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On the floor




".... the humeral head ended up on the floor..."

Case:


Young male with high energy (closed) 4 part intra-articular proximal humeral fracture. Despite the severity and complexity of the injury the decision was made to fix the fracture and the patient was consented for ORIF (but replacement was not discussed).


The fracture was accessed via a standard delto-pectoral approach. Upon opening the capsule the broken head 'escaped' and ended up on the floor of the operating theatre, presenting a significant conundrum.


Options:


- Wash the fragment and put it back? This carries a risk of infection.

- Discard the fragment and proceed with a hemiarthroplasty, although the patient has not been consented for this?

- Close the wound, wake the patient up and explain / further planning?

- Other options?


What happened next:


The patient was not in immediate danger and so the operation was temporarily suspended. The consultant in charge of the case made several phone calls to senior / trusted colleagues. The above options were discussed and contemporaneous notes documented.


The critical fragment was placed in Betadine and copiously irrigated. It was then replaced and fixed.


Satisfactory results were achieved and the patient rehabilitated. Unfortunately it failed to unite although infection was never isolated. The patient required arthroplasty and made a complaint.


This might be the first time this has happened to you, but it's unlikely it's the first time it's happened ever

Lessons:


- Although not much literature exists on this topic, AS USUAL THIS HAS HAPPENED BEFORE! Studies on extruded Tali and ACL grafts suggest that the sooner you pick it up and put it in antiseptic the better.

- In these situations it is always wise to phone a friend and make acurate and contemporaneous notes.



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