0:00

40-year-old, motor vehicle accident,

0:01

irreducible dislocation.

0:05

This case is not a secret.

0:06

Axial T1-weighted, fat-weighted imaging, water

0:10

weighted imaging, and T2 fat-suppressed sagittal

0:13

imaging, showing the humerus dislocated posteriorly.

0:18

Let's begin with our bone lesion, which is very extensive.

0:22

It occupies almost half of the

0:25

circumference of the humeral head.

0:28

And typically, defects that involve up

0:30

to 25 percent of the articular surface.

0:33

and posterior dislocations can be treated with

0:35

closed reduction if they're stable and acute.

0:38

In other words, you get them within

0:40

three weeks after dislocation.

0:43

Or, if they're unstable and not reducible, then

0:46

you have to go open and reduce them that way.

0:50

If a small defect requires surgery, uh, to stabilize

0:55

it and you have If you have injured the anterior

0:59

mechanism, then you may have to use a subscapularis

1:03

transfer to help additionally stabilize the bone.

1:06

And in this case, the subscapularis

1:09

is just completely pulverized.

1:11

It's off, and this patient is going

1:13

to require, uh, subscapularis repair.

1:17

Now typically, defects that are 25-50 percent of the surface

1:20

area, And this qualifies for that, are often treated with

1:24

transfer of the lesser tuberosity, uh, into the defect.

1:31

Patients with greater than 50 percent, uh, separation or 50

1:36

percent diminished bone surface, those are patients that are

1:41

going to get bone block transfers for further stabilization.

1:50

In the back, the labrum, believe it or not, is still on.

1:56

The capsule is this squiggly, wiggly line, no longer

2:00

attached, so it is ruptured, it's buried right here.

2:04

There's the, there's the edge of the,

2:06

free edge of the capsule right there.

2:08

This black structure is a central tendon

2:10

of the rotator cuff, so let's be clear.

2:12

Capsule, which should be coming

2:15

back here, completely ripped off.

2:18

This is just a small piece of tendon in the rotator

2:21

cuff, and the rotator cuff stops right there.

2:25

So it should be going all the way around back, it's not.

2:29

The posterior rotator cuff structures are torn.

2:32

There's another stump of the posterior

2:35

cuff in the capsule in the back.

2:37

There's a little bit of the anteroinferior IGHL.

2:42

That's injured or torn.

2:44

The subscapularis is torn.

2:46

The biceps is also torn.

2:50

So this is a, this is a massive

2:52

injury with multiple problems.

2:56

First, patient's not reducible.

2:58

So we have to go open into the OR to reduce it.

3:01

Second, we have to fix the subscapularis.

3:04

Third, we have to figure out what to do with the biceps.

3:07

Fourth, the anterior capsule is torn.

3:11

Fifth, the posterior capsule is torn.

3:14

Sixth, the posterior rotator cuff is torn.

3:17

Seventh, the anterolateral humerus has

3:20

a massive, a massive bone abnormality.

3:24

It's actually A patient that's in,

3:26

in internal rotation right now.

3:28

So that's why the position is rather

3:30

funny for a posterior, uh, dislocation.

3:33

Actually, I apologize.

3:35

He's externally rotated.

3:37

So, that's why this defect is in such a funny position.

3:41

I'm not sure of the mechanism of dislocation in this case.

3:46

But, this is going to have to be dealt

3:48

with, with either some type of subscapularis

3:51

transfer, or a bone block graft into this area.

3:55

Probably a remplissage, which is French

3:58

for filling in, is not going to do it.

4:01

And a remplissage would be sewing the torn

4:04

infraspinatus into the defect, along with some capsule.

4:09

We typically do that in simple anterior Hill

4:13

Sachs lesions, but in posterior dislocations,

4:17

this is a less commonly performed procedure.

4:20

Massive dislocation.

4:22

Locked in the dislocation position,

4:24

going to require an open reduction.