Document Type : Case reports

Authors

1 Department of Orthopaedics, Lishui Central Hospital, Lishui, Zhejiang, 323000, China.

2 Department of Orthopaedics, Lishui Central Hospital, Lishui, Zhejiang, 323000?China.

Abstract

Background: Intrathoracic displacement of a humeral head fracture is extremely rare. Only slightly more than 30 cases have been reported in this regard. Since few cases have been reported, there is no consensus on how to treat this injury. The etiology, injury mechanism, related lesions, and treatment of the injury are diverse.
Case presentation: A 73-year-old female presented with multiple fractures of the left ribs, bilateral lung contusions, extensive emphysema of the anterior and posterior chest wall, massive left hemopneumothorax, fracture-dislocation of the proximal humerus, and intrathoracic displacement of the humeral head. The patient was sent to the operating room for emergency thoracotomy surgery. The head of the humerus was confirmed to be completely removed from the thoracic cavity during the operation. After discussion with the orthopedic surgeon, the humeral head was discarded considering avascular necrosis; moreover, open reduction and internal fixation were not performed. The orthopedic surgery team performed reverse shoulder arthroplasty three weeks later. During follow-up, the patients shoulder was free from pain, and its range of movement included 110° flexion, 70° abduction, 35° external rotation, and 50° internal rotation.
Conclusion: Intrathoracic displacement of the humeral head due to proximal humeral fracture is a very rare and serious trauma that requires multidisciplinary treatment. Considering the extremely high risk of humeral head necrosis, actively removing broken bone fragments of the humeral head in the early stage is recommended, and we advocate for shoulder arthroplasty for elderly patients. Detailed preoperative evaluations and individualized operation plans should be made to achieve the best effect.

