43 yo man, left shoulder right handed

1
Clinical History
Mr ALZ. Pat.

• 43 yo man, left shoulder (right handed)
• Carpenter
• Fall on his arm at work
• -Proximal humeral fracture
• -No neurovascular problem

2
Left Shoulder
3
What is your diagnosis ?

• 2-part fracture
• 3-part fracture
• 4-part fracture
• Posterior fracture dislocation

4
Imaging
3-part fracture
5
What would be your treatment option ?

• Hemiarthroplasty
• Locking plate
• Non locking plate
• Nail
• Orthopedic treatment

6
Imaging
7
What is your feeling about this osteosynthesis ?

• Acceptable
• Not enough screws in the diaphysis
• Not enough screws in the head
• Too many screws
• I wouldnt have chosen this option

8
Clinical history

• 7 days later,
• He had pain, fever,
• His shoulder was red and warm.
• CRP 230
• An aspiration found a Staph. Aureus.

9
What would be your treatment option ?

• Remove the plate and put a sling
• Debridement and antibiotics
• Only antibiotics
• Remove the plate, the head and put an
  arthroplasty later
• Remove the plate and the infected bone and put an
  hemi at the same time

10
Clinical History

• The infection has been treated by debridement,
  antibiotics and the local and biological
  evolution has been favorable but..
• 7 months later,
• The patient is painful and he has a poor range
  of motion.
• Constant Score 35
• The strength is low.
• No clinical or biological sign of infection
• An aspiration has been done negative.

11
Imaging
True AP and Lateral views
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What is your diagnosis ?

• Infection
• Rotator cuff tear
• Non union
• Avascular necrosis

13
Imaging
14
What would be your treatment option ?

• Only bone graft
• Change the plate and put a bone graft
• Remove the plate and put a nail and bone graft
• Remove the plate and do an hemiarthroplasty
• Just a sling for 6 weeks

15
Take home messages
1- 3-part fracture -No arthroplasty 2- Be
aware of metaphyseal Comminution -Risk of non
union
16
Clinical History
Mr FEN. Ray.

• 65 yo man, left shoulder (right handed)
• Retired (non manual worker)
• Occasional Pain since 15 years
• More painful since 1 year may be after he made an
  effort
• The pain is increasing despite analgesic but
  until now no NSAI, no infiltration.
• He saw rheumatologist who asked for X rays and A
  CT.

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X rays
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What is your diagnosis ?

• Rheumatoid arthritis
• Infection
• Villo nodular synovitis
• Primary osteoarthritis
• Avascular necrosis

19
Imaging
20
What would be your diagnosis option ?
No health problem excepted the replacement of
aortic valve

• Rheumatoid arthritis
• Infection
• Villo nodular synovitis
• Primary osteoarthritis
• Avascular necrosis

21
Imaging
22
Clinical history

• He is sent to me for the treatment of this
  pathology
• The pain is major
• The patient cannot move his shoulder because its
  too painful.
• Constant score Pain 2 Activity 4
  Mobility 4 Strength 0

23
Imaging
2 months before
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What would be your treatment option ?

• Open synovectomy
• Arthroscopic synovectomy
• Synovectomy and TSA
• Synovectomy and RSA
• Other treatment

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What I did

• Biology CRP 20
• Aspiration
• Negative culture after 2 weeks
• No improvement
• I decide to do a synovectomy, resection of bone,
  culture and no arthroplasty

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Answer

• The day before surgery
• Culture of the aspiration became positive
• TUBERCULOSIS

27
Take home messages
1- Villonodular synovitis is very rare in the
shoulder 2- The clinical feeling is
important 3- Dont believe systematically the
radiologist if there is a discordance with the
clinical exam
28
Clinical History
Mr Bin. Pau.

• 56 yo man, left shoulder (right handed)
• Butcher
• Pain since 8 years
• More painful since 1 or 2 year.
• The pain is more important during effort.
• Constant Score Pain 5 Activity 9 Mobility
  24 Strength 13

29
X rays
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What is your diagnosis ?

• Fracture sequelea
• Primary osteoarthritis
• Infection
• Avascular necrosis
• Osteoarthritis and glenoid
• dysplasia

31
Imaging
32
What would be your treatment option ?

• Total shoulder arthroplasty
• Hemi arthroplasty
• Glenoidoplasty
• Reverse shoulder arthroplasty
• Osteotomy of the glenoid
• Other

33

Litterature
Sperling JBJS 2000 Incomplete ossification of
the inferior aspect of the glenoidAmong 7
arthroplasties, 4 hemi and 3 TSA3 hemi required
revision to switch to a TSA The single hemi not
revised was associated with an osteotomy
34

Key point posterior excentration
No posterior subluxation hemi Posterior sub
luxation osteotomy hemi?