Monday, April 11, 2016

Total shoulder - tuberosity fracture and pseudoparalysis

We were recently referred a patient who had had a total shoulder for arthritis. It is of note on the preoperative film that the head was in slight varus with a cyst in the tuberosity.

A total shoulder was performed.

Close examination revealed a displaced fracture of the greater tuberosity.

Which seems to have resorbed with time - no possibility of reconstructing the cuff.

The humerus is now superiorly displaced because of the resulting supraspinatus deficiency.  The patient has pseudoparalysis. It appears that there may be some rocking horse loosening of the glenoid component.

A reverse total shoulder is being considered with the plan to leave the glenoid peg and cement in place to help fix the glenosphere.

This case is presented to show the relationship of preoperative anatomy to the challenges faced at surgery, especially if a prosthesis with a large stem is used.

Our preference is to use a small humeral stem with impaction grafting and a glenoid component inserted with minimal cement as shown below. Should a revision become necessary, plenty of secure bone stock remains on both sides of the articulation and the risk of stress shielding is minimized.



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