Ann Thorac Surg 2007;84:1400
© 2007 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Intrathoracic Displacement of a Fractured Humeral Head
Noreen C. Griffin, CNPa,
Roy T. Temes, MD, MBAb,*,
Inderjit S. Gill, MDb,
Thomas W. Rice, MDb
a MetroHealth Medical Center, Cleveland, Ohio
b Cleveland Clinic, Cleveland, Ohio
* Address correspondence to Dr Temes, Cardiothoracic Surgery, S-325, 2500 MetroHealth Dr, Cleveland, OH 44109-1998 (Email: temest{at}ccf.org).
A 78-year-old woman fell on her right side while walking in a parking lot. She presented to another hospital complaining of right shoulder pain and shortness of breath. There were decreased breath sounds on the right side and subcutaneous emphysema was present bilaterally. A chest roentgenogram revealed a right hemopneumothorax, fractures of the third and fourth right ribs, and a complex fracture of the proximal right humerus (Fig 1). Although the head of the humerus was within the right pleural space, the rib fragments were not significantly displaced. A computed tomographic scan of the chest did not show major pulmonary injury (Fig 2). A right-sided chest tube was placed. Her air leak was resolved, her chest tube was removed, and she was discharged 8 days after injury.
Six weeks after injury a magnetic resonance image of the thoracic inlet showed no injury of the brachial plexus, subclavian artery, or subclavian vein. She underwent right thorascopy and removal of the migrated humeral head. The procedure was hampered by extensive adhesions. The humeral head was embedded within the lung. It was enucleated using blunt and electrocautery dissection, and removed through an enlarged port using a bag retrieval system. Pathology was benign and her postoperative course was unremarkable.
Her humerus fracture was managed with physical therapy. Roentgenograms at 7 months after injury showed healed fractures with malunion of the humeral tuberosities. The humerus articulates with the glenoid and degenerative changes of the joint were present. However the patient had good range of motion, satisfactory strength, and minimal pain in the arm. Consequently the orthopedic surgeons anticipate continued nonoperative management. Arthroplasty may be required in the future for posttraumatic arthritis.
