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Summary
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Proximal humerus fractures are common fractures often seen in older patients with osteoporotic bone following a ground-level fall on an outstretched arm.
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Diagnosis is made with orthogonal radiographs of the shoulder.
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Treatment with sling immobilization is indicated for minimally displaced fractures with surgical fixation versus arthroplasty indicated in more complex and displaced fractures.
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Epidemiology
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Incidence
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common
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4-6% of all fractures
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third most common non-vertebral fracture pattern seen in the elderly (>65 years old)
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two-part surgical neck fractures are most common
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Demographics
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2:1 female to male ratio
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increasing age associated with more complex fracture types
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Anatomic location
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may occur at the surgical neck, anatomic neck, greater tuberosity, and lesser tuberosity
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two-part surgical neck fractures are most common
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Risk factors
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osteoporosis
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diabetes
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epilepsy
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female gender
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Etiology
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Pathophysiology
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mechanism
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low-energy falls
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elderly with osteoporotic bone
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high-energy trauma
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young individuals
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concomitant soft tissue and neurovascular injuries
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pathoanatomy
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vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
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predictors of humeral head ischemia (Hertel criteria)
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<8 mm of calcar length attached to articular segment
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disrupted medial hinge
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increasing fracture complexity
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displacement >10mm
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angulation >45°
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predictors of humeral head ischemia does not necessarily predict subsequent avascular necrosis
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Associated conditions
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nerve injury
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axillary nerve injury most common
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arterial injury
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uncommon (incidence 5-6%), higher likelihood in older patients
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most often occur at level of surgical neck or with subcoracoid dislocation of the head
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Anatomy
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Osteology
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anatomic neck
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represents the old epiphyseal plate
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surgical neck
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represents the weakened area below head
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more often involved in fractures than anatomic neck
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average neck-shaft angle is 135 degrees
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Muscles
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pectoralis major displaces shaft anteriorly and medially
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deltoid displaces proximal fragment laterally
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supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity
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subscapularis internally rotates articular segment or lesser tuberosity
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Ligaments
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Coracohumeral ligament
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attaches to coracoid and greater tuberosity and strengthens the rotator interval
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SGHL
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restraint to inferior translation at 0° degrees of abduction (neutral rotation)
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MGHL
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resists AP translation in the midrange (~45°) of abduction
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IGHL
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restraint to AP translation at 90° degrees of abduction
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Blood Supply
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anterior humeral circumflex artery
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large number ofanastomosiswith other vessels in the proximal humerus
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branches
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anterolateral ascending branch
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arcuate artery is the terminal branch and main supply to greater tuberosity
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posterior humeral circumflex artery
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recent studies suggest it is the main blood supply to humeral head
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Classification
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AO/OTA
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organizes fractures into 3 main groups and additional subgroups based on
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fracture location
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status of the surgical neck
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presence/absence of dislocation
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Neer classification
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based on anatomic relationship of 4 segments
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greater tuberosity
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lesser tuberosity
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articular surface
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shaft
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considered a separate part if
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displacement of > 1 cm
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45° angulation
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Neer Classification
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Minimally displaced
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Two-part
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Three-part
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Four-part
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Anatomical neck
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Surgical Neck
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Greater Tuberosity
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Lesser Tuberosity
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Fracture-Dislocation
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Head Split
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Presentation
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Symptoms
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pain and swelling
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decreased motion
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Physical exam
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inspection
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extensive ecchymosis of chest, arm, and forearm
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neurovascular exam
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axillary nerve injury most common
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determine function of deltoid muscle and lateral shoulder sensation
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arterial injury may be masked by extensive collateral circulation preserving distal pulses
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examine for concomitant chest wall injuries
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Imaging
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Radiographs
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recommended views
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complete trauma series
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true AP (Grashey)
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scapular Y
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axillary
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additional views
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apical oblique
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Velpeau
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West Point axillary
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findings
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combined cortical thickness (medial + lateral thickness >4 mm)
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studies suggest correlation with increased lateral plate pullout strength
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pseudosubluxation (inferior humeral head subluxation) caused by blood in the capsule and muscular atony
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CT scan
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indications
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preoperative planning
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humeral head or greater tuberosity position uncertain
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intra-articular comminution
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concern for head-split fracture
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MRI
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indications
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rarely indicated
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useful to identify associated rotator cuff injury
