Complications and Difficulties Encountered in the Management of a Neglected Osteoporotic Proximal Humerus Fracture.

Introduction: Osteoporosis is a known complication of prolonged steroid therapy. Osteoporotic fracture is common in such a scenario and poses several challenges in its management. We present a case of neglected proximal humerus fracture in a 57-year-old osteoporotic female and the difficulties encountered in its management. Case Report: A 57- year-old female, rheumatoid arthritis patient, is on steroids for the past ten years. Four years back, she sustained a fracture of the left humerus neck following a trivial trauma. The fracture was not managed by an orthopaedician and was treated by a general practitioner. She presented to us in a state of painless displaced non-union of fragments with severe osteoporosis. DEXA scan revealed severe osteoporosis. She was started on oral calcium, magnesium, and vitamin D supplementation. Along with oral supplementation, the patient was advised 20 mcg of Teriparatide subcutaneously once daily and single dose of Denosumab 60 mg subcutaneously. Non -vascularized free fibular graft was harvested from the ipsilateral lower limb. A five-hole PHILOS plate was used to fix the fracture. Intra-operatively, the humeral head appeared too indistinct under fluoroscopy leading to difficulty in estimating screw length. An indirect method was used to assess the screw length. The post-operative radiograph was satisfactory but radiograph after two weeks showed an un-displaced fracture adjacent to the distal end of the plate. It was decided to continue with conservative management by a "'U"' cast. A follow- up radiograph at three months showed complete union of the stress fracture at the distal end of the plate end and progressive union of the fracture at the primary site. But En- block pull-out of the locking plate was noticed in the distal fragment of the fracture in the follow-up radiograph at 9 months from surgery. The limb was further immobilized in an arm sling for more four weeks. At one year from operation, there was good union of fracture with acceptable shoulder movement. Conclusion: Osteoporotic fractures are often difficult to treat. Careful pre-operative planning, active osteoporosis management, good implant selection, careful bone handling, and judicious rehabilitation are key to avoid complications and achieve good functional outcome.