Introduction

Among the gleno-humeral fracture-dislocations which have been reported in Literature, those ones, concerning an intrathoracic displacement of the humeral head, are by far the least common. [₁, ₂, ₃, ₄]

Intrathoracic fracture-dislocation of the humeral head is an uncommon injury, usually associated with high-impact trauma. Various methods to treat such injury have been described. We report a case of a two-part humeral head fracture with concomitant intrathoracic dislocation treated with thoracotomy.

Case Report

A 69 year-old, right-handed man was seen in the Emergency Department (ED) after sustaining a high-impact fall down a ladder. He had used his right upper limb to break the fall, and subsequently reported dyspnea, severe pain in his right shoulder and elbow. Apart from this, he sustained no other injuries. On examination, his right forearm and shoulder were exquisitely tender, and no range of motion was possible. There were no associated neurovascular injuries. Radiographs done in ED showed a closed comminuted right humeral head fracture with concomitant intrathoracic dislocation of the humeral head; multiple right rib fractures and closed displaced fractures of the left proximal radius and ulna (Figure 1).

Figure 1

Figure 1: Posterior-Anterior chest roentgenogram: right humeral head fracture with concomitant intrathoracic dislocation (arrow), and multiple right rib fractures.

Computed Tomography (CT) of the chest and right shoulder showed a two-part humeral head fracture with intrathoracic dislocation with fractures of the second and third ribs, and right upper lobe contusion (Figure 2).

Figure 2

Figure 2: Computed Tomography (CT) of the chest: humeral head fracture with intrathoracic dislocation with fractures of the second and third ribs, and right upper lobe contusion.

The distal left radius and ulna fractures were promptly treated with open reduction and internal fixation. The dislocated humeral head was removed with a right lateral thoracotomy (Figure 3).

Figure 3

Figure 3: Dislocated humeral head removed.

According with the intra-operative findings, the humeral head appeared to have passed through the second and third ribs, stopping against the right upper lung lobe which appeared contused. Intra-operatively, the fractured humeral head was noted to be devoid of any soft tissue connections. Meanwhile, his right upper limb was immobilized with an arm sling. Postoperatively, the patient was commenced on a shoulder and a respiratory rehabilitation schedule, starting with muscle strengthening and pendulum motion exercises for one month. Three months after the previous operation, the patient underwent another operation to implant a total shoulder arthroplasty in order to improve the range of motion of the shoulder. He had no complaint of right shoulder pain and had since returned to his previous quality of life.

Discussion

Fracture-dislocation of the humeral head is a rare but severely disabling injury. [₁, ₂, ₃, ₄] The diagnosis is frequently delayed or missed, in view of its rarity and paucity of telltale physical signs and failure to make adequate radiographs. [₅] One should raise the suspicion of a fracture-dislocation when a patient reports shoulder pain and inability to move his shoulder following a trauma. [₆] Physical signs may be subtle and easily missed, if not actively sought. They include internal rotation contracture with the shoulder having zero degree of external rotation. This occurs because the dislocated humeral head gets locked behind the glenoid. Other signs, which may be present, include a prominent coracoid process, flattening of the anterior aspect of the shoulder, and prominence over the back of the shoulder. [₇] More specific physical and radiographic signs could raise the suspects of an intrathoracic dislocation of the humeral head: i.e., a rigid and abducted upper limb which appears foreshortened, an increased intercostals space and an outline of pleura around the humeral head. A standard trauma roentgenograms series is mandatory and it should include a true antero-posterior radiograph of the scapula, a lateral scapular view, obtained with the patient in a 60° anterior oblique position, and an axillary view. CT scans provide the most reliable informations and are quite helpful in many instances including the evaluation of intra-articular fractures to evaluate the degree and nature of damage to the joint surface and the evaluation of fracture displacement. [₈] Prompt diagnosis and treatment of the fracture is of paramount importance in preventing avascular necrosis and subsequent collapse of the humeral head. The evaluation of the risk of post-traumatic avascular necrosis of the humeral head requires knowledge of its blood supply. [₉] Selection of the most appropriate treatment option is complex and multifactorial. Due to the rarity of the injury, evidence based treatment protocols are difficult to devise. Hence, treatment needs to be individualized according to the demographics of the patient. Deciding on the optimal choice of management requires taking various factors into consideration, i.e. age, occupation, medical status and lifestyle of the patient, degree of devascularisation, and fragmentation of the humeral head and bone quality. In our patient, non-operative management is unacceptable, given the patient's relatively young age, occupation and active lifestyle. [₁] However, the patient's age is once again a relative contraindication to this choice of management, because he is most likely to outlive and outlast the longevity of his prosthesis, requiring further revision surgery later in his lifetime.

Correspondence to

Luca Bertolaccini, MD PhD FESTS Division of General Thoracic Surgery Maria Vittoria Hospital Via Cibrario 72 – 10149 Turin (Italy) Tel: +39-011-4393447 Fax: +39-011-4393403 E-mail: l.bertolaccini@asl3.to.it