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A unique case of complex shoulder injury
Injury Extra (2004) 35, 3—5
A unique case of complex shoulder injury B.M. Horner*, K.M. Venu, M.A. Smith 1 Raleigh Court, Clarence Mews, London SE16 5GB, UK Accepted 17 November 2003
KEYWORDS Shoulder injury; Proximal humerus fracture; Acromioclavicular joint disruption; Threaded pin fixation; Fracture management
Summary We report a case of a complex shoulder injury not previously described which presented unique challenges in its management. A motorcyclist sustained an injury to his right shoulder consisting of a Rockwood type 5 dislocation of the acromioclavicular joint, fracture of the coracoid process and a displaced comminuted fracture of surgical neck of humerus extending into the proximal diaphysis. The humeral fracture was directly reduced and stabilised with a contoured AO buttress plate. The acromioclavicular joint was reduced and held by two percutaneous 4 mm threaded pins. The shoulder was immobilised in a poly-sling. Post-operatively there was a restricted exercise program involving pendular movements only. The acromioclavicular joint threaded pins were removed at 8 weeks following which further mobilisation was encouraged. He made satisfactory progress with complete radiographic fracture healing by 4 months. The management of each of these injuries in isolation has been well described, however when managed together there are unique challenges. This is unique and severe complex shoulder injury never previously reported. The method of management described, treating the injuries promptly using simple techniques, resulted in a good functional recovery. ß 2003 Elsevier Ltd. All rights reserved.
Case history A 20-year-old man travelling at a low speed on a motorbike hit a traffic island and was thrown on to the ground landing on his right side. He was brought to the local casualty with an isolated right shoulder injury. He exhibited swelling and tenderness over the right acromioclavicular joint and deltoid region. He had parasthesia along the axillary nerve distribution but the rest of the neurological examination was normal. Radiographs revealed a complex shoulder injury consisting of a Rockwood type 5 dislocation of the acromioclavicular joint, fracture of the coracoid process and a displaced comminuted *Corresponding author. Tel.: þ44-7946-604464. E-mail address: [email protected] (B.M. Horner).
fracture of surgical neck of humerus extending into the proximal diaphysis (Fig. 1). Surgery was undertaken within two hours of assessment by the orthopaedic team. An anteromedial deltoid splitting approach was used. The humeral fracture was directly reduced and stabilised with a contoured AO buttress plate. The acromioclavicular joint was reduced and held by two percutaneous 4 mm threaded pins (Fig. 2). The shoulder was immobilised in a poly-sling. Post-operatively his axillary nerve related paraesthesia resolved. There was a restricted exercise program involving pendular movements only. The acromioclavicular joint threaded pins were removed at 8 weeks following which further mobilisation was encouraged. He made satisfactory progress with complete radiographic fracture healing
1572–3461/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.008
4
B.M. Horner et al.
Figure 1 X-ray at initial presentation.
Figure 2 X-ray post-fixation.
A unique case of complex shoulder injury
5
proximal humeral fracture in a young patient would be open reduction and internal fixation5 followed by early post-operative mobilisation. However a standard mobilisation regime requires a stable coracoacromial arch, which was not present in this case and so a more limited mobilisation program was used. Reconstruction of ACJ disruption is often done by a Weaver-Dunn type of procedure or by coracoclavicular fixation. This is because using a threaded pin fixation has been associated with pin migration and failure of fixation.1—4 However, due to the associated coracoid process fracture in this patient, the threaded pin fixation was chosen. To minimise the risk of migration of the threaded pins, the patient’s mobility was restricted for 8 weeks until the pins were removed. The ACJ remained stable subsequently and the patient regained satisfactory range of shoulder movements with intensive physiotherapy.
Conclusion Figure 3 X-ray at 10 months.
by 4 months. However because of continuing limited shoulder abduction to 808 due to impingement, the humeral metalwork was removed at 7 months (Fig. 3). The final follow-up at 10 months following surgery revealed satisfactory shoulder movements with an abduction of 1508, forward elevation of 1808, external rotation of 458 and internal rotation to T8 level.
Discussion The combination of a comminuted fracture of the proximal humerus and Rockwood grade 5 ACJ disruption indicates a very high energy injury; this is consistent with a motorcycle accident. This combination of injuries has never been reported before. The management of each of these injuries in isolation has been well described, however when managed together there are unique challenges: Usual management of a displaced comminuted
This is unique and severe complex shoulder injury never previously reported. The method of management described, treating the injuries promptly using simple techniques, resulted in a good functional recovery.
References 1. Janssens de Varebeke B, Van Osselaer G. Migration of Kirschner’s pin from the right sternoclavicular joint resulting in perforation of the pulmonary artery main trunk. Acta Chir Belg 1993;93(6):287—91. 2. Lindsey RW, Gutowski WT. The migration of a broken pin following fixation of the acromioclavicular joint. A case report and review of the literature. Orthopedics 1986;9(3): 413—6. 3. Loncan LI, Sempere DF, Ajuria JE. Brown-Sequard syndrome caused by a Kirschner wire as a complication of clavicular osteosynthesis. Spinal Cord 1998;36(11):797—9. 4. Regel JP, Pospiech J, Aalders TA, Ruchholtz S. Intraspinal migration of a Kirschner wire 3 months after clavicular fracture fixation. Neurosurg Rev 2002;25(1—2):110—2. 5. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84A(11):1919—25.
