladder and landed on her dominant right arm with pain in the right shoulder and unable to perform movements; her shoulder did not allow for passive movements as well.
DIAGNOSES
Proximal humerus fracture combined with shoulder dislocation.
INTERVENTIONS
The patient was treated with open reduction, elastic stable intramedullary nail (ESIN) fixation, immobilization with U-shape cast and shoulder spica brace.
OUTCOMES
The patient was pain-free, with full range movement of the injured shoulder and no sign of avascular necrosis in a 2-year follow-up period.
LESSONS
We recommend open reduction with ESIN fixation for severely displaced proximal humeral metaphyseal fractures with shoulder dislocation in children. Preoperative bilateral anteroposterior shoulders x-ray is needed to confirm the shoulder location.
Topics: Accidental Falls; Casts, Surgical; Child; Female; Fracture Fixation, Internal; Humans; Open Fracture Reduction; Shoulder Dislocation; Shoulder Fractures
PubMed: 29310407
DOI: 10.1097/MD.0000000000008977 -
JPMA. the Journal of the Pakistan... Aug 2022Posterior shoulder dislocation is a rare condition, while bilateral posterior shoulder fracture is extremely rare. Dislocations with a fracture of the bilateral...
Posterior shoulder dislocation is a rare condition, while bilateral posterior shoulder fracture is extremely rare. Dislocations with a fracture of the bilateral posterior shoulder are observed more often after epileptic seizures. As dislocations with posterior shoulder fracture are rare, clinicians sometimes experience difficulty in diagnosing it timely. Although it can be diagnosed and treated early, based on a proper shoulder examination and accurate radiological imagery. In the treatment of posterior shoulder dislocations, closed reduction can be performed at an early stage, while methods of osteosynthesis with open reduction or arthroplasty are the most frequently used procedures at delayed stage. In this study, it was shown for the first time in literature, that a very rare case of dislocation with bilateral posterior shoulder fracture after epileptic seizure, in a 68 years old patient, had good clinical and functional results, following simultaneous hemiarthroplasty treatment.
Topics: Humans; Aged; Hemiarthroplasty; Shoulder Fractures; Shoulder Dislocation; Fracture Fixation, Internal; Seizures; Epilepsy
PubMed: 36280938
DOI: 10.47391/JPMA.3976 -
JAMA Mar 1966
Topics: Fracture Fixation; Humans; Shoulder Dislocation; Shoulder Fractures
PubMed: 5952086
DOI: No ID Found -
Acta Bio-medica : Atenei Parmensis Sep 2016About 4% of glenohumeral dislocations are posterior and only 1% is associated with fracture of the humeral head. Most frequent causes are high energy traumas, seizures...
BACKGROUND
About 4% of glenohumeral dislocations are posterior and only 1% is associated with fracture of the humeral head. Most frequent causes are high energy traumas, seizures and electrocution. The fracture and the posterior dislocation, associated with the trauma and capsular lesion can cause an important vascular damage of the humeral head.
METHODS
We describe 5 cases of posterior fracture-dislocation of the shoulder that required open reduction and internal fixation treated using double approach: posterior approach for reduction humeral head and eventually bone and capsular posterior repair and anterior approach for osteosynthesis. A Clinical examination was performed at one year and follow-up was at two years.
CONCLUSIONS
This combined approach is less invasive, easier for dislocation reduction of the humeral head, with minimal biological damage that may occur during the reduction maneuvers. Our thought is that the posterior approach reduce vascular and bone damages during humeral head reduction and permit to suture and retention posterior capsula that is often damaged by the trauma.
Topics: Adult; Female; Fracture Fixation, Internal; Humans; Male; Middle Aged; Shoulder Dislocation; Shoulder Fractures
PubMed: 27649001
DOI: No ID Found -
BMC Musculoskeletal Disorders Jan 2021The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical...
BACKGROUND
The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA).
METHODS
This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals).
RESULTS
Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings.
CONCLUSIONS
RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved.
LEVEL OF EVIDENCE
Level III.
Topics: Aged; Arthroplasty, Replacement, Shoulder; Humans; Middle Aged; Range of Motion, Articular; Retrospective Studies; Shoulder Fractures; Shoulder Joint; Treatment Outcome
PubMed: 33419418
DOI: 10.1186/s12891-020-03903-0 -
European Journal of Orthopaedic Surgery... Apr 2017Shoulder dislocations are common. It is known that incongruent shoulder should be promptly reduced. However, when associated with fracture of the proximal humerus, there...
INTRODUCTION
Shoulder dislocations are common. It is known that incongruent shoulder should be promptly reduced. However, when associated with fracture of the proximal humerus, there is a clinical dilemma if reduction under sedation is a safe option. We wanted to establish when it is safe to attempt reduction of a shoulder fracture dislocation under sedation in emergency room.
METHODS
This is a retrospective cohort study assessing consecutive patients presenting with a dislocation of a gleno-humeral joint with an associated fracture of the humerus between 2007 and 2015. The radiographs and patients' records were examined. The number of fragments according to Neer's criteria and size of fragments were recorded.
RESULTS
We identified 102 patients who presented with 104 cases of fracture dislocation of shoulder joint. 10 of the dislocations were posterior, remainder were anterior. All posterior dislocations were reduced under general anaesthesia. Sixty-two anterior fracture dislocations had attempted reduction under sedation in emergency department. Eight of those were unsuccessful, and patient required general anaesthetic for further management. In five of those cases, significant displacement of humeral head in relation to the shaft after attempted reduction.
CONCLUSION
We propose pragmatic approach to the initial treatment of fracture dislocations of shoulder. In type I injury, where there is an anterior dislocation with greater tuberosity fracture, one should attempt a reduction under sedation; 94% of attempted reductions under sedation were successful and no fracture propagation occurred. In case of a type II injury, when the fracture is involving a surgical neck of the humerus with or without greater tuberosities fracture, our experience suggests that no attempt of reduction is undertaken under sedation and patient has general anaesthetic. Posterior dislocation with any fracture remains an unsolved problem, but in our series no attempt of reduction under sedation was made.
Topics: Adult; Aged; Aged, 80 and over; Algorithms; Anesthesia, General; Closed Fracture Reduction; Deep Sedation; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Radiography; Retrospective Studies; Shoulder Dislocation; Shoulder Fractures; Treatment Failure; Young Adult
PubMed: 28050700
DOI: 10.1007/s00590-016-1899-z