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© 1998 The Journal of Bone and Joint Surgery, Inc.
Fracture-Dislocation of the Humerus with Intrathoracic Displacement of the Humeral Head. A Case Report* , KANSAS CITY, KANSASInvestigation performed at the Section of Orthopedic Surgery, University of Kansas Medical Center, Kansas City
Of the glenohumeral fracture-dislocations that have been described in the orthopaedic literature, those involving intrathoracic displacement of the humeral head are the least common3. We describe here the case of an adolescent patient who sustained a fracture-dislocation of the proximal part of the humerus with intrathoracic displacement of the humeral head when she was struck by a motor vehicle.
A fourteen-year-old girl was running across the road when she was struck on her left side by a motor vehicle that was traveling at a speed of approximately thirty-five miles (fifty-six kilometers) per hour. She was thrown about twenty feet (six meters) and landed on her right side. When she was seen in the emergency department at the University of Kansas Medical Center, she had pain in the right shoulder and upper extremity and she resisted attempts to move the extremity. The vital signs included a pulse of seventy-two beats per minute, a blood pressure of 130/70 millimeters of mercury (17.33/9.33 kilopascals), a temperature of 36.6 degrees Celsius, and a respiratory rate of eighteen breaths per minute. Physical examination revealed the right arm to be rigidly held in 80 degrees of abduction and 70 degrees of internal rotation. The proximal portion of the upper extremity appeared to be foreshortened. There was no neurovascular deficit, and the skin was intact. The lungs were clear on auscultation. The patient was also found to have a minimally displaced fracture of the tibial plateau. Physical examination was difficult because the patient was combative and obese. An anteroposterior radiograph of the chest, made with portable equipment, was interpreted as demonstrating a posterior subscapular glenohumeral dislocation with an avulsion fracture of the greater tuberosity (Fig. 1). However, close examination of the radiograph revealed widening of the intercostal space between the second and third ribs and an outline of pleura around the humeral head. These findings were thought to indicate fracture-dislocation of the humerus with intrathoracic displacement of the humeral head. A computerized tomography scan demonstrated the intrathoracic position of the humeral head inferior to the glenoid as well as a hemopneumothorax (Fig. 2).
After the thoracic surgery service was consulted, the patient was taken to the operating room. Placement of a thoracostomy tube at the fourth intercostal space in the anterior axillary line was attempted with the patient under general anesthesia, but passage of the tube was blocked by the head of the humerus. The tube could be advanced only after the head had been reduced by gentle lateral traction on the upper extremity and pressure had been applied to the humeral head by a finger inserted through the thoracostomy wound. The humeral head was easily removed from the thoracic cavity. No fractures of the ribs could be palpated. The reduction of the glenohumeral joint was confirmed radiographically, but ten millimeters of displacement of the greater tuberosity was noted. A limited deltopectoral incision was made, and the greater tuberosity was reduced and was fixed with number-2 non-absorbable sutures through drill-holes in the proximal part of the humerus. An associated longitudinal two to three-centimeter tear of the rotator cuff, located between the supraspinatus and subscapularis tendons, was also repaired. The greater tuberosity fragment was reduced by externally rotating and slightly abducting the humerus. To limit forces on the repair, this position was maintained after the procedure by application of an above-the-elbow cast that was connected, by wooden struts, to a waistband. The chest tube was kept in place for four days because the fracture of the tibial plateau was to be treated operatively with the patient under general anesthesia with use of positive-pressure ventilation. The cast was removed at three weeks, and gentle pendulum exercises were initiated. Active range-of-motion exercises were begun three weeks later. Fifteen weeks after the injury, the patient was free from pain and had a full passive range of motion of the shoulder but a limited active range of motion. The neurological function of the extremity was normal. Radiographs revealed healing of the greater tuberosity (Figs. 3-A and 3-B), and the function of the limb improved slowly with physical therapy. At the time of the two-year follow-up, she was asymptomatic, with normal shoulder strength and a full, pain-free active and passive range of motion.
Intrathoracic dislocation of the humeral head is exceedingly rare. Watson-Jones described a report on such a dislocation that had appeared in the German literature in 1865, and West reported on a case in 1949. Our review of the literature revealed the case reports of two additional patients, who differed from our patient in that both were elderly and had sustained a fracture-dislocation with only part of the humeral head in an intrathoracic location1,2. The intrathoracic displacement of the humeral head was not immediately recognized in our patient. The initial appearance of foreshortening of the proximal part of the upper extremity was suggestive of a fracture of the humeral diaphysis. The patient's combativeness limited the physical examination, and any subcutaneous emphysema, as described by West, was masked by obesity. In retrospect, the initial anteroposterior radiograph of the chest (made with portable equipment) demonstrated the dislocation, but it was not identified until the increased intercostal space between the second and third ribs and an outline of pleura around the humeral head were noted. The computerized tomography scan was diagnostic for intrathoracic dislocation. We speculate that the mechanism of injury was an initial glenohumeral dislocation that was followed by a medially directed axial force driving the humeral head between the ribs. Like the patient reported on by West, our patient was young and healthy and had sustained a high-energy injury. The only osseous disruption was the fracture of the greater tuberosity. Our findings differed from those in the elderly patients, who had a fracture-dislocation with only part of the humeral head in an intrathoracic location1,2. Young patients may have more mobility of the ribs, making fractures of the ribs and the humeral head less likely. In the report by West, the dislocation was reduced with traction and the displaced fracture of the greater tuberosity was treated non-operatively, which resulted in limited abduction. In our patient, reduction was facilitated by digital manipulation of the humeral head through the thoracostomy wound. Internal fixation of the greater tuberosity and repair of the tear of the rotator cuff allowed complete return of function, but only after a considerable period of time and an extended duration of physical therapy. In summary, we propose that three physical and radiographic signs should alert the orthopaedist to intrathoracic dislocation of the humeral head: (1) a rigid, abducted upper extremity that appears to be foreshortened; (2) an increase in the intercostal space at the level at which the humeral head is seen on the initial radiograph of the chest; and (3) an outline of pleura around the humeral head. Placement of a chest tube frequently is necessary, and reduction can be facilitated by manipulation of the humeral head through the thoracostomy wound. If the diagnosis is in doubt, a computerized tomography scan can provide definitive findings.
*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.
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