Images in Clinical Rheumatology
Poor Progression After Proximal Humerus Fracture
Evolución tórpida tras fractura humeral proximal
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=> "Servicio de Cirugía Ortopédica y Traumatología, Hospital FREMAP Sevilla, Sevilla, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital FREMAP Sevilla, Sevilla, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evolución tórpida tras fractura humeral proximal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1411 "Ancho" => 951 "Tamanyo" => 60982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image of the spacer positioned and centered in height relative to the glenoid.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Proximal humeral osteosynthesis is not without complications (45%<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>). Infection has a frequency of 0%–4%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Our objective was to report a case of osteomyelitis, after osteosynthesis and review current treatments.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Presentation</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 54-year-old male with liver disease, allergic to penicillin, presenting a proximal humeral fracture with a cervicodiaphysal angle of 80° and a trochiter ascent of 11<span class="elsevierStyleHsp" style=""></span>mm. Pl osteosynthesis was performed with a Philos plate (Synthes<span class="elsevierStyleSup">®</span>) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient began rehabilitation, with a limited arc (60° of active abduction and 50° of anterior active flexion), fever and wound seroma (ultrasound size: 25<span class="elsevierStyleHsp" style=""></span>mm×12<span class="elsevierStyleHsp" style=""></span>mm), at 2 months and 22 days after the intervention, requiring 2 surgical debridements and the taking of cultures and antibiograms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Proximal humeral osteomyelitis with stage IV B Cierny–Mader,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> due to coagulase-negative <span class="elsevierStyleItalic">Staphylococcus</span>. Culture antibiogram indicated susceptibility to penicillin, cephotaxime, erythromycin, tetracycline, levofloxacin, and vancomycin cotrimoxazole. Scintigraphic uptake (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Progression</span><p id="par0020" class="elsevierStylePara elsevierViewall">Given the pathogenic agent, the clinical progression and the increased erythrocyte sedimentation rate (ESR: 140<span class="elsevierStyleHsp" style=""></span>mm/h), we removed the material and put a spacer cemented with gentamicin (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). We postsurgically started (intravenous (iv)) clindamycin. The patient was under treatment with antibiotics PO: levofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>1/24<span class="elsevierStyleHsp" style=""></span>h vo rifampin 600<span class="elsevierStyleHsp" style=""></span>mg and 1/24<span class="elsevierStyleHsp" style=""></span>h PO for the first 3 months following surgery (considering the sensitivity of the pathogen and the patient's allergy to penicillin). Six months after intervention the infection was controlled (ESR: 17<span class="elsevierStyleHsp" style=""></span>mm/h), with an arc of 100° (flexion/active abduction). The patient refused to undergo withdrawal of the spacer. One year after surgery, the infection remained controlled, with a similar arc.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Athwal et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> recommend 3.3 surgical lavages to eradicate the infection, achieving 53 points in the <span class="elsevierStyleItalic">American Shoulder and Elbow Surgeons Score</span> (ASES), but recurrences of 50%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Seitz et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> recommend removing the material, placing a spacer with antibiotics and arthroplasty (although 33.3%<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> of patients refuse arthroplasty). Spacers improve the VAS (8.4–0.5 points), for forward flexion (65–110°) and the ASES Score (16–74 points).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Themistocleous et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> recommend keeping the spacer, eradicating osteomyelitis in 81.8% of test with a <span class="elsevierStyleItalic">Disabilities of Arm, Shoulder and Hand</span> (DASH) score of 37.5 points. Stine et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> maintain spacers if comorbidity is present, although controlling renal function, due to the risk of kidney failure.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, in humeral osteomyelitis cases, placement of a cemented spacer may be an effective treatment for infection control.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects.</span> The authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of Data.