JBJS | Avascular Necrosis of the Proximal Humeral Epiphysis after Physeal Fracture. A Case Report*

The Journal of Bone & Joint Surgery, Volume 79, Issue 5

Articles | May 01, 1997

Avascular Necrosis of the Proximal Humeral Epiphysis after Physeal Fracture. A Case Report*

ROBERT P. MARTIN, M.D.†; DAVID L. PARSONS, M.D., F.R.C.S.(C)‡, ST. JOHN'S, NEWFOUNDLAND, CANADA

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Investigation performed at Charles A. Janeway Child Health Center, St. John's

The Journal of Bone & Joint Surgery. 1997; 79:760-62

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Introduction

Introduction | Case Report | Discussion | References

Neer and Horwitz reported that eighty-nine (4 per cent) of 2500 consecutive physeal fractures involved the proximal humeral physis, and Peterson and Peterson reported that twenty-two (7 per cent) of 330 physeal fractures involved the proximal portion of the humerus. Complications associated with fractures of the proximal humeral physis are uncommon^{1,3-5,7,9-14,16,17}. Avascular necrosis of the humeral head is a well known complication following proximal humeral fractures in adults, particularly three-part and four-part fractures². We report the first documented case, to our knowledge, in the English-language literature, of avascular necrosis of the humeral head following a fracture of the proximal humeral physis.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†61 Duckworth Street, Apartment 207, St. John's, Newfoundland A1C 1E6, Canada.

†44 Torbay Road, St. John's, Newfoundland A1A 2G4, Canada.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†61 Duckworth Street, Apartment 207, St. John's, Newfoundland A1C 1E6, Canada.

†44 Torbay Road, St. John's, Newfoundland A1A 2G4, Canada.

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Fig. 1 Anteroposterior radiograph of the right shoulder, showing a Salter-Harris type-II fracture of the proximal humeral physis. Note the Thurstan Holland fragment medially. A lateral radiograph showed less than 10 degrees of angulation at the fracture.

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Fig. 2 Anteroposterior radiograph of the right shoulder, made seven months after the injury, showing a subchondral fracture (arrow) of the humeral head indicative of avascular necrosis.

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Fig. 3 Magnetic resonance imaging of the right shoulder confirmed the diagnosis of avascular necrosis. Note the well demarcated band of low signal intensity (arrows) surrounding a region of normal bone marrow in the humeral head.

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Fig. 4 Anteroposterior radiograph of the right shoulder, made one year after the injury, showing a healing subchondral fracture (arrow) with mild flattening of the humeral head. Healing is indicated by the much less prominent fracture line and the filling of the defect with new bone.

Case Report

Introduction | Case Report | Discussion | References

A fourteen-year-old boy was seen in the emergency department because of pain in the right shoulder that had begun immediately after he was body-checked during a hockey game. There was no evidence of dislocation of the shoulder. The results of a neurovascular examination of the right upper extremity were normal. He was otherwise healthy. Radiographs revealed a Salter-Harris type-II fracture of the right proximal humeral physis with slight displacement and angulation (Fig. 1). A Gilchrist sling was applied, and the patient was referred to the orthopaedic clinic.

When he was seen in our clinic, the day after the injury, the results of examinations of neurovascular and motor function of the right shoulder were normal. Palpation revealed tenderness about the humeral head. It was elected to continue immobilization in the Gilchrist sling. After three weeks of immobilization, there was no tenderness of the proximal portion of the right humerus. The patient started a physiotherapy program, and he had a full, pain-free range of motion of the right shoulder by six weeks after the injury. One month later, radiographs revealed a healed fracture of the proximal portion of the right humerus with no radiographic changes in the epiphysis. By this time, the patient had joined a rowing team and had no discomfort or problems with the right shoulder.

Seven months after the injury, the patient returned to our clinic. He described a mild, intermittent ache in the right shoulder, which he had first noticed after colliding with the boards during hockey practice three weeks previously. He had not had pain at night, fever, chills, or other systemic symptoms.

Examination revealed a full, pain-free range of motion of the shoulder without tenderness of the proximal portion of the humerus or the shoulder joint. The results of an impingement test were negative, and there was no evidence of instability of the shoulder.

Plain radiographs revealed avascular necrosis of a portion of the proximal humeral epiphysis Fig. 2). There was a subchondral fracture of the epiphysis, mixed sclerosis, and lysis of the surrounding bone. T1 and T2-weighted magnetic resonance images in the axial, sagittal, and coronal planes confirmed the diagnosis of avascular necrosis of the right humeral head Fig. 3). A review of the medical history failed to reveal any risk factors for avascular necrosis.

The patient was managed conservatively. He was instructed to avoid contact sports and activities requiring excessive loading of the shoulder.

One year after the initial injury, he was asymptomatic. On examination, he had no tenderness and a full, pain-free range of motion of the right shoulder. Radiographs revealed a healing subchondral fracture with mild flattening of the humeral head (Fig. 4.

Discussion

Introduction | Case Report | Discussion | References

Several large series of fractures of the proximal humeral physis have been reported, but avascular necrosis of the humeral head has not been noted as a complication in any of them^{1,5,7,9,10,13}.

Complications of these fractures, although rare, include malunion, humeral shortening, varus angulation, valgus angulation, and restricted motion of the shoulder³. Neurovascular injury can also occur¹⁸. To the best of our knowledge, textbooks on pediatric fracture do not mention avascular necrosis as a complication of proximal humeral physeal fractures^{3,4,6,11,12,14,16,17,19}.

Arterial injection studies of the humeral head have shown that the anterolateral ascending branch of the anterior humeral circumflex artery provides the most important blood supply to the head of the humerus⁸. We speculate that this vessel, or one of its major branches, was injured in our patient.

References

Introduction | Case Report | Discussion | References

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Curtis, R. J., Jr.; Dameron, T. B., Jr.; and Rockwood, C. A., Jr. Fractures and dislocations of the shoulder in children. In Fractures in Children, edited by C. A. Rockwood, Jr., K. E. Wilkins, and R. E. King. Vol. 3, pp. 829-919. Philadelphia, J. B. Lippincott, 1991.

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Epps, C. H., Jr., and Bowen, J. R.: Complications in Pediatric Orthopaedic Surgery. Philadelphia, J. B. Lippincott, 1995.

Fraser, R. L.; Haliburton, R. A.; and Barber, J. R.: Displaced epiphyseal fractures of the proximal humerus. Canadian J. Surg.,10: 427-430, 1967.10427 1967

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Neer, C. S., II, and Horwitz, B. S.: Fractures of the proximal humeral epiphysial plate. Clin. Orthop.,41: 24-31, 1965.4124 1965 [PubMed]

Ogden, J. A.: Humerus. In Skeletal Injury in the Child, pp. 345-423. Philadelphia, W. B. Saunders, 1990.

Peterson, C. A., and Peterson, H. A.: Analysis of the incidence of injuries to the epiphyseal growth plate. J. Trauma,12: 275-281, 1972.12275 1972 [PubMed]

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Sullivan, C. A., and Burman, J. A.: Blunt axillary artery injury in children: case reports. Vasc. Surg.,22: 60-65, 1988.2260 1988

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