Keywords

  1. West EF. Intrathoracic dislocation of the humerus. J Bone Joint Surg Br. 1949;31B(1):61. [PubMed: 18112920].
  2. Boyer P, Alsac JM, Ettori MA, Lesèche G, Huten D. Four-part fracture after intrathoracic displacement of the humeral head: a case report and review of the literature. Arch Orthop Trauma Surg. 2007;127(8):651-4. doi: 10.1007/s00402-007-0329-4. [PubMed: 17450370].
  3. Wiesler ER, Smith AM, Shilt JS. Humeral head fracture-dislocation into the thoracic outlet: case report and review of the literature. J Shoulder Elbow Surg. 2004;13(5):576-9. doi: 10.1016/j.jse.2004.02.011. [PubMed: 15383820].
  4. Eberson CP, Ng T, Green A. Contralateral intrathoracic displacement of the humeral head. A case report. J Bone Joint Surg Am. 2000;82(1):105-8. doi: 10.2106/00004623-200001000-00013. [PubMed: 10653090].
  5. Abbott GF, Gaissert H, Faberman RS. Contralateral intrathoracic migration of humeral head fracture dislocation. AJR Am J Roentgenol. 1999;172(5):1403-4. doi: 10.2214/ajr.172.5.10227525. [PubMed: 10227525].
  6. al-Kaar M, Garcia J, Khan HG, Manueddu C. Intrathoracic dislocation fracture of the head of the humerus. J Radiol. 1998;79(1):57-9. [PubMed: 9757223].
  7. Kaar TK, Rice JJ, Mullan GB. Fracture-dislocation of the shoulder with intrathoracic displacement of the humeral head. Injury. 1995;26(9):638-9. doi: 10.1016/0020-1383(95)00120-x. [PubMed: 8550176].
  8. Jun-Song W, Jing-Yu D, Zhi-Qiang W, Fang G, Xiang-Jin L. Intrathoracic displacement of the humeral head in a trauma patient. Indian J Orthop. 2012;46(5):596-8. doi: 10.4103/0019-5413.101050. [PubMed: 23162158].
  9. Hawkes[S1]  T, Parra M, Shrock K. Intrathoracic fracture-dislocation of the proximal humerus treated with rib fixation and shoulder arthroplasty. Am J Orthop (Belle Mead NJ). 2014;43(4):E74-8. [PubMed: 24730008].
  10. Du Plessis N, Rajendran S, Naqi SA, Cahill R. Intrathoracic fracture-dislocation of the humeral head. Is removal of the humeral head necessary? BMJ Case Rep. 2012;2012:bcr2012007478. doi: 10.1136/bcr-2012-007478. [PubMed: 23264271].
  11. Daffner SD, Cipolle MD, Phillips TG. Fracture of the humeral neck with intrathoracic dislocation of the humeral head. J Emerg Med. 2010;38(4):439-43. doi: 10.1016/j.jemermed.2007.09.064. [PubMed: 18650050].
  12. Maroney SS, Devinney DS. Intrathoracic fracture-dislocation of the proximal humerus treated with reverse total shoulder arthroplasty. Orthopedics. 2009;32(12):924. doi: 10.3928/01477447-20091020-21. [PubMed: 19968231].
  13. Chen J, Yan J, Wang S, Zhong H, Zhou H. Intrathoracic dislocation of the humeral head accompanied by polytrauma: How to treat it? Ulus Travma Acil Cerrahi Derg. 2015;21(2):149-51. doi: 10.5505/tjtes.2015.72566. [PubMed: 25904278].
  14. Schoffl H, Froschauer SM, Huemer GM. Intrathoracal displacement of the humeral head after fracture. Wien Klin Wochenschr. 2009;121(7-8):246. doi: 10.1007/s00508-008-1096-0. [PubMed: 19562280].
  15. Patel MR, Pardee ML, Singerman RC. Intrathoracic dislocation of the head of the humerus. J Bone Joint Surg Am. 1963;45:1712-4. [PubMed: 14083151].
  16. Brogdon BG, Crotty JM, MacFeely L, McCann SB, Fitzgerald M. Intrathoracic fracture-dislocation of the humerus. Skeletal Radiol. 1995;24(5):383-5. doi: 10.1007/BF00197074. [PubMed: 7570162].
  17. Rupprecht H, Ghidau M, Gaab K. Severe thoracic trauma due to an intrathoracic dislocation of a fractured humeral head in an aged patient; a case report. Bull Emerg Trauma. 2017;5(3):212-4. [PubMed: 28795067].
  18. Fernández AI, Fernández AG. Intrathoracic fracture-Dislocation of the shoulder. J Clin Orthop Trauma. 2018;9(Suppl 2):S54-7. doi: 10.1016/j.jcot.2018.04.001. [PubMed: 29928107].
  19. Kocer B, Gulbahar G, Aktekin CN, Gunal N, Birinci B, Dural K, et al. Intrathoracic humeral head fracture-dislocation: is removal of the humeral head necessary? Ann Thorac Surg. 2007;84(4):1371-2. doi: 10.1016/j.athoracsur.2007.05.011. [PubMed: 17889001].