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Treatment
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Nonoperative
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sling immobilization followed by progressive rehabilitation
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indications
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most proximal humerus fractures can be treated nonoperatively including
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minimally displaced surgical and anatomic neck fractures
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greater tuberosity fracture displaced < 5mm
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>5mm displacement will result in impingement with loss of abduction and external rotation
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fractures in patients who are not surgical candidates
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additional variables to consider
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age
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fracture type
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fracture displacement
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bone quality
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dominance
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general medical condition
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concurrent injuries
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outcomes
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immediate physical therapy results in faster recover
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Operative
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closed reduction percutaneous pinning (CRPP)
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indications
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2-part surgical neck fractures
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3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar
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outcomes
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considerably higher complication rate compared to ORIF, HA, and RSA
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axillary nerve at risk with lateral pins
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musculocutaneous nerve, cephalic vein, and bicep tendon at risk with anterior pins
See AlsoDistal Humeral fractures -
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ORIF
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indications
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greater tuberosity displaced > 5mm
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displaced 2-part fractures
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3-, and 4-part fractures in younger patients
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head-splitting fractures in younger patients
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outcomes
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medial support necessary for fractures with posteromedial comminution
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consider use of a fibula strut if concerned about medial support or bone quality
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calcar screw placement critical to decrease varus collapse of head
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Intramedullary nailing
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indications
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surgical neck fractures or 3-part greater tuberosity fractures in younger patients
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combined proximal humerus and humeral shaft fractures
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outcomes
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biomechanically inferior with torsional stress compared to plates
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favorable rates of fracture healing and ROM compared to ORIF
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Arthroplasty
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indications
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hemiarthroplasty
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in younger patients (40-65 years old) with complex fracture-dislocations or head-splitting components that may fail fixation
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recommended use of convertible stems to permit easier conversion to RSA if necessary in future
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reverse total shoulder
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low-demand elderly individuals with non-reconstructible tuberosities and poor bone stock
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older patients with fracture-dislocation
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reverse total shoulder arthroplasty following failed nonoperative management is associated with better functional outcomes than reverse total shoulder arthroplasty following failed open reduction and internal fixation
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outcomes
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improved results if
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anatomic tuberosity reduction and healing
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restoration of humeral height and version
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humeral height is best judged from the superior border of the pectoralis major insertion
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poor results with
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tuberosity nonunion or malunion
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retroversion of humeral component > 40°
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Treatment by Fracture Type
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Two-part fractures
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Surgical Neck
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Most common fx pattern
Deforming forces:
1) pectoralis pulls shaft anterior and medial
2) head and attached tuberosities stay neutral
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Nonoperative
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Closed reduction often possible
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Sling
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Operative
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-indications controversial
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-technique
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--- CRPP
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--- Plate fixation
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--- IM nail
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Greater tuberosity
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Often missed
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Deforming forces: GT pulled superior and posterior by SS, IS, and TM
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Can only accept minimal displacement (<5mm) or else it will block ER and ABD
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Nonoperative
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indicated forGT displaced < 5 mm
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Operative
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indicated for GTdisplacement > 5 mm
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- isolated screw fixation only in young with good bone stock
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- non-absorbable suture technique for osteoporotic bone (avoid hardware due to impingement)
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-tension band wiring
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Lesser tuberosity
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Assume posterior dislocation until proven otherwise
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Nonoperative
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Minimally or non-displaced
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Operative
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ORIF if large fragment
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excision with RCR if small
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Anatomic neck
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Rare
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Nonoperative
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Minimally or non-displaced
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Operative
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ORIF in young
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ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly
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Three-part fracture
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Surgical neck and GT
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Subscap will internally rotate articular segment
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Often associated with longitudinal RCT
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Nonoperative if:
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Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees)
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Poor surgical candidate
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Operative:
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Young patient
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- percutaneous pinning (good results, protect axillary nerve)
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- IM fixation (violates cuff)
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- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)
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Elderly patient
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- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty
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Surgical neck and LT
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Unopposed pull of posterior cuff musculature leads articular surface to point anterior
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Often associated with longitudinal RCT
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Trend towards nonoperative management given high complications with ORIF
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Young patient
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- percutaneous pinning (good results, protect axillary nerve)
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- IM fixation (violates cuff)
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- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)
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Elderly patient
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- hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty
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Four-Part Fracture
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Valgus impactedfracture
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Radiographically will see alignment between medial shaft and head segments
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Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply
