Reconstruction of a missed posterior locked shoulder fracture-dislocation with bone graft and lesser tuberosity transfer: a case report
© Chalidis et al; licensee BioMed Central Ltd. 2008
Received: 10 March 2008
Accepted: 05 August 2008
Published: 05 August 2008
Posterior shoulder fracture-dislocation is a rare emergency condition with poor prognosis when there is a delay in diagnosis and presence of associated injuries.
We present a case of a neglected four-part fracture-dislocation of the proximal humerus in a 34-year-old Greek woman. Except from the substantially displaced and comminuted tuberosity fractures, an anterolateral defect of approximately 50% of the articular surface was apparent. Open reduction of the humeral head was followed by reconstruction of the proximal humerus with allograft impaction, transfer of lesser tuberosity to the humeral defect and anatomic fixation of the greater tuberosity and humeral neck fractures. At two and a half years postoperatively, the humeral head was revascularised and properly articulated with the glenoid fossa.
The presented case underlines the variability of injury pattern, the potential of missed diagnosis and the need for preserving the humeral head in young patients regardless of the amount of articular surface defect and disruption of soft tissue attachments.
Posterior locked shoulder dislocation is an uncommon injury (2–4% of all shoulder dislocations) which may be misdiagnosed and overlooked in up to 60% of cases . The spectrum of associated injuries varies from the isolated impaction fracture of the anteromedial aspect of the humeral head ("reverse Hill-Sachs lesion") to more complex fracture types of the proximal humerus (less than 1%) and shoulder girdle [1, 2]. The unrecognised dislocation-fracture pattern can jeopardise the joint mobility and the vascularity of the humeral head predisposing to chronic instability, osteonecrosis and osteoarthritis .
We present a case of a neglected four-part posterior fracture-dislocation of the proximal humerus in a young woman. The vascularity and integrity of the humeral head were at high risk due to a large reverse Hill-Sachs lesion (50% of the articular surface) and severely displaced tuberosities fractures. Open reduction and internal fixation of the humeral neck and greater tuberosity fractures in combination with grafting and transfer of the lesser tuberosity to the humeral defect led to joint stability, viability of the humeral head and favourable functional outcome.
A 34-year-old right-hand dominant Greek woman, presented at the Upper Limb Clinic of the Hospital complaining of persisting pain and stiffness in her right shoulder. The symptoms began 3 months earlier after a fall on her outstretched hand from a height of approximately 3 metres. The patient reported that the initial clinical assessment in the local emergency department and the anteroposterior radiograph of the right shoulder did not reveal any significant abnormality and a diagnosis of shoulder sprain and contusion was established. Pain medication was prescribed and a sling was applied for 10 days. After that time, the patient was re-examined and physical therapy with active and passive shoulder and upper limb exercises was commenced. As there was no improvement in pain and shoulder mobility, she was finally referred to our clinic for a second opinion and further evaluation.
The rarity of incidence of posterior-fracture dislocation, the potential for delay in diagnosis and the lack of evidence-based management strategies make this specific injury type challenging to treat. Recently, Robinson et al.  divided posterior-fracture dislocations into three subtypes according to the extent of fracture lines and the involvement of tuberosities. In Type I, a Neer Two-Part anatomic fracture is present without associated tuberosity fractures. In Type II, there is an additional fracture of the lesser tuberosity and in rare Type III both tuberosities are involved. The authors found the latter fracture type in 17 cases and noticed that in all of the cases, the greater and lesser tuberosities were held together giving the characteristic "shield" fragment which was first described by Edelson et al. . Even if internal comminution exists and more fracture lines are apparent ("shattered shield" configuration), the intact periosteal sleeve averts secondary displacement. In the present case, the tuberosities were substantially displaced outlining a Neer Four-Part fracture of the proximal humerus. This finding illustrates the variability of the fracture pattern and the complexity of the underlying mechanism of injury.
Apart from the severity of injury and fracture deformity, the final prognosis is further affected by the extent of the underlying glenoid or reverse Hill-Sachs lesion [5, 6]. As extensive erosion of the posterior margin of the glenoid fossa is rarely encountered even in long-standing dislocations , the focus is concentrated on treatment of the anteromedial defect of the humeral head. Transfer of the subscapularis or lesser tuberosity, rotational osteotomy of the humerus and allograft or autograft reconstruction have been advocated for the treatment of medium (25–40% of articular surface) or large (more than 40%) defects in cases where the articular cartilage has been impressed but not destroyed [6, 7]. Hemiarthroplasty has been suggested in patients with an impression fracture involving more than 50% of the articular surface or when the humeral head is very soft and not viable . However, in young patients, all efforts should be made to retain the humeral head and restore its shape, roundness and normal anatomy. Similar to our case, good results have been reported after reconstruction of defects equal to or greater than 40% of the articular surface using allograft or lesser tuberosity transfer [8, 9]. Regardless of the selected treatment option, elevation of the cartilage with the adjacent bone from the impressed area and subsequent subchondral support should be carried out .
The transfer of lesser tuberosity instead of subscapularis alone was first introduced by Hawkins et al. . The osteotomised or fractured bone fragment offers better filling of the defect and more secure reinsertion of the tendon . Finkelstein et al.  reported that full flexion, abduction, and external rotation were achieved at 3 months in seven acutely treated shoulders with a 20% to 45% humeral head defect. The authors stated that the technique allowed earlier joint mobilisation because of the increased confidence in the immediate stability of the repaired shoulder. Checchia et al.  noted similar results but emphasised the importance of the time interval between injury and diagnosis. Specifically, posterior fracture-dislocations which were treated within 2 years of the injury had good shoulder function in comparison with neglected and misdiagnosed cases. However, Aparicio et al.  found radiographic signs of glenohumeral arthritis in six out of seven cases. The mild dislocation arthropathy was attributed to the loss of the concavity-compression effect and alteration of joint biomechanics after lesser tuberosity transfer in a non-anatomic position.
Although avascular necrosis of the humeral head is unpredictable and may occur in any posterior fracture-dislocation pattern, neglected injuries and fracture of the anatomic neck substantially increase the above incidence . Accurate reduction and stable internal fixation – even if performed late – enhance the probability of successful revascularisation of the humeral head and avoid the development of avascular necrosis . Head reperfusion seems to occur by the intact posteromedial vessels or alternatively by "creeping substitution" in cases with severe disruption of the arterial flow and soft tissue attachments . In the presented case, the impaction of demineralised bone matrix might contribute to the viability of humeral head due to its osteoconductive and osteoinductive properties . Even though it does not offer structural support, it is well suited for filling bone defects and cavities and it can be revascularised quickly. We believe that transposition of lesser tuberosity combined with allograft impaction can effectively address large humeral defects and decrease the potential of subchondral collapse or avascular necrosis.
Posterior shoulder fracture-dislocation continues to be a "diagnostic trap" for the unaware physician despite the advances in imaging techniques and the continuous flow of information about the risk of missed diagnosis. In neglected injuries, open reduction of the humeral head, stable fixation of all of the associated fractures and filling of the anterolateral defect with graft and/or transfer of lesser tuberosity may lead to optimum result and good functional recovery.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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