Patient age and gender:
25 yearold Male
History of present illness:
A 25yearold righthand dominant male presented
after a quad bike accident where the vehicle stalled while ascending a hill,
rolled back, and tipped over, causing him to land directly on his right
shoulder. He was wearing a helmet at the time and denied any loss of
consciousness or head trauma. He reported isolated right shoulder pain with
no other injuries or antecedent pain, and there were no attempted treatments
prior to hospital evaluation.
Relevant past medical history:
No significant past medical history.
Relevant physical findings:
Examination of the right upper extremity:
significant anterior shoulder swelling and tenderness to palpation throughout
the anterior aspect of the shoulder. There was no tenderness noted over the
distal right arm, left arm, or lower extremities. Sensation was intact in the
axillary (sergeant’s patch), radial, median, and ulnar nerve distributions, with
brisk capillary refill to the hand. No focal neurological deficits were present.
There was no cervical spine, thoracic spine, lumbar spine, or lower extremity
tenderness, and the patient demonstrated full range of motion of the neck.
Interpretation of laboratory and imaging studies:
Preoperative radiographs of
the right shoulder demonstrated a threepart fracture of the proximal right
humerus, with the articular segment separated and anteriorly dislocated from
the glenoid, with separate fracture of the greater tuberosity. CT imaging
further delineated a threepart fracture of the proximal right humerus, with the
largest fragment containing the entirety of the articular surface and a portion
of the medial proximal diaphysis, displaced and translated anteriorly relative
to the glenoid, and avulsion of the greater tuberosity.
Diagnoses (differential diagnoses):
Three part proximal right humerus fracture
dislocation with anterior dislocation of the articular segment and separate
Treatment plan (operative and nonoperative options:
Nonop: Nonoperative
management options for this displaced, multipart proximal humerus fracture
with anterior dislocation include prolonged immobilization with a sling, pain
management, and physical therapy after a period of immobilization. However,
given the degree of displacement and dislocation of anterior segment,
nonoperative treatment would likely result in poor functional outcomes,
significant stiffness, and increased risk of malunion. Operative: Surgical
options discussed included open reduction and internal fixation of the
proximal humerus to improve alignment, stability, and joint congruity.
Operative intervention was chosen to optimize function and shoulder
mechanics given the patient’s age, activity level, the complex fracture pattern,
and dislocation.
Primary surgical indications:
The patient sustained a multipart proximal
humerus fracture with dislocation of the articular segment, resulting in loss of
shoulder alignment and risk of lasting dysfunction if left untreated. Given his
young age, functional demands, and the displacement seen on advanced
imaging, nonoperative means would not restore anatomy or shoulder
function. The decision for operative fixation was driven by the need to restore
joint congruity, optimize range of motion, and minimize longterm disability.
Procedure(s) and date(s) of surgery:
04/27/2024 Open reduction and internal fixation proximal humerus fracture
Length of surgery:
2 hours 36 minutes.
Estimated blood Loss:
250 cc
Postoperative course:
: POD 0: arm in sling, incision dressed, pain controlled,
instructed to keep in sling at most times, no external rotation beyond neutral,
no forward flexion beyond 90°, gentle pendulums allowed. POD 1: Aquacel
dressing with mild spotting stable, able to recruit deltoid, sensation intact
lateral deltoid, abduction limited by pain, neurovascular exam normal distally,
xray shows acceptable reduction, cleared for discharge when pain controlled,
weightbearing restricted to 〈1 lb R hand, sling use con’t, continue ROM
restrictions. POD 362 (52 wk): the patient was lost to follow up despite
multiple attempts to have him return for follow up. A certified letter was sent
by the clinic but still no response.
Date of most recent followup:
4/28/2024
Is the patient happy with the outcome?
The patient reported satisfaction at
discharge and was eager to return to his home city, noting improvement in
pain control and functional recovery during the immediate postoperative
period.
Are you happy with the outcome?
Yes, overall I felt the reduction and fixation
of the shoulder was acceptable, even though there was mild residual
displacement noted.
What went well in this case?
The patient achieved satisfactory reduction and
fixation, maintained shoulder stability, and demonstrated improvement in
function with an uncomplicated hospitalization and discharge.
What might you do differently in future?
I would reinforce the need for timely
postoperative clinic followup to ensure longterm outcome assessment and
radiographic monitoring.
