Fracture-dislocations of the proximal part of the humerus that are characterized by displacement of the humeral head to a remote location are exceedingly uncommon. A review of the literature led to the identification of only four such injuries, and all involved intrathoracic displacement of the humeral head2,4-6.
We report the case of a patient who sustained a fracture-dislocation of the proximal part of the humerus with retroperitoneal displacement of the humeral head.
*Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. No funds were received in support of this study.
†Department of Orthopaedics, The University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774.
‡9150 Huebner Road, Suite 250, San Antonio, Texas 78240.
In May 1988, a twenty-eight-year-old man was involved in a single-automobile accident. He was found walking at the scene of the accident and was brought to the emergency ward of a local hospital. He reported severe pain in the left shoulder and the left lateral aspect of the chest.
On admission to the emergency ward, the patient was hypotensive, tachycardic, and tachypneic. Multiple abrasions were noted over the left upper extremity and the left side of the chest wall. Ecchymosis was present in the anterior and lateral aspects of the shoulder and circumferentially in the region of the elbow. A twenty-centimeter laceration was found on the posterior aspect of the arm; probing revealed that the lesion had not penetrated the fascia of the posterior compartment muscles. With the exception of a complete motor and sensory axillary-nerve palsy, the neurological examination of the upper limb revealed normal findings. The radial and ulnar pulses were present and were equal to those in the contralateral limb.
Examination of the chest revealed subcutaneous emphysema of the left hemithorax and palpable crepitation over the fifth through ninth ribs in the mid-axillary line. Auscultation of both lungs revealed normal breath sounds. Abdominal examination revealed tenderness of the left upper quadrant, an abrasion of the right lower quadrant, and the absence of bowel sounds.
Radiographs of the left upper extremity revealed a comminuted intra-articular fracture of the distal part of the humerus as well as a fracture of the proximal part of the humerus with absence of the humeral head (Fig. 1). Radiographs of the chest showed a pulmonary contusion characterized by a progressive fluffy infiltrate in the field of the left lung and multiple fractures of the ribs with subcutaneous emphysema along the left lateral aspect of the chest wall.
Radiographs of the abdomen and the pelvis revealed the humeral head superimposed on the renal parenchyma in the left upper quadrant of the abdomen (Fig. 2). A computerized tomography scan of the abdomen, made with radiopaque contrast medium, localized the humeral head to a retroperitoneal position behind the left kidney and demonstrated a wedge-shaped area of decreased opacity in the renal parenchyma adjacent to the displaced humeral head, consistent with vascular compression or a tissue infarct (Fig. 3). Additional computerized tomographic findings included an intrasplenic hematoma and a left pleural effusion without evidence of a pneumothorax.
Laboratory data revealed gross hematuria and a hematocrit that decreased from an initial value of 0.43 to a value of 0.30 on serial determinations.
After the initial evaluation and resuscitation with fluids, the patient was taken to the operating room for an exploratory laparotomy. The operative findings included a laceration of the spleen and a renal contusion with anterior displacement of the kidney secondary to the retrorenal position of the humeral head. A splenectomy was performed, and, after incision of the Gerota fascia, the humeral head was removed from the retroperitoneal space. No obvious injury of the diaphragm was noted.
The humeral head was soaked in an antibiotic solution while the glenohumeral joint was exposed through a deltopectoral approach; it then was replaced onto the proximal part of the humerus with two AO/ASIF screws (Synthes, Paoli, Pennsylvania) (Fig. 4). The subscapularis, which was completely avulsed from the lesser tuberosity, was repaired back to the fragment of the humeral head with non-absorbable sutures. The remaining portion of the rotator cuff was found to be attached to a thin avulsed fragment of the greater tuberosity and was repaired in similar fashion, followed by copious irrigation with saline solution and closure of the wound. The shoulder was immobilized in an abduction splint.
Five days later, open reduction and internal fixation of the fracture of the distal part of the humerus was performed. With the exception of a pulmonary effusion that necessitated the placement of a chest tube, the postoperative course was without complications, and the patient was discharged on the ninth postoperative day.
Complete paralysis of the deltoid, both clinically and electromyographically, persisted on serial examinations. Six months after the injury, the axillary nerve was operatively explored and was found to have a several-centimeter region of extensive intrafascicular fibrosis. The lesion of the axillary nerve was resected, and the defect was bridged with an interfascicular sural-nerve graft.
