Ann Thorac Surg 2007;84:1371-1372
© 2007 The Society of Thoracic Surgeons
Case Reports
Intrathoracic Humeral Head Fracture-Dislocation: Is Removal of the Humeral Head Necessary?
Bulent Kocer, MDa,*,
Gultekin Gulbahar, MDa,
Cem Nuri Aktekin, MDb,
Nesimi Gunal, MDa,
Baris Birinci, MDb,
Koray Dural, MDa,
Unal Sakinci, MDa
a Division of Thoracic Surgery, Numune Teaching and Research Hospital, Ankara, Turkey
b Division of Orthopaedics and Traumatology, Numune Teaching and Research Hospital, Ankara, Turkey
Accepted for publication May 1, 2007.
* Address correspondence to Dr Kocer, Numune Teaching and Research Hospital, Division of Thoracic Surgery, Kuleli Sok. No: 41/11 Gaziosmanpasa, Ankara, 06700, Turkey (Email: drbkocer{at}gmail.com).
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Abstract
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Intrathoracic fracture dislocation of the humeral head due to a blunt trauma is very rare. It may be accompanied by local and systemic injuries associated with high-energy trauma. Because a limited number of cases were reported, appropriate treatment modality remains unclear. A case of intrathoracic humeral head fracture-dislocation caused by a high-speed motor vehicle accident is presented herewith, along with the treatment methods used within the scope of the current literature.
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Introduction
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A fracture and intrathoracic dislocation of the humeral head (HH) is extremely rare. Literature reveals 10 cases to date. Although three of the reported cases were treated nonsurgically, seven cases were treated surgically. In two of these cases, contralateral intrathoracic migration of the HH were described [1, 2]. In the other two cases, intrathoracic humerus dislocations with greater tuberous fractures were encountered [3, 4]. In some cases, accompanying pneumothorax or hemothorax were encountered [4–7].
A 58-year-old woman was admitted to the emergency clinic of our hospital, after being injured in a high-speed motor vehicle accident. The patient complained of pain in her right shoulder and intensifying chest pain during respiration. Her medical history disclosed a 15-year history of using oral antidiabetics for diabetes mellitus. During her physical examination, a deformity and limited abduction accompanied by pain were detected in her right shoulder. The lateral wall of the right hemithorax was sensitive. Roentgenograms showed that the HH had been detached at the anatomical neck level, which was dislocated within the thorax. In addition to fractures of the first, second, and third ribs, a separate fracture line was observed at the humeral neck level (Fig 1). A computed tomographic scan of the thorax disclosed a scapular fracture and pleural fluid was observed. In addition, a fragmented caput humerus with an intrathoracic location, compressing the lung parenchyma, were noted (Fig 2). The patient was seen by a vascular surgeon. Peripheral pulses were palpable without any hematoma. A vascular Doppler examination confirmed the physical findings. The results of a neurologic examination were negative. The arm of the patient was stabilized by being placed in a sling. Oral antidiabetics were stopped and insulin treatment was started. After regulating the blood glucose level, the patient underwent surgery on the fifth day by performing a right mini-thoracotomy (Fig 3). The hemothorax was evacuated and the HH, which compressed the lung parenchyma, was removed. The lung parenchyma and the rotator cuff were found to be intact. The hemothorax was considered secondary to the intercostal vascular injury. After relieving the hemothorax, a hemiarthroplasty was performed successfully with a shoulder system procedure (Bio-Modular Shoulder System, Biomet Inc, Warsaw, IN). The patient was discharged on day 6 after the operation, with recommendations of physical therapy.
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Fig 1. An x-ray image of the patient of the proximal humerus fracture, first, second, and third rib fracture, and intrathoracically dislocated humeral head.
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Fig 2. The chest computed tomographic scan of the patient. Compression on the lung parenchyma on the right by the humeral head, scapula fracture, and pleural fluid.
