Authors: Dr Amie Jade Ford, Dr Maninder Bhambra, Dr Hossam Ghazzawi, Worcester Royal Hospital

We, the authors, have no conflict of interest.

Abstract:

We present an unusual case of an attempt at reducing an anterior shoulder dislocation, resulting in subsequent shearing of the humeral head and proximal humeral head (PHF) fracture, requiring surgical intervention in the form of reverse total shoulder arthroplasty.

Background:

The shoulder is the most commonly dislocated major joint in the human body comprising up to 45% of dislocations (1). Kocher's manoeuvre is one of the methods used for reduction of anterior shoulder dislocation. There are many documented complications of the Kochers method of reduction, including injury to the brachial plexus and axillary vessels, avulsion of the rotator cuff (2) and fracture of the humerus during manipulation (3). The fracture of the proximal humerus does complicate the treatment of the dislocation and requires fracture stablisation that has attendant risks of non-union, avascular necrosis, post-traumatic arthritis and infection (4). In recent years, reverse shoulder arthroplasty gained acceptance as an alternative treatment for complex PHF in elderly patients because it relies on the deltoid muscle to restore shoulder function and hence circumvents poor tuberosity healing or concomitant rotator cuff tears (5,6).

Case report:

A 76 year old retired gentleman with no past medical history of note self-presented to accident and emergency following a mechanical fall at home, landing forwards on to outstretched hands. His primary presenting complaint was pain and deformity to the left shoulder.

On examination the patient was systemically well and observations remained stable throughout with a gross deformity to the left shoulder. The left upper limb remained neurovascularly intact, radial artery was palpable; median, ulnar and radial sensation intact and he was able to wiggle fingers and thumb.  There were also concurrent superficial injuries to the face and left arm which were managed with simple dressings.

X-Ray imaging was obtained to confirm the suspected dislocation and to assess position with a view to potential reduction.

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Figures 1 and 2: PA and lateral X-Rays showing dislocation of the left shoulder with no glenoid fracture involvement and left distal greater tuberosity fracture.

On review of these images a plan was made by the trauma and orthopaedic (T+O) team to reduce in A&E. The patient was sedated with Propofol 50mg + 20mg + 20mg and Alfentanyl 250mcg and a reduction was attempted using the Kocher technique.

Following the first attempt at reduction, the left deltoid had subjectively decreased sensation to light touch; median, ulnar and radial remained intact and pulses remained palpable. Swelling and tenderness of the left shoulder joint was still apparent.

Further imaging was requested to confirm realignment of the glenohumeral joint.

 

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Figures 3, 4, 5: X-Rays showing a sheared humeral head sitting in the axilla.

Unfortunately this reduction attempt had resulted in a proximal humeral head (PHF) fracture, concomitant shearing of the humeral head and displacement into the axilla. The T&O on-call team reviewed the images and a decision for surgical intervention was made.

The patient underwent a reverse total shoulder arthroplasty to good effect as evidenced below by the final imaging.

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Figure 6: X-Ray showing successful placement of the reverse total shoulder arthroplasty following iatrogenic proximal humeral head fracture.

 

Key Learning Points:

  • Imaging is essential prior to reduction in order to gain an accurate glenohumeral relationship and consider any existing fractures that may hinder reduction techniques and potentially causing further injury.
  • Surgical reduction should be considered in those with pre-existing fractures, including iatrogenic, or risk factors such as osteoporosis.
  • Acute medical staff should be aware of potential complications of reductions such as non-union, avascular necrosis, post-traumatic arthritis and infection.
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References:

 

  1. Green DP, Rockwood CA, Bucholz RW, Heckman JD. Rockwood and Green's Fractures in Adults. 4. Philadelphia: Lippincott; 1996. p. 1215.

  2. De Palma AF. Surgery of the Shoulder. 2. Philadelphia; JB Lippincott; 1973. pp. 358–359

  3. Rockwood CA, Green DP, Bucholz RW. Rockwood and Green's Fractures in Adults. 3. Philadelphia: JB Lippincott; 1991. pp. 1088–1090.

  4. Ogawa K, Yoshida A, Inokuchi W. Posterior shoulder dislocation associated with fracture of the humeral anatomic neck: Treatment guidelines and long term outcomes. J Trauma. 1999;46:318–323.

  5. Cuff DJ, Pupello DR (2013) Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am 95:2050–2055

  6. Mata-Fink A, Meinke M, Jones C et al (2013) Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg 22:1737–1748

 

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