The following case is a 4 year old female who fell off a trampoline. Presented with an angulated proximal humerus fracture. She was treated with a sling. At one year followup the fracture is completely remodelled and there is no visible angulation or fracture line.
There is almost never the need for surgery in this patient population for this type of injury. However, in patients greater than 12 years of age a careful assessment of the degree of angulation and displacement needs to be done .
The indication for surgery are for:
severly displaced fractures in adolescents
<50% apposition or >45° angulation
It is important to remember that the proximal humerus in the pediatric population has:
Three centers of ossification
humeral head appears at 6 mos
greater tuberosity appears at 3 yrs
lesser tuberosity appears at 5 yrs
Secondary ossification centers unite together at age 6-7
Proximal humerus physis closes at 14-17 in girls, 16-18 in boys
80% of humerus growth comes from the proximal physis
highest proximal:distal ratio difference (femur is second with 30:70 proximal:distal ratio)
A 60 y/oF with a failed hemiarthroplasty performed at a University Center presented to our office 1
year after her surgery. Her hemi-arthroplasty was performed for proximal humerus fracture. Her problems at the time of presentation to our office were: a nonunion of tuberosities, loose humeral stem, no subscapularis
function, active forward elevation (FE) to 30 deg, intact deltoid function, anterosuperior
escape with FE of the shoulder
She had no signs of infection at the time of surgery with normal lab values (WBC, CRP, ESR) at the time of presentation. 12 cultures obtained during surgery demonstrated the presence of the p acnes bacterium.
Her problems from this surgery were:
1) Infected loose humeral stem (p acnes)
2) fracture of the humeral stem during revision surgery that required ORIF
3) Neuropraxia of the radial nerve that resolved 10 weeks after her surgery
She was seen 18 months after her operation, she had minimal pain and active forward elevation of the shoulder to 140 degrees. The Xrays are shown below
This preop xray shows that the stem was cemented, there is failure of the tuberosity healing
Anterior dislocation of the prosthesis with motion of the shoulder. Non union of the lesser tuberosity
CT scan shows failure to reproduce the retroversion of the humerus or free rotation of the stem
The failed hemi arthroplasty was revised to a reverse shoulder replacement, the humeral shaft fracture was fixed with 4.5mm DCP plate and eventually healed. Notice the working length of the plate
18 months after surgery and antibiotic treatment for 12 months she has minimal pain. The glenoid component shows no signs of loosening
Her postoperative active shoulder forward elevation is shown below.
Same authors have suggested the use of humeral allograft for the proximal humeral bone loss as seen in this case. There is no high level evidence studies to support the use of allograft. In the setting of a possible low grade p acnes infection the use of allograft would have complicated the infection further. In addition based on the following study the chances of complications after reverse arthroplasty for failed hemi-arthroplasty are high including humeral fracture as in this case.
Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary?
Patients undergoing revision shoulder arthroplasty frequently have deficient proximal humeral bone stock. Proximal humeral allograft has been recommended to augment reverse total shoulder arthroplasty (RTSA) to improve stability and function. This study reports the results of RTSA without proximal humeral allograft in patients with proximal humeral bone loss secondary to failed shoulder arthroplasty.
MATERIALS AND METHODS:
From 2005 to 2008, 251 patients were enrolled in a prospective RTSA cohort study. Significant humeral bone loss was demonstrated in 15 of 56 undergoing revision for failed arthroplasty. Average age was 67 years. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years with American Shoulder and Elbow Surgeons (ASES), Subjective Shoulder Value (SSV), Constant Score (CS), and visual analog scale (VAS) pain scores, as well as self-reported satisfaction and radiographs.
RESULTS:
Patients demonstrated significant improvement in mean CS (23.0 to 44.2), ASES (38.2 to 68.3), ASES activities of daily living (7.0 to 15.9), SSV (19.2 to 75.8), and VAS pain (4.6 to 1.6) scores. Thirteen of 15 patients reported satisfaction (87%). Range of motion improved in forward flexion (38.3° to 103.2°) and external rotation (-0.5° to 11.9°). Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture of 1 modular humeral stem.
CONCLUSIONS:
Use of RTSA for failed shoulder arthroplasty and deficient humeral bone stock provides a significant clinical benefit without the need for allograft augmentation. Monoblock humeral component use may diminish risk for prosthetic fracture.
