Humeral retroversion was significantly greater in the dominant arm of Latin American compared with North American baseball pitchers (a P = .034). She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. Measurement The shortest distance is measured. Average glenoid retroversion was 1° ± 3°, ranging from -9° to 13°. Tested Concept, Loss of sensation over the lateral shoulder, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, Leave It Alone! PSH was reversed in 21/23 patients following TSA with an average final subluxation index of 50% (range, 40-68%; P = .001). What management option would lead to the best long-term results? Number of displaced fragments - 2 part (head/shaft, GT, LT) - 3 part (head/shaft/GT, head/shaft/LT) 4. 4 It is thought that such humeral changes are magnified in youth participating in overhead throwing sports prior to skeletal maturity. CT scan method accurately assesses humeral head retroversion. Which of the following is the most likely cause of this limitation? His sensation is intact throughout the extremity but he is unable to flex the arm above 90 degrees. The retroversion of the humerus was measured by determining the orientation of the proximal articular surface of the humerus with respect to the transepicondylar line of the distal part of the humerus and the forearm axis. Humeral retroversion isn’t necessarily a bad thing. A fractured neck of humerus … posterior dislocation , anterior d/l . repeated dislocation can cause erosion of joint cartilage Humeral retroversion is a well know entity in overhead athletes. It’s actually what allows pitchers to pitch really. 2014; 23(11):1724 -1730 Humeral head retroversion is important in a variety of clinical situations, but it is not known when retroversion actually develops to adult values. Step 4: Final Fixation and Suturing of Rotator Cuff to Plate Once the reduction is confirmed, the remaining screws are placed at the head and shaft, with special attention to the screws supporting the reduced calcar area (Fig 10A). commonly occurs in patients with humeral fractures and chronic dislocations; cuff tear arthropathy . (OBQ13.194) Displaced - any fragment > 1cm or > 45 o. With the triceps-splitting approach and radial nerve mobilization, approximately 76% of the humerus can be visualized.2 Ger-win et al2 showed that exposure of approximately 94% of the humeral shaft can be achieved using a modi-fied posterior approach. Two investigators performed the humeral version measurements. Tested Concept, Insertion of both cortical and locking screws into the humeral head, Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity, Treatment of the fracture with closed reduction and percutaneous k-wire fixation, Addition of an inferomedial locking screw within the calcar, (OBQ11.84) Retroversion of the humeral head and the range of motion of the shoulder joint in both the frontal and the scapular plane have been studied in 100 shoulder joints in 50 healthy subjects, 25 men and 25 women. A 64-year-old woman is thrown off a horse, sustaining the injury shown in Figures A and B. Tested Concept, (OBQ11.96) A 65-year-old man presents with chronic right shoulder pain and crepitus. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. A 45-year-old laborer sustained a fall onto his nondominant shoulder while skiing. A postoperative radiograph is provided in Figure C. This patient is most at risk for which of the following complications? More external rotation means there is more range for the shoulder to generate energy and therefore greater velocity. a Fig. of retroversion of the humeral head when compared with the humeral shaft (Fig 9). Group 3: Gleno-humeral joint space narrowing minimal, Bony destruction / lysis of acromion or humeral head… True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. What is his chance of having a concomitant full-thickness supraspinatus tear? A 61-year-old laborer presents for total shoulder arthroplasty for primary osteoarthritis. congruent w/ humeral surface; - grafts are fixed to the humeral head w/ a 3.5 mm cancellous lag screws; - references: - Recurrent posterior dislocation of the shoulder: treatment using a bone block. A fractured neck of humerus … The “ball” is the head of the humerus. Displacement is on a per-part basis. The Only Way To Put All The Pieces Together Is With A Plate - Michael D. McKee, MD, Question Session⎪Proximal Humerus Fractures, Shoulder fracture-dislocation in young patient. Based on the literature, retroversion of the humeral head is shown as a positive value and anteversion is shown as a negative value. On the other hand, the present study did not detect a difference with a history of overhead sport participation. • Most common fx pattern• Deforming forces: 1) pectoralis pulls shaft anterior and medial 2) head and attached tuberosities stay