</span> The authors declare that no patient data appears in this article.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent.</span> The authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Presentation" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Progression" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Jiménez-Martín A, et al. Evolución tórpida tras fractura humeral proximal. Reumatol Clin. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2012.04.005">http://dx.doi.org/10.1016/j.reuma.2012.04.005</span>.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1267 "Ancho" => 951 "Tamanyo" => 87132 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Osteosynthesis with plate and screws. Note the impossibility of correction of the initial cervicodiaphysal angle, worsening the mobile arc and predisposing pseudoarthrosis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 892 "Ancho" => 900 "Tamanyo" => 67214 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scintigraphic uptake in the right proximal humerus.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1411 "Ancho" => 951 "Tamanyo" => 60982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image of the spacer positioned and centered in height relative to the glenoid.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute deep infection after surgical fixation of proximal humeral fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 15 | 23 |
| 2024 October | 45 | 45 | 90 |
| 2024 September | 37 | 38 | 75 |
| 2024 August | 54 | 39 | 93 |
| 2024 July | 50 | 45 | 95 |
| 2024 June | 55 | 63 | 118 |
| 2024 May | 54 | 40 | 94 |
| 2024 April | 59 | 31 | 90 |
| 2024 March | 39 | 27 | 66 |
| 2024 February | 35 | 25 | 60 |
| 2024 January | 46 | 28 | 74 |
| 2023 December | 30 | 40 | 70 |
| 2023 November | 62 | 35 | 97 |
| 2023 October | 48 | 45 | 93 |
| 2023 September | 80 | 50 | 130 |
| 2023 August | 43 | 29 | 72 |
| 2023 July | 35 | 31 | 66 |
| 2023 June | 56 | 19 | 75 |
| 2023 May | 52 | 21 | 73 |
| 2023 April | 42 | 10 | 52 |
| 2023 March | 82 | 31 | 113 |
| 2023 February | 61 | 32 | 93 |
| 2023 January | 74 | 42 | 116 |
| 2022 December | 61 | 40 | 101 |
| 2022 November | 57 | 37 | 94 |
| 2022 October | 77 | 32 | 109 |
| 2022 September | 47 | 56 | 103 |
| 2022 August | 52 | 46 | 98 |
| 2022 July | 60 | 42 | 102 |
| 2022 June | 60 | 38 | 98 |
| 2022 May | 60 | 55 | 115 |
| 2022 April | 72 | 55 | 127 |
| 2022 March | 75 | 53 | 128 |
| 2022 February | 88 | 36 | 124 |
| 2022 January | 96 | 42 | 138 |
| 2021 December | 53 | 44 | 97 |
| 2021 November | 61 | 46 | 107 |
| 2021 October | 65 | 42 | 107 |
| 2021 September | 62 | 45 | 107 |
| 2021 August | 65 | 36 | 101 |
| 2021 July | 72 | 33 | 105 |
| 2021 June | 92 | 46 | 138 |
| 2021 May | 95 | 36 | 131 |
| 2021 April | 187 | 70 | 257 |
| 2021 March | 114 | 22 | 136 |
| 2021 February | 89 | 17 | 106 |
| 2021 January | 45 | 20 | 65 |
| 2020 December | 51 | 18 | 69 |
| 2020 November | 31 | 19 | 50 |
| 2020 October | 29 | 9 | 38 |
| 2020 September | 30 | 20 | 50 |
| 2020 August | 37 | 18 | 55 |
| 2020 July | 22 | 18 | 40 |
| 2020 June | 29 | 17 | 46 |
| 2020 May | 30 | 29 | 59 |
| 2020 April | 25 | 23 | 48 |
| 2020 March | 20 | 15 | 35 |
| 2020 February | 2 | 4 | 6 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 7 | 1 | 8 |
| 2018 April | 73 | 7 | 80 |
| 2018 March | 76 | 11 | 87 |
| 2018 February | 78 | 4 | 82 |
| 2018 January | 70 | 8 | 78 |
| 2017 December | 34 | 5 | 39 |
| 2017 November | 39 | 1 | 40 |
| 2017 October | 27 | 5 | 32 |
| 2017 September | 42 | 4 | 46 |
| 2017 August | 58 | 8 | 66 |
| 2017 July | 59 | 11 | 70 |
| 2017 June | 73 | 8 | 81 |
| 2017 May | 60 | 11 | 71 |
| 2017 April | 70 | 7 | 77 |
| 2017 March | 51 | 34 | 85 |
| 2017 February | 33 | 6 | 39 |
| 2017 January | 34 | 9 | 43 |
| 2016 December | 81 | 16 | 97 |
| 2016 November | 61 | 6 | 67 |
| 2016 October | 66 | 11 | 77 |
| 2016 September | 103 | 4 | 107 |
| 2016 August | 67 | 11 | 78 |
| 2016 July | 25 | 5 | 30 |
| 2016 June | 0 | 7 | 7 |
| 2016 May | 0 | 6 | 6 |
| 2016 April | 0 | 5 | 5 |
| 2016 March | 0 | 15 | 15 |
| 2016 February | 1 | 13 | 14 |
| 2016 January | 0 | 22 | 22 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 26 | 7 | 33 |
| 2015 June | 34 | 4 | 38 |
| 2015 May | 60 | 8 | 68 |
| 2015 April | 49 | 10 | 59 |
| 2015 March | 36 | 4 | 40 |
| 2015 February | 42 | 8 | 50 |
| 2015 January | 45 | 11 | 56 |
| 2014 December | 75 | 6 | 81 |
| 2014 November | 49 | 9 | 58 |
| 2014 October | 50 | 10 | 60 |
| 2014 September | 64 | 19 | 83 |
| 2014 August | 54 | 17 | 71 |
| 2014 July | 62 | 13 | 75 |
| 2014 June | 57 | 11 | 68 |
| 2014 May | 67 | 11 | 78 |
| 2014 April | 52 | 9 | 61 |
| 2014 March | 73 | 15 | 88 |
| 2014 February | 57 | 10 | 67 |
| 2014 January | 57 | 13 | 70 |
| 2013 December | 42 | 15 | 57 |
| 2013 November | 52 | 13 | 65 |
| 2013 October | 58 | 15 | 73 |
| 2013 September | 49 | 9 | 58 |
| 2013 August | 73 | 17 | 90 |
| 2013 July | 59 | 18 | 77 |
| 2013 June | 55 | 26 | 81 |
| 2013 May | 10 | 4 | 14 |
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