The following case is a 55 y/o female with long history of shoulder pain and instability. She was diagnosed with cuff tear arthropathy and has no history of trauma. She has pseudoparalysis of the L shoulder with active FE of the shoulder to 45 degrees and intact deltoid muscle function. Due to pain and inability to maintain her active lifestyle she was treated with a reverse total shoulder replacement and was informed that the chances of glenoid loosening at 10 years postoperatively can be up to 25%.
The picture below demonstrates her active forward elevation
Radiographs below demonstrate a high riding humeral head, superior erosion of the glenoid and loss of glenohumeral joint space.
There are several classification systems for the cuff tear arthropathy however their value for clinical use is limited. A few of those are reported below
Type 1A - Centered stable, Minimal superior migration, C-A arch acetabularization
Type 1B - Centered medialized, Minimal superior migration, medial glenoid erosion, C-A arch acetabularization
Type 2 A - Decentered limited stable, superior translation, superior-medial erosion significant C-A arch acetabularization
Type 2 B - Decentered unstable, anteriorsuperior escape, C-A arch and anterior structures deficient Glenoid erosion in cuff tear arthropathy: Sirveaux Classification Sirveaux et al, JBJS (B), 86: 388-3985, 2004
E0: Humeral head migration without glenoid erosion E1: Concentric glenoid erosion E2: superior glenoid erosion E3: inferior glenoid erosion
Intra-operative pictures are shown below. We found no rotator cuff tendons attached to the humerus with the exception of the subscapularis tendon that was repaired at the end of surgery.
No rotator cuff seen at the time of surgery
45 degree minimal humeral cut at 30 degrees of retroversion
Glenoid exposure. Suction tip placed at the 3 o'clock position
Placement of Guide Tap tilted 15 degrees inferior
After Reaming to the subchondral plate the baseplate was inserted and a 32mm -4 glenosphere was implanted
The humeral component was implanted and sutures were placed on the humerus for repair of the subscapularis tendon.
We prefer to implant the glenosphere first and do a conservative cut on the humeral side. During the trialing process with trail only on the humeral side and sequential reaming of the humeral side and bone resection aims at balancing of the shoulder. This method allows for bone preservation on the humeral side and the chances of intraoperative glenoid fracture are minimized because of no trailing on the glenoid side.
Final Xray is seen below with inferior placement of the glenoid to avoid notching. Minimal humeral bone resection was performed
6 Months after surgery her ROM and active forward elevation has significantly improved as shown below.
The following case is a 49 y/o female who was treated with AC joint cortizone injections for 6 months (2 injections) prior to treatment of her AC joint arthritis with an arthroscopic Mumford procedure. During a previous post (please click here) it was highlighted that the CA ligament not only provides stability to the cuff deficient and cuff intact shoulder but it also has mechanoreceptors that are important for the proprioception of the shoulder joint.
During the arthroscopic procedure for AC joint arthritis we always preserve the CA ligament by placing our working instruments just medial to the CA ligament as demonstrated below. This technique allows for direct access to the AC joint and resection of 0.5 to 1 cm of distal clavicle which has been proven to prevent AC joint instability and provide adequate relief of symptoms. The posterior superior capsule needs to be preserved as well because it provides stability to the AC joint.
Most rotator cuff tears start at the articular side of the supraspinatus tendon and at the leading fibers near biceps
Love is great, but it’s actually empathy that makes the world go ‘round. Understanding other peoples’ viewpoints is so essential to human functioning that psychologists sometimes refer to empathy as “social glue, binding people together and creating harmonious relationships.”
Narcissists tend to lack this ability. Think of the charismatic co-worker who refuses to cover for a colleague who’s been in a car accident. Or the affable friend who nonetheless seems to delight in back-stabbing.
These types of individuals are what’s known as “sub-clinical” narcissists—the everyday egoists who, though they may not merit psychiatric attention, don’t make very good friends or lovers.
“If people are in a romantic relationship with a narcissist, they tend to cheat on their partners and their relationships break up sooner and end quite messily,” Erica Hepper, a psychologist at the University of Surrey in the U.K., told me. “They tend to be more deviant academically. They take credit for other peoples' work.”
