engleski

Does teriparatide improve functional outcome by reducing pain in post traumatic avascular necrosis of humeral head?

Objective: Post traumatic avascular necrosis is one of the most common complications of the humeral head fracture. Although literature shows some beneficial effect of teriparatide treatment on other osteonecrosis locations there is no evidence yet in those cases. Materials and methods: a 56-year-old female patient, cook by profession, with a medical history positive for low back pain, presented with a right multifragmentary proximal humeral fracture with shoulder dislocation and left proximal and shaft humeral fracture, after a fall from standing height. Two surgeries were performed: proximal humeral plate on the right and intramedular fixation with long nail on the left shoulder. Physical therapy with emphasis on kinesiotherapy was performed. Six months after the start of the outpatient rehabilitation, she complained of severe pain and worsening of the right shoulder function. Right humerus X-ray verified avascular necrosis of humeral head. This prompted surgical metal extraction and continuation of rehabilitation. We performed dual-energy X-ray absorptiometry (DXA) which showed osteoporosis with T-scores as follows ; Total Spine -2.1, L1 -3.1, L2 -1.3, L3 -0.9, L4 -2.9, Total Hip -0.5, Neck -1.3. X-ray of thoracic and lumbar spine was performed and verified a grade 1 fracture on the third lumbar vertebrae. Due to the verified osteoporosis, teriparatide injections were introduced into therapy, as well as 1200 mg of calcium and 1000 IU vitamin D daily. Results: After 24 months of teriparatide treatment and approximately 3 years after initial trauma she reported mild pain in right shoulder and low back just during heavy activity. A new DXA showed improvement in T scores: Total Spine -1.4, L1 -2.2, L2 0.5, L3 -1.2, L4 -2.1, Total hip -0.6, Neck -1.5. She achieved right shoulder active abduction of 100 °, forward flexion 110°, extension 60 °, both rotations 60 °. Patient is satisfied with functional outcome and has been working for 18 months, feeling well with no limitation in her regular daily activities and her work. Conclusion: Authors believe that although repeated x rays scans showed radiologically worsening of humeral head osteonecrosis, functional outcome and reducing pain could be improved due to teriparatide treatment.

post traumatic avascular necrosis of the humeral head ; pain ; teriparatide

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