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A 31-year-old woman with left shoulder trauma
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A 31-year-old right-hand dominant woman presented to the Yale New Haven Hospital’s Emergency Department as a polytrauma patient following a head-on motor vehicle collision. She was a restrained driver and experienced loss of consciousness. However, she had a Glasgow Coma Scale score of 15 on arrival. She had bilateral upper extremity deformities. The patient’s medical history was significant for bipolar disorder, depression, anorexia and alcohol abuse.
On physical examination, she had tenderness of the left shoulder, notable deformity of the proximal humerus and pain with any range of motion of the left shoulder. The patient had palpable pulses and an intact neurological exam. In addition to this injury, the patient also sustained an ipsilateral transolecranon fracture dislocation and contralateral comminuted humeral shaft fracture. Anteroposterior (AP) (Figure 1a) and scapular (Figure 1b) radiographs of the left shoulder were obtained as part of the patient’s initial trauma evaluation.
Images: Kovacevic D
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Comminuted proximal humerus fracture with severe metaphyseal bone loss
Diagnosis and background
The patient was diagnosed with a left 4-part proximal humerus fracture dislocation, featuring a head-splitting fracture and a severe posteromedial calcar comminution with extension to involve the proximal third of the humeral shaft. As seen on the AP and scapular views of the left shoulder, the articular portion of the proximal humerus is in multiple fragments and there was severe comminution of the metaphyseal bone, which constitutes the critical calcar portion of the proximal humerus. Three-dimensional reconstruction of the CT scan of the left shoulder provided a more detailed view of the severity of the injury (Figure 2).
Comminuted proximal humerus fractures with involvement of the articular cartilage represent a challenging reconstructive dilemma. The classification systems for proximal humerus fractures are well-described. The qualitative Codman classification is based on epiphyseal lines, which was subsequently expanded by Neer’s quantitative classification scheme. The less commonly used AO classification focuses on characterizing the vascularity of the articular portion in assessing the severity of injury. Work by Hertel and his colleagues highlighted the importance of the calcar region as a predictor of humeral head ischemia. The interobserver and intraobserver reliability of the classification schema have been extensively studied and have been found to be of moderate benefit. However, the addition of CT and 3-D imaging did not improve reproducibility.
As our patient had both comminuted articular involvement and a segmental defect separating the articular fragments from the diaphysis, it was vital to recognize that the fracture pattern did not neatly fit into an accepted classification system. Therefore, it was important to take a personalized approach for the treatment of this patient.
Discussion and management
To summarize, this was a young polytrauma patient with multiple psychiatric issues who sustained an irreparable proximal humerus fracture. Nonoperative management of this injury is typically reserved for minimally displaced proximal humerus fracture with adequate vascularity, elderly patients with low activity demands or medically unstable patients in which the risks of surgery significantly outweigh potential benefits. Given a fracture pattern that includes a humeral head split, her chances of osteonecrosis and nonunion were significantly elevated. Therefore, despite the patient’s psychiatric comorbidities, surgical management of this fracture was indicated, with the goals of restoring function to her left shoulder and minimizing pain.
Treatment options for this injury include osteosynthesis, hemiarthroplasty with proximal fixation, proximal humerus replacement with distal fixation, reverse total shoulder arthroplasty (TSA) with distal fixation or allograft prosthesis composite. Given the degree of comminution and significant vascular compromise to the articular portion, osteosynthesis was ruled out as a potential treatment option. Hemiarthroplasty has been evaluated for the treatment of 3- or 4-part proximal humerus fractures compared to head-split fractures with similar outcomes.
Treatment of comminuted proximal humerus fractures with either hemiarthroplasty or reverse TSA have also led to similar outcomes. However, these studies assessed patients older than the age of 70 years. A typical humeral head replacement relies on proximal bone fixation, as well as an intact calcar region, for implant stability. In contrast, a proximal humerus replacement relies on distal bone fixation. This patient had no reliable proximal bone stock that would support a humeral head replacement. An allograft prosthesis composite would be a viable option for this patient, but would have required additional time to secure the allograft bone required for this case.