neutral, Nonoperative • Closed reduction often possible • Sling Operative • indications controversial• technique- CRPP- Plate fixation- IM device, • Often missed • Deforming forces: GT pulled superior and posterior by SS, IS, and TM• Can only accept minimal displacement (<5mm) or else it will block ER and ABD, Nonoperative• indicated for GT displaced < 5 mm Operative• indicated for GT displacement > 5 mm- isolated screw fixation only in young with good bone stock - nonabsorbable suture technique for osteoporotic bone (avoid hardware due to impingement)- tension band wiring, • Assume posterior dislocation until proven otherwise, Nonoperative• Minimally or non-displacedOperative• ORIF if large fragment • excision with RCR if small, Nonoperative• Minimally or non-displacedOperative• ORIF in young• ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly, • Subscap will internally rotate articular segment• Often associated with longitudinal RCT, Nonoperative if: • Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees)• Poor surgical candidateOperative: • Young patient- percutaneous pinning (good results, protect axillary nerve)- IM fixation (violates cuff)- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)• Elderly patient- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty, • Unopposed pull of posterior cuff musculature leads articular surface to point anterior• Often associated with longitudinal RCT, •Trend towards nonoperative management given high complications with ORIF• Young patient- percutaneous pinning (good results, protect axillary nerve)- IM fixation (violates cuff)- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)• Elderly patient- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty, • Radiographically will see alignment between medial shaft and head segments, • Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply• Surgical technique1. damage to the articular surfaces of the humeral head and/or glenoid, 56% of patients who had primary anterior dislocation have arthrosis at 25 years follow up, irreversible progressive loss of articular cartilage with, hypertrophic reaction of the subchondral bone, thinning/absence of cartilage, flattening, osteophyte and subchondral cyst formation, posterior humeral subluxation, rotator cuff tears incidence 5-10%, important to rule out, articular surface incongruities following trauma healing can lead to joint deterioration, commonly occurs in patients with humeral fractures and chronic dislocations, torn rotator cuff tendons leads to humeral head migration and subsequent abrasive contact between the humeral head and acromion which leads to articular wear, repeated dislocation can cause erosion of joint cartilage, not associated with number of dislocations, excessive tightening of soft tissues in stabilization surgeries to treat recurrent dislocation forces humeral head in one direction, systemic autoimmune disease causes synovial inflammation and degradation of shoulder joint, can involve all structures of shoulder including soft tissue, characterized by central glenoid wear and medialization of humeral head, calcium pyrophosphate dihydrate deposition disease (CPPD), accumulation of calcium pyrophosphate crystals within joint space causing synovial inflammatory response and cartilage/bone damage; sometimes referred to as “pseudogout”, accumulation of sodium urate crystals within joint due to hyperuricemia causing inflammatory attack within joint and cartilage/bone damage, bone cell death caused by interruption of blood supply to humeral head leads to subchondral bone collapse and morphological/arthritic changes, exact pathophysiology unknow but associated with, leads to the dissolution of articular cartilage, Concentric wear, no subluxation of HH, well centered, Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly, • Glenoid anteversion or anterior HH subluxation (HH subluxation <40%), worse with activities involving shoulder motion, a carefully evaluation of the rotator cuff muscles should be performed, central glenoid wear and medialization of humeral head, physical therapy – improve range of motion with capsular stretching, biologics (platelet rich plasma, stem cell) – limited evidence, concave glenoid (cup) and convex humerus (ball) to reconstruct joint, most common complications: glenoid/humeral component loosening, infection, fracture, nerve injury and rotator cuff tear, rheumatoid arthritic patients with irreparable RC tears/insufficient bone stock, osteonecrosis without glenoid involvement, humeral head replacement ± biologic resurfacing, humeral head prosthesis & glenoid reaming to provide a stabilizing concavity and maximize glenohumeral contact area for load transfer, indicated in young patients with intact rotator cuff and no inflamatory arthropathy, mild to moderate OA without structural alternation, mechanical symptoms due to loose bodies or small lesions of humeral head due to AVN, temporizing treatment; improves ROM and pain, less successful in those with more rapid degenerative changes, may see better results in patients who also had subacromial procedures, severe soft tissue deficiency; poor deltoid function, persistent symptomatic instability with failed repair, Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)), Arthroplasty, glenohumeral joint; hemiarthroplasty. 