Psychologists have long thought that narcissists were largely incorrigible—that there was nothing we could do to help them be more empathetic. But for a new study in the Personality and Social Psychology Bulletin, Hepper discovered a way to measurably help narcissists feel the pain of others.
First, she gathered up 282 online volunteers who hailed from various countries but were mostly young and female. They took a 41-question personality quiz designed to assess their levels of subclinical narcissism, checking boxes next to statements like “I like to have authority over other people” or “I will be a success.” They then read a story about a person named Chris who had just gone through a breakup, and then took another quiz to determine how bad they felt for Chris. The more narcissistic among them were indeed less likely to feel empathy for the fictional jilted man.
An important note here: The study participants, though they’re described as “narcissists,” were not clinically diagnosed with Narcissistic Personality Disorder, a bona-fide mental illness. Psychologists aren’t sure how much overlap there is between functional people who are very narcissistic and those who suffer from NPD. One rule of thumb, Hepper tells me, is that most ordinary narcissists are happy, while NPD tends to lead its sufferers to extreme dissatisfaction with life.
Personality and Social Psychology BulletinFor her next manipulation, Hepper and her co-authors asked a group of 95 female undergrads to take the same narcissism quiz, and then later to watch a 10-minute documentary about Susan, a victim of spousal abuse. Half were told to try to put themselves in Susan’s shoes (“Imagine how Susan feels. Try to take her perspective in the video...”), while the others were told to imagine they were watching the program on TV one evening.
The subjects who were told to take Susan’s perspective were significantly more likely to score higher on empathy. In fact, the more narcissistic they were, the more the trick seemed to work.
“I think what's going on here is that people who are low on narcissism are already responding to people—telling them what to do it isn't going to increase their empathy any further,” Hepper said. “But the higher on narcissism you get, the less empathy [you feel]. By instructing them to think about it, it activates this empathic response that was previously much weaker.”
And the narcissists weren’t just faking it. In a third experiment, Hepper showed that extreme narcissists had lower-than-average heart rates when listening to a recording of a woman in distress. (That is, “Their lack of empathy is more than skin-deep,” Hepper writes.) But if they were told to take the woman’s perspective, their heart rates leapt back up to a normal level.
Hepper thinks that eventually, this research could help shape therapeutic interventions aimed at narcissists. Teachers or human resources representatives could use such tools to try to get their resident egomaniacs to be more charitable.
Perhaps one day we can banish all the world’s narcissists to a desert island littered with tanning beds and TV cameras. Until that day, this type of compassion training might be the best weapon we have against the self-absorbed. As Hepper said, maybe it can help make the world “a nicer, more prosocial place. ”
The following case is a 50 year old male who presented in a office with a 4 part proximal humerus fracture after a fall. He underwent ORIF of the fracture using a proximal humerus locking plate. His preoperative and postoperative imaging studies as shown below. At 8 weeks post operatively he has active forward elevation to 90 degrees and assistive passive forward elevation to 160 degrees. He has an intact axillary nerve on exam and he complains of minimal pain. The postoperative Xrays demonstrate a shoulder inferior subluxation..
8 weeks postop
8 weeks postop
This finding is of limited clinical importance as most of the time within a year or two from the surgery it resolves without any functional limitations. Below please see reference:
Inferior subluxation of the humeral head can occur after shoulder trauma or surgery. One hundred consecutive patients were evaluated prospectively after shoulder surgery or injury. The radiographic incidence of inferior subluxation of the humeral head 2 weeks after rotator cuff repair was 10%. The radiographic incidence of inferior subluxation after fracture of the proximal humerus was 42%, and the incidence 2 weeks after prosthetic humeral head replacement was 60%. The immediate postoperative radiograph showed an inferior subluxation of the humeral head in 4% of patients after prosthesis insertion, but no subluxations were seen immediately after rotator cuff repair. Radiographs made immediately after fracture of the humerus showed a 16% incidence of inferior subluxation. The inferior subluxation resolved by 6 weeks in 92% of patients with humeral fractures, 96% of patients with humeral head prostheses, and all patients who had undergone rotator cuff repair. No subluxations were seen 2 years after injury or surgery. The treatment used--early active exercises and a sling when not exercising--was effective.