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Surgical technique
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1. raise articular surface and fill defects
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2. repair tuberosities
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4-part with head-splitting fracture
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Characterized by high risk of AVN (21-75%)
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Deforming forces:
1) shaft pulled medially by pectoralis
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Young patient
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- ORIF vs. hemiarthroplasty (hemiarthroplasty favored for non-reconstructible articular surface, severe head split, extruded anatomic neck fracture)
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Elderly patient
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- hemiarthroplasty v. reverse total shoulder arthroplasty
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Techniques
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Sling immobilization followed by progressive rehabilitation
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technique
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sling for comfort x2-3wks, immediate physical therapy for early ROM
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CRPP (closed reduction percutaneous pinning)
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approach
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percutaneous
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technique
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use threaded pins but do not cross cartilage
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externally rotate shoulder during pin placement
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engage cortex 2 cm inferior to inferior border of humeral head
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complications
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with lateral pins
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risk of injury to axillary nerve
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with anterior pins
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risk of injury to biceps tendon, musculocutaneous n., cephalic vein
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possible pin migration
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ORIF
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approach
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anterior (deltopectoral)
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lateral (deltoid-splitting)
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increased risk of axillary nerve injury
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technique
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heavy nonabsorbable sutures
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figure-of-8 technique should be used for isolated greater tuberosity fx reduction and fixation (avoid hardware due to impingement)
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isolated screw
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may be used for greater tuberosity fx reduction and fixation in young patients with good bone stock
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locking plate
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screw cut-out (up to 14%) is the most common complication following ORIF with a periarticular locking plates
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more elastic than blade plate making it a better option in osteoporotic bone
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place plate lateral to the bicipital groove and pectoralis major tendon to avoid injury to the ascending branch of anterior humeral circumflex artery
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placement of an inferomedial calcar screw(s) can prevent postoperative varus collapse, especially in osteoporotic bone
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postoperative Rehabilitation
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important part of management
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best results with guided protocols (3-phase programs)
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early passive ROM
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active ROM and progressive resistance
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advanced stretching and strengthening program
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prolonged immobilization leads to stiffness
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Intramedullary nailing
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approach
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superior deltoid-splitting approach
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technique
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lock nail with trauma or pathologic fractures
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straight nails are placed through the superior articular cartilage (more central entry point)
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nails with proximal bend are placed through an entry point just medial to rotator cuff insertion
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complications
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rod migration in older patients with osteoporotic bone is a concern
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shoulder pain from violating rotator cuff
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nerve injury with interlocking screw placement
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radial nerve at risk with lateral to medial distal screw
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musculocutaneous nerve at risk with anterior to posterior distal screw
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Hemiarthroplasty
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approach
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anterior (deltopectoral)
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technique for fractures
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cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability
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place greater tuberosity ~8 mm below articular surface of humeral head (HTD = head to tuberosity distance)
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nonanatomic placement of tuberosities results in impairment in external rotation kinematics with an 8-fold increase in torque requirements
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height of the prosthesis best determined off the superior edge of the pectoralis major tendon
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5.6cm between top of humeral head and superior edge of tendon
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post-operative passive external rotation places the most stress on the lesser tuberosity fragment
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Reverse shoulder arthroplasty
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approach
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anterior (deltopectoral)
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anterolateral deltoid split
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technique for fractures
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ensure adequate glenoid bone stock
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ensure functioning deltoid muscle
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repair of the greater tuberosity is always recommended despite ability of RSA design to compensate for non-functioning tuberosities/rotator cuff
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improves range of motion
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Complications
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Screw cut-out
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incidence
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most common complication following periarticular locking plating fixation (up to 14%)
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Avascular necrosis
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risk factors
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risk factors for humeral head ischemia are not the same for developing subsequent avascular necrosis
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better tolerated than in lower extremity
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no relationship to type of fixation (plate or cerclage wires)
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Nerve injury
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incidence
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axillary nerve injury most common (up to 58% with studies using EMG)
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increased risk with lateral (deltoid-splitting) approach
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axillary nerve is usually found ~5-7cm distal to the tip of the acromion
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at risk with lateral pins in CRPP
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suprascapular nerve (up to 48%)
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musculocutaneous nerve
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at risk with anterior pins in CRPP
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Malunion
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usually varus apex-anterior or malunion of GT
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results inferior if converting from varus malunited fracture to TSA
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use reverse shoulder arthroplasty instead
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Nonunion
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most common after two-part surgical neck fracture
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treatment of chronic nonunion/malunion in the elderly should include arthroplasty
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lesser tuberosity nonunion leads to weakness with lift-off testing
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greater tuberosity nonunion after arthroplasty leads to lack of external rotation and, to a lesser degree, active shoulder elevation
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greatest risk factors for nonunion are age and smoking
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Rotator cuff injuries and dysfunction
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Long head of biceps tendon injuries
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also at risk with anterior pin in CRPP
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Missed posterior dislocation
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consider in all patients with lesser tuberosity fracture
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Adhesive capsulitis and scar tissue
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Posttraumatic arthritis
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Infection
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