The patient was placed in a beach chair position, and a deltopectoral approach was utilized. Once the fracture fragments were exposed, traction sutures were placed in the tendon-bone junction of the subscapularis, supraspinatus, infraspinatus and teres minor. The humeral head was split in three fragments, and the biceps tendon was scarred to the pectoralis major tendon. A suture was placed in this landmark to facilitate re-establishment of humeral head height. A nondisplaced superior glenoid fracture was confirmed, and the remainder of the glenoid articular cartilage appeared healthy. As expected, the proximal humeral shaft was significantly comminuted, and these fragments were removed. The posterior cortex was in continuity with the rest of the humeral shaft. The salient features of this fracture are again noted in the intraoperative fluoroscopy images (Figure 3).
The distal shaft was then prepared and prosthesis trialing initiated, taking care to ensure the center of the humeral head was pointing toward the center of the glenoid and recreating the scapulohumeral line (ie, Maloney’s line), which was composed of the medial border of the humeral shaft and the lateral border of the scapular body. Cementation of the prosthesis was necessary to maintain the appropriate height of the prosthesis, and the prosthesis was placed in 30° of retroversion. The tuberosity repair was the final step in securing the prosthesis. The two anterior pairs of posterosuperior rotator cuff tendon-bone junction sutures were passed through the upper peripheral eyelet of the greater tuberosity soft tissue augment in a simple fashion, while the two posterior pairs of posterosuperior rotator cuff sutures were passed through the lower peripheral eyelet of the greater tuberosity soft tissue augment in a simple fashion. All four pairs were sequentially passed deep to the lesser tuberosity fragment and out the subscapularis tendon-bone junction.
This same step was repeated for the three pairs of subscapularis tendon-bone junction sutures with the proximal pair passed through the upper peripheral eyelet of the lesser tuberosity soft tissue augment in a simple fashion, while the two distal pairs were passed through the lower peripheral eyelet. Two sutures were passed in a vertical fashion, with one pair of suture limbs going through the lesser tuberosity augment and exiting at the upper border of the subscapularis, and the other pair going through the greater tuberosity augment and exiting at the posterosuperior rotator cuff.
Two cerclage sutures were placed: one below the prosthetic head-taper junction and one through the inferior eyelets of both soft tissue augments. Final intraoperative fluoroscopic images were obtained to confirm appropriate head height, restoration of Maloney’s line, greater tuberosity height and stem position (Figure 4).
The patient was made to wear a sling at all times for non-weight-bearing of the left upper extremity. At the 6-week follow-up appointment, the patient had minimal left shoulder pain and radiographic landmarks including maintenance of the gothic arch (Figure 5). She was advanced to partial weight-bearing of her left upper extremity and instructed to continue with weekly physical therapy.
- References:
- Codman E. 1934. The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, MA: R.E. Kreiger.
- Cuff DJ, et al. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.01637.
- Hertel R, et al. J Shoulder Elbow Surg. 2004;doi:10.1016/S1058274604000795
- Greiwe RM, et al. Orthopedics. 2013;doi:10.3928/01477447-20130624-21.
- Neer CS II. J Bone Joint Surg Am. 1970;52(6):1077-1089.
- Sebastiá-Forcada E, et al. J Shoulder Elbow Surg. 2014;doi: 10.1016/j.jse.2014.06.035.
- Sjödén GO, et al. Acta Orthop Scand. 1997; 68(3):239-242.
- Sjödén GO, et al. Acta Orthop Scand. 1999; 70(4):325-328.
- For more information:
- Wayne W. Chan, MD, PhD; Glenn S. Russo, MD, MS; Theodore A. Blaine, MD; and David Kovacevic, MD, can be reached at Yale University School of Medicine, 47 College St., New Haven, CT 06510; Chan’s email: wayne.chan@yale.edu; Russo’s email: glenn.russo@yale.edu; Blaine’s email: theodore.blaine@yale.edu; Kovacevic’s email: david.kovacevic@yale.edu.
Disclosures: Chan, Kovacevic, Russo and Blaine report no relevant financial disclosures.