Readin' Med

This might be good news. Might.

Computed tomography of the left shoulder shows a comminuted, impacted and infra-articular fracture of the proximal end of the left humerus. The anatomic neck is impacted into the humeral head cleaving the humeral head into several fragments which are in close apposition to each other. The shaft is displaced slightly laterally and superiorly with the humeral head fragments rotated medially and inferiorly on the humeral shaft. There is mild upward subluxation of the humeral head on the glenoid. There is no significant joint space widening and there are no free fragments of bone identified within the glenohumeral joint.

There is no-fracture of the bony glenoid. There is no fracture of the scapula. There is no fracture or separation about the acromioclavicular joint.

The soft tissue windows show mild edema of the deltoid and pectoralis muscles and there is a mild degree of supraclavicular edema and subcutaneous edema over the anterior aspect of the shoulder. There is no hematoma identified in the soft tissues.

And here's what I get from that.

Remember that the humerus looks like a golf club, with the head of the club being the offset head of the bone. When I fell, the shaft pushed into the anatomic neck (more or less the base of the club head), splitting the head into multiple fragments which are still close to each other. The shaft has shifted slightly, and it moved in and possibly up out of the groove where it meets the shoulder to form the joint, but no bone fragments are apparent in that area. The part of the shoulder where the humerus joins to form the shoulder joint meets looks intact. There is evidence that there was bleeding. The muscles areas are slightly swollen.

When the humerus head breaks into chunks, mobility goes way down; hence my problem. I'm wearing the shoulder immobilizer to keep those chunks from shifting and doing damage to themselves or the socket. (Like forming chips; not good because they cause abrasion and wear on the socket.) If they're close enough, they can actually remerge on their own by forming connections via calcium buildup. In that case, surgery isn't needed. If they aren't close enough, or malform, it is. Even if I do need surgery, the shoulder appears intact. There's a chance only relatively minor surgery would be needed -- screws and such to contain the fragments rather than bone replacement and possibly partial shoulder replacement.

Here's an example of what I'd like to have happen, found here:

This is the radiograph of a 50 year old, otherwise normal woman who presented with a comminuted fracture of her proximal humerus sustained in a fall (see figure 1). She had a normal neurovascular examination.

Our concerns include :

1. Could this fracture be successfully managed non-operatively?
2. If operative intervention were necessary, what would be the best method of internal fixation?

Management

The fracture was managed nonoperatively. At 6 weeks the radiographs (see figure 2) showed early callous and the position remained acceptable so gentle motion was commenced. Twelve months later the fracture was solidly united. She had full use of her arm and a full range of movement both of her shoulder and elbow.

Let's hope, shall we?