In January 1995, approximately six years and seven months after the injury, the patient reported occasional aching that necessitated the use of analgesics. He had successfully completed vocational rehabilitation and was employed as a laser technician. A functional capacity evaluation revealed a functional level comparable with the category of light-medium work as defined by the United States Department of Labor1. This category indicates that the individual can exert a maximum of thirty-five pounds of force (156 newtons) to lift, carry, push, pull, or otherwise move objects occasionally (less than one-third of the time) or a maximum of twenty pounds of force (eighty-nine newtons) frequently (one-third to two-thirds of the time), or both.
On physical examination, the posterior and lateral portions of the deltoid demonstrated good motor function and a nearly normal appearance; the anterior portion was atrophic in appearance but was able to contract against the examiner's hand during active elevation of the extremity. Glenohumeral motion consisted of 105 degrees of active forward elevation, 0 degrees of external rotation, and internal rotation to the spinous process of the tenth thoracic vertebra. Radiographs of the left shoulder showed changes in the humeral head consistent with avascular necrosis with associated deformity of the proximal part of the humerus (Fig. 5).
Fracture-dislocations of the glenohumeral joint with wide displacement of the fracture fragment are exceedingly rare. To our knowledge, this is the first report of displacement of the humeral head into the retroperitoneal space.
In 1949, West described an intrathoracic dislocation of the humerus associated with a fracture of the greater tuberosity after a patient fell twenty feet (six meters) and landed on an outstretched upper limb. In 1956, Watson-Jones described a similar case but did not provide details involving the mechanism of injury, physical examination, or treatment. Intrathoracic displacement of the humeral head after a fracture of the surgical neck of the humerus was later described by Glessner and by Patel et al. The three patients described by West, Glessner, and Patel et al. sustained the injury in a fall, with two of them2,6 landing on an outstretched upper extremity.
The mechanism of injury in our patient was not entirely clear; however, he recalled crossing the arms in an overhead position in an effort to protect the head and face after losing control of the vehicle. We believe that the left upper extremity was in this overhead position when it sustained a violent downward force, which drove the proximal part of the humerus inferiorly along the posterolateral aspect of the chest wall and finally into a retroperitoneal position, before the fracture of the surgical neck of the humerus was sustained.
Examination of our patient revealed several differences from the findings in previous reports. These differences included an intra-abdominal injury, multiple fractures of the ribs, and an axillary nerve palsy. Interestingly, none of the previously reported intrathoracic injuries were associated with fractures of the ribs, and all of the patients were neurologically intact on initial examination. In the patient described by Patel et al., a radial nerve palsy developed approximately three days after the injury, but it resolved within seven months.
The treatment of these unusual injuries of the proximal part of the humerus has been quite variable, and there are no clear guidelines. The patient described by West was managed successfully with closed reduction under general anesthesia. The surgeon who performed the reduction described a sensation similar to that of removing a cork from a bottle. The limb was immobilized for four weeks, and the patient returned to work as a carpenter six months later with only a mild limitation in abduction. Glessner reported a fracture-dislocation of the surgical neck of the proximal part of the humerus with displacement of the humeral head into an intrathoracic location in a seventy-five-year-old patient. The patient was managed with a resection arthroplasty and removal of the humeral head through a deltopectoral approach. At the two-year follow-up evaluation, function was only fair but the patient had no pain. The patient of Patel et al. also had intrathoracic displacement of the humeral head after a fracture-dislocation of the shoulder. These authors managed the patient non-operatively because of unrelated medical problems. At the fourteen-month follow-up evaluation, the patient had 70 degrees of flexion and was reportedly doing well, performing household activities and volunteer work.
In the present report, the patient was managed with open reduction and limited internal fixation. The stability of this construct was tested in several different positions of the arm at the time of the operation and was thought to be satisfactory, obviating the need for more extensive methods of stabilization and the risks of additional bone fragmentation, extensile exposure and soft-tissue dissection, and neurovascular injury.
It was apparent, at the latest follow-up evaluation, that avascular necrosis of the humeral head had developed in our patient. This complication is commonly associated with a stiff, painful shoulder and has been reported in association with 13 to 34 per cent of four-part fractures of the proximal part of the humerus3. This complication was not unexpected in our patient because of the complete displacement of the humeral head. Additional radiographic findings included malunion of the fracture of the proximal part of the humerus, deformity of the articular surface of the humeral head, and glenohumeral osteoarthrosis. Although loss of function of the shoulder was noted, disabling pain had not developed.
NOTE: The authors thank Dr. Douglas Duncan, who kindly allowed us to report on this patient.