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Comment
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The mechanism of dislocation of the humerus within the thorax after a high-energy trauma associated with abduction and external rotation, which then leads to an HH fracture and its confinement in the thorax has been defined [8]. Another account for a possible mechanism is the post-traumatic transmission of the force along the humeral shaft, causing the dislocation of the humerus within the thorax [6]. However, independent of the mechanism of injury, a serious trauma that can dislocate the HH in the thorax may lead to accompanying life-threatening conditions. Thus, if there was no indication for urgent surgical intervention, the patient should undergo a detailed systemic pre-surgical examination, and strategies should be determined before planning the surgery. Then the patient should be operated on after stabilization.
In direct x-ray imaging, the HH can be detected intrathoracically. However, detection of soft tissue injuries, such as pulmonary contusion, may be skipped. Some of the reported cases could not be initially identified with x-ray films [4, 8]. With suspicions of HH dislocation, based on x-ray films and physical examination findings, the diagnosis of our case was confirmed through a thoracic computed tomographic scan. There is no consensus on the proper treatment of the dislocation of an HH because of the limited number of reported cases [8]. One of the cases reported in recent years was treated nonsurgically. After the treatment, the patient was able to abduct her right shoulder to a 40° angle and suffered no respiratory symptoms [5].
One of the cases with dislocation of the humerus in the pleural cavity involved a patient who had undergone traction and reduction, and the displaced fracture of the greater tuberosity was treated nonsurgically. This treatment resulted in limited abduction and no complication [3]. Another case involved the application of reduction, with the help of digital manipulation, and was performed by internal fixation and repair of the tear of the rotator cuff, resulting in no loss of function [4].
Various therapy approaches have been attempted for the treatment of a free HH in the pleural cavity [1, 2, 6–8]. Hardcastle and Fisher [6] applied internal fixation through an open reduction in an 18-year-old patient. However, because vascular necrosis had developed 10 months later, humeral hardware had to be removed. As a result, sufficient reduction for abduction and rotation was achieved 4 years later. Glessner [7], on the other hand, removed the HH operatively and advanced the rotator cuff tendon to the humeral shaft in a 75-year-old woman. Two years later, the patient regained 50% of her shoulder joint functions. Reconstruction, using humeral implants, was another method used [1, 2, 8]. In two cases, physical therapy after reconstruction provided a successful outcome [2, 8].
It has been argued that removal of the HH from the pleural cavity might not be indicated, unless cardiovascular complications arise [5]. Furthermore, in some nonsurgically treated cases, the desired outcome has been reported [3, 5]. However, in recent years surgical treatment has prevailed when considering potential pleural symptoms and cardiopulmonary risks of the dislocated HH in the pleural cavity. For example, Harman and colleagues [8] have proposed that the HH should be removed through the injury tract if possible, and if not possible, then it should be removed through a thoracoscopy or thoracotomy. They preferred a thoracotomy and successfully removed the HH from the pleural cavity of two cases by thoracoscopy [1, 2]. In our case, the HH could not be removed through HH injury tract, and thus a mini-thoracotomy had to be performed.
In conclusion, a HH fracture dislocation is a rare occasion. In our opinion, the removal of the HH from the pleural cavity is crucial to avoid potential pleural symptoms and complications. To this end, although a thoracoscopy is the preferred surgical choice, which is also a less invasive method, in other cases in which there is no chance of a thoracoscopy, the HH can be removed and the pleural cavity can be explored through a thoracotomy. In such patients, a hemiarthroplasty is an efficient treatment modality for joint reconstruction.
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References
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- Simpson NS, Schwappach JR, Toby EB. Fracture-dislocation of the humerus with intrathoracic displacement of the humeral head. A case report J Bone Joint Surg Am 1998;80:889-891.[Free Full Text]
- Kaar TK, Rice JJ, Mullan GB. Fracture-dislocation of the shoulder with intrathoracic displacement of the humeral head fracture Injury 1995;26:638-639.[Medline]
- Hardcastle PH, Fisher TR. Intrathoracic displacement of the humeral head with fracture of the surgical neck Injury 1981;12:313-315.[Medline]
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- Harman BD, Miller NG, Probe RA. Intrathoracic head fracture-dislocation J Orthop Trauma 2004;18:112-115.[Medline]
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Abstract
Introduction
