Fracture dislocation of the humerus with intrathoracic humeral head fragment - A case report

Freiburg, Germany:Intrathoracic fracture dislocation of the humeral head is a very rare injury. Hematopneumothorax and fragment proximity to the lung and pulmonary vessels can cause life threatening conditions. It was first described by West in 1949, there are only 28 documented case-reports to this type of upper extremity lesion.

A. Frodl et al. presents a 74-year-old female diabetic patient with known asthma bronchiale, who was transported to a major regional trauma facility after falling on her right arm while gardening. Physical examination showed a hemodynamic stable patient with decreased breath sounds over the right chest. The Glasgow Coma Scale was 15. There was no laceration of the skin but had a clinical prominent emphysema over the right shoulder. At admission vascular and neurological examinations of the right arm were normal. Plain radiographs of the arm and chest showed a proximal humeral head fracture with absence of parts of the humeral head, rib fractures of costa 2 and 3 and a right sided hematopneumothorax.

Given this diagnosis, a chest drainage was placed. Review of the x-Rays showed an intrathoracic displaced humeral head lying apical to the right lung. The CT-scan evidenced no laceration or compression of pulmonary vessels. Subsequently, the patient was taken to intermediate care unit for further monitoring.

Three days after trauma and stabilization of the patient, definitive fracture treatment and removal of the humeral head were initiated. The procedure was done interdisciplinary in collaboration with thoracic surgeons. For surgery, a double lumen tube was installed to deflate the right lung during fragment removal. Thoracoscopically the humeral head was seen on the apex of the lung. The fragment then was carefully taken out with a gripper. The lung showed no sign of active bleeding or further laceration. After thoracoscopic recovering of the humeral fragment, insertion of an additional thoracic drainage, full arthroplasty of the humerus via deltopectoral approach was performed using a cemented reverse shoulder prosthesis. The right arm was then placed in a 15◦ abduction cushion with range of motion limited to passive abduction of 90◦ for six weeks. Postoperatively the patient was referred to intermediate care, where she was discharged 5 days after, but stayed hospitalized for 5 consecutive days. The patient had no complaints when she was seen 3 months postoperatively for routine follow up examination. At 6 month postoperatively range of motion was reported as abduction/adduction 120◦/0/40◦, retro-/anteversion 120◦/0/20◦, internal/external rotation 60◦/0/20.

The authors commented that this case report demonstrates that these rare injuries can also occur in elderly patients after a common fall. Therefore the treating surgeon should be alert, especially when typical radiological signs are present.

The authors recommend, especially when bone quality is diminished and the rotator cuff is torn, the implantation of a reverse shoulder prosthesis in elderly patients.

Further reading:

Fracture dislocation of the humerus with intrathoracic humeral head fragment – A case report and review of the literature.

A. Frodl, H. Eberbach, O. Senbaklavaci, H. Schmal, M. Jaeger.

Trauma Case Reports 37 (2022) 100592

https://doi.org/10.1016/j.tcr.2021.100592