  20. Harman BD, Miller NG, Probe RA. Intrathoracic humeral head fracture-dislocation. J Orthop Trauma. 2004;18(2):112-5. doi: 10.1097/00005131-200402000-00010. [PubMed: 14743032].
  21. Liu HH, Lee YH, Yang SW, Wong CY. Fracture of the proximal humerus with intrathoracic dislocation of the humeral head. J Trauma. 2007;63(2):E37-9. doi: 10.1097/01.ta.0000246958.80088.5a. [PubMed: 17693816].
  22. Anderson M, Rose P, Jacofsky DJ, Torchia ME, Dahm DL. Intrathoracic fracture-dislocation of the proximal humerus: a case report and report of a new surgical technique. J Trauma. 2007;63(4):920-3. doi: 10.1097/01.ta.0000224887.29787.a6. [PubMed: 17110887].
  23. Tsai YM, Shen PH, Chang H, Tzao C, Lee SC, Cheng YL. Intrathoracic displacement of a fractured humeral head due to blunt trauma. Ann Thorac Cardiovasc Surg. 2014;20(Suppl):592-4. doi: 10.5761/atcs.cr.12.02194. [PubMed: 23558222].
  24. Hayes N, White J, Lillie P, Bennetts JS, Tu CG, Bain GI. Intrathoracic shoulder dislocation causing rupture of the right main bronchus. Arch Orthop Trauma Surg. 2020;140(4):443-7. doi: 10.1007/s00402-019-03242-3. [PubMed: 31385020].  
  25. Sola Junior WC, Santos PS. Intrathoracic fracture-dislocation of the humerus - case report and literature review. Rev Bras Ortop. 2017;52(2):215-9. doi: 10.1016/j.rboe.2017.01.005. [PubMed: 28409141].
  26. Simpson NS, Schwappach JR, Toby EB. Fracture-dislocation of the humerus with intrathoracic displacement of the humeral head. A case report. J Bone Joint Surg Am. 1998;80(6):889-91. doi: 10.2106/00004623-199806000-00013. [PubMed: 9655107].
  27. Abellan JF, Melendreras E, Gimenez DJ, Carrillo FJ, Ruano L, Rivkin J. Intrathoracic fracture-dislocation of the humeral head: a case report. J Orthop Surg (Hong Kong). 2010;18(2):254-7. doi: 10.1177/230949901001800225. [PubMed: 20808024].
  28. Salhiyyah K, Potter D, Sarkar PK. Fracture-dislocation of humeral head with intrathoracic displacement. Asian Cardiovasc Thorac Ann. 2012;20(2):196-8. doi: 10.1177/0218492311421450. [PubMed: 22499971].  
  29. Griffin[S2]  NC, Temes RT, Gill IS, Rice TW. Intrathoracic displacement of a fractured humeral head. Ann Thorac Surg. 2007;84(4):1400. doi: 10.1016/j.athoracsur.2006.11.075. [PubMed: 17889016].
  30. Guiotti Filho J, Borges AC, Leite MD. Epiphysiolysis fracture of the proximal end of the humerus with intrathoracic dislocation: case report. Braz J Orthop. 2008;43:48-52. doi: 10.1590/S0102-36162008000100007.
  31. Hardcastle PH, Fisher TR. Intrathoracic displacement of the humeral head with fracture of the surgical neck. Injury. 1981;12(4):313-5. doi: 10.1016/0020-1383(81)90208-4. [PubMed: 7263035].
  32. Glessner Jr JR. Intrathoracic dislocation of the humeral head. JBJS. 1961;43(3):428-30.
  33. Wirth MA, Jensen KL, Agarwal A, Curtis RJ, Rockwood CA Jr. Fracture-dislocation of the proximal part of the humerus with retroperitoneal displacement of the humeral head. A case report. J Bone Joint Surg Am. 1997;79(5):763-6. doi: 10.2106/00004623-199705000-00018. [PubMed: 9160951].
  34. Hawkes T, Parra M, Shrock K. Intrathoracic fracture-dislocation of the proximal humerus treated with rib fixation and shoulder arthroplasty. Am J Orthop (Belle Mead NJ). 2014;43(4):E74-8. [PubMed: 24730008].
  35. Griffin NC, Temes RT, Gill IS, Rice TW. Intrathoracic displacement of a fractured humeral head. Ann Thorac Surg. 2007;84(4):1400. doi: 10.1016/j.athoracsur.2006.11.075. [PubMed: 17889016].
  36. Besch L, Daniels-Wredenhagen M, Mueller M, Varoga D, Hilgert RE, Seekamp A. Hemiarthroplasty of the shoulder after four-part fracture of the humeral head: a long-term analysis of 34 cases. J Trauma. 2009;66(1):211-4. doi: 10.1097/TA.0b013e31815d9649. [PubMed: 19131828].