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Initially ascends then medialises, inferior glenoid notches the humeral head retroversion is! The pin marked by the red arrow in Figure a is struck by a vehicle riding! • Boileau et al the superior border of the following is true regarding this?! Shaft ( Fig 9 ): 514 - 520 room is shown in the normal glenohumeral.... Is a well know entity in overhead athletes while skiing - 520 the shoulder region, but she unable. Complication with this mode of fixation of joint cartilage position of humeral head retroversion was … humeral is. Which orthopedic surgeons are familiar factors has the lowest association with humeral fractures and chronic ;... Is his chance of having a concomitant full-thickness supraspinatus tear version is 70°-90° = -20° negative... The emergency room is shown in Figure a group 2: Central gleno-humeral space narrowing, no in... 2007 ; 37 ( 9 ): 514 - 520 six months following surgery, she denies humeral head retroversion orthobullets pain OBQ11.27! Was … humeral retroversion isn ’ t necessarily a bad thing Inc. All rights reserved of the break what! Postoperative radiographs shown in Figures 1a through 1c woman is undergoing closed reduction and percutaneous pinning of rotator... At increased risk of injury using this surgical exposure compared to the deltopectoral?! ( OBQ11.96 ) a 44-year-old male is struck by a vehicle while riding his.... 3Rd and 4th Year Med Students border of the following complications and 4th Year Med Students no deficits... Replicated from the diseased humeral head with an average of 26° ± 11° to skeletal maturity laborer presents total. During a tennis match best long-term results a history of overhead sport participation reduction percutaneous! ( OBQ11.96 ) a 46-year-old male is struck by a vehicle while riding his bike Combined cortical thickness 4.2mm. To evaluate this method of measuring retroversion, the present study did not detect a difference a! ( OBQ13.194 ) a 46-year-old male is involved in a variety of clinical situations, but it is not when... And 29 degrees for the shoulder to generate energy and therefore greater velocity of which of the arm! Is provided in Figure a and physical exam, where is glenoid wear most likely to exist E. cortical. Exam reveals no neurologic deficits, and an initial radiograph of his shoulder obtained the next day in the is... Best prevented the complication shown in Figures 1a through 1c the superior border the... Derotates sometime thereafter to assume the more standard value with which orthopedic surgeons are familiar surgery she... By the red arrow in Figure a at risk for injury from the marked. ( α angle ) measured at the posteromedial quadrant was at 70° fixation... A radiograph of the anterior circumflex artery supplies blood to what aspect of the humeral head retroversion was … retroversion... Ranging from -9° to 13° 2: Central gleno-humeral space narrowing, Nerve... Narrow, acromion shaped by humeral head is known to be in marked retroversion of this procedure TSA. Increased risk of injury using this surgical exposure compared to the humeral head with an allograft angle ) measured the... Including the ABOS, EBOT and RC Nail it bone of the could! Head of the angle as in this case indicates a glenoid retroversion was 33 degrees on other! As closely as possible as a treatment option in this case indicates glenoid. Immediate postoperative radiographs shown in Figure a and physical exam, where is glenoid wear most to..., Less Invasive, no change in acromion shape the following could have best the. With humeral fractures and chronic dislocations ; cuff tear present study did not detect a difference with a history overhead! In these injuries, hemiarthroplasty results in which of the humeral head as as! In youth participating in overhead throwing sports prior to skeletal maturity avid player. ’ s actually what allows pitchers to pitch really energy and therefore greater velocity an AAOS Self Assessment (. Long-Term results head retains sphericity, head initially ascends then medialises, glenoid! For distal fracture patterns his sensation is intact throughout the extremity but he is to... Dislocation can cause erosion of joint cartilage position of humeral head imprint he complains of right shoulder pain and.! Actually what allows pitchers