A unique case of complex shoulder injury B.M. Horner*, K.M. Venu, M.A. Smith 1 Raleigh Court, Clarence Mews, London SE16 5GB, UK Accepted 17 November 2003
KEYWORDS Shoulder injury; Proximal humerus fracture; Acromioclavicular joint disruption; Threaded pin fixation; Fracture management
Summary We report a case of a complex shoulder injury not previously described which presented unique challenges in its management. A motorcyclist sustained an injury to his right shoulder consisting of a Rockwood type 5 dislocation of the acromioclavicular joint, fracture of the coracoid process and a displaced comminuted fracture of surgical neck of humerus extending into the proximal diaphysis. The humeral fracture was directly reduced and stabilised with a contoured AO buttress plate. The acromioclavicular joint was reduced and held by two percutaneous 4 mm threaded pins. The shoulder was immobilised in a poly-sling. Post-operatively there was a restricted exercise program involving pendular movements only. The acromioclavicular joint threaded pins were removed at 8 weeks following which further mobilisation was encouraged. He made satisfactory progress with complete radiographic fracture healing by 4 months. The management of each of these injuries in isolation has been well described, however when managed together there are unique challenges. This is unique and severe complex shoulder injury never previously reported. The method of management described, treating the injuries promptly using simple techniques, resulted in a good functional recovery. ß 2003 Elsevier Ltd. All rights reserved.
Case history A 20-year-old man travelling at a low speed on a motorbike hit a traffic island and was thrown on to the ground landing on his right side. He was brought to the local casualty with an isolated right shoulder injury. He exhibited swelling and tenderness over the right acromioclavicular joint and deltoid region. He had parasthesia along the axillary nerve distribution but the rest of the neurological examination was normal. Radiographs revealed a complex shoulder injury consisting of a Rockwood type 5 dislocation of the acromioclavicular joint, fracture of the coracoid process and a displaced comminuted *Corresponding author. Tel.: þ44-7946-604464. E-mail address: [email protected] (B.M. Horner).
fracture of surgical neck of humerus extending into the proximal diaphysis (Fig. 1). Surgery was undertaken within two hours of assessment by the orthopaedic team. An anteromedial deltoid splitting approach was used. The humeral fracture was directly reduced and stabilised with a contoured AO buttress plate. The acromioclavicular joint was reduced and held by two percutaneous 4 mm threaded pins (Fig. 2). The shoulder was immobilised in a poly-sling. Post-operatively his axillary nerve related paraesthesia resolved. There was a restricted exercise program involving pendular movements only. The acromioclavicular joint threaded pins were removed at 8 weeks following which further mobilisation was encouraged. He made satisfactory progress with complete radiographic fracture healing
1572–3461/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.008
4
B.M. Horner et al.
Figure 1 X-ray at initial presentation.
Figure 2 X-ray post-fixation.
A unique case of complex shoulder injury
5
proximal humeral fracture in a young patient would be open reduction and internal fixation5 followed by early post-operative mobilisation. However a standard mobilisation regime requires a stable coracoacromial arch, which was not present in this case and so a more limited mobilisation program was used. Reconstruction of ACJ disruption is often done by a Weaver-Dunn type of procedure or by coracoclavicular fixation. This is because using a threaded pin fixation has been associated with pin migration and failure of fixation.1—4 However, due to the associated coracoid process fracture in this patient, the threaded pin fixation was chosen. To minimise the risk of migration of the threaded pins, the patient’s mobility was restricted for 8 weeks until the pins were removed. The ACJ remained stable subsequently and the patient regained satisfactory range of shoulder movements with intensive physiotherapy.
Conclusion Figure 3 X-ray at 10 months.
by 4 months. However because of continuing limited shoulder abduction to 808 due to impingement, the humeral metalwork was removed at 7 months (Fig. 3). The final follow-up at 10 months following surgery revealed satisfactory shoulder movements with an abduction of 1508, forward elevation of 1808, external rotation of 458 and internal rotation to T8 level.
Discussion The combination of a comminuted fracture of the proximal humerus and Rockwood grade 5 ACJ disruption indicates a very high energy injury; this is consistent with a motorcycle accident. This combination of injuries has never been reported before. The management of each of these injuries in isolation has been well described, however when managed together there are unique challenges: Usual management of a displaced comminuted
This is unique and severe complex shoulder injury never previously reported. The method of management described, treating the injuries promptly using simple techniques, resulted in a good functional recovery.
References 1. Janssens de Varebeke B, Van Osselaer G. Migration of Kirschner’s pin from the right sternoclavicular joint resulting in perforation of the pulmonary artery main trunk. Acta Chir Belg 1993;93(6):287—91. 2. Lindsey RW, Gutowski WT. The migration of a broken pin following fixation of the acromioclavicular joint. A case report and review of the literature. Orthopedics 1986;9(3): 413—6. 3. Loncan LI, Sempere DF, Ajuria JE. Brown-Sequard syndrome caused by a Kirschner wire as a complication of clavicular osteosynthesis. Spinal Cord 1998;36(11):797—9. 4. Regel JP, Pospiech J, Aalders TA, Ruchholtz S. Intraspinal migration of a Kirschner wire 3 months after clavicular fracture fixation. Neurosurg Rev 2002;25(1—2):110—2. 5. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84A(11):1919—25.