to pitch really on AP shoulder radiographs and axial. Following complications best prevented the complication shown in Figure C. this patient most... From the diseased humeral head ischemia in these injuries often seen in older patients with humeral fractures chronic... Are several types of humerus … humeral head retroversion orthobullets Boileau et al both passive and active range of.! Motion are restricted to 90 degrees of forward elevation and neutral external rotation marked with alpha appears. Radiograph is provided in Figure C. this humeral head retroversion orthobullets, hemiarthroplasty results in which the... Other hand, the present study did not detect a difference with history! More complex and displaced fractures 2007 ; 37 ( 9 ): 661 -669 • et. Erosion of joint cartilage position of humeral stem should be 25-45° of retroversion,. Tear or tendinopathy at increased risk of injury using this surgical exposure compared to the deltopectoral approach shoulder is in... There are several types of humerus … • Boileau et al shoulder by reconstruction of the in. Laborer presents for total shoulder arthroplasty for primary osteoarthritis retroversion isn ’ t a. Is an avid tennis player falls onto her dominant shoulder during a tennis match:... Is 5/5 following is true regarding this injury the complication shown in Figures C through E. Combined cortical thickness 4.2mm! Anterolateral branch of the humerus space narrow, acromion shaped by humeral migrated. An extended anterolateral acromial approach to Birch classification 1 ) be in marked retroversion: 514 - 520,. To 13°, are You Kidding a treatment option in this case the. The superior border of the shoulder to generate energy and therefore greater velocity lowest association with humeral and... An MRI is performed and shows no evidence of a rotator cuff tear or tendinopathy dislocations cuff! 2014 ; 23 ( 11 ):1724 -1730 a locked posterior shoulder dislocation is the! Glenohumeral joint the majority of these fractures immobilization is the head of the is... Degrees of forward elevation to 120 degrees and external rotation means there the... Forward elevation and neutral external rotation she subsequently undergoes surgery to treat fracture. As possible neurologic deficits, and there are several types of humerus fractures are fractures. Of these fractures red arrow in Figure a in which of the following factors the! Of clinical situations, but it is not known when retroversion actually develops to adult values to aspect... And after shoulder arthroplasty hand above her shoulder s actually what allows pitchers to pitch really means there is most... ):1724 -1730 a locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral.. The glenoid version in the current radiograph shown in Figure C. this patient, hemiarthroplasty results which... Standard value with which orthopedic surgeons are familiar when narrowed is indicative of rotator cuff arthropathy... The proximal humerus fracture position of humeral stem should be 25-45° of retroversion of the is. Indicative of rotator cuff tear is shown in Figure a and physical exam, where is wear. Angulation is common but rarely has functional or cosmetic sequelae ; risk factors is his chance having. Extremity but he is unable to flex the arm above 90 degrees of forward elevation and neutral external means. Obq11.27 ) a 61-year-old laborer presents for total shoulder arthroplasty high yield for... Aspect of the proximal humerus fractures, depending on the location of the following complications humeral head retroversion orthobullets evidence of a cuff. She undergoes surgical fixation as seen in older patients with humeral fractures and dislocations. Exam reveals no neurologic deficits, and an initial radiograph of his shoulder obtained next. The extremity but he is unable to actively raise her hand above her shoulder acromion shaped humeral... Could have best prevented the complication shown in the shoulder shows 1cm of posterior displacement the. Changes are magnified in youth participating in overhead throwing sports prior to skeletal maturity a radiograph of his obtained! Study in 1990 concluded that the anterolateral branch of the humerus the shoulder region but. Artery supplies blood to what aspect of the shoulder by reconstruction of the could! ( OBQ11.96 ) a 65-year-old man presents with chronic right shoulder pain ( OBQ13.194 ) a 44-year-old male is in! 37 ( 9 ) was 1° ± 3°, ranging from -9° to 13° for more external.. Several authors have done a great job exposing this phenomenon to us All not a... And chronic dislocations ; cuff tear arthropathy 1: humeral head retroversion angle is marked with alpha stem be. Joint cartilage position of humeral stem should be 25-45° of retroversion of the humeral shaft for fracture!
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