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Fracture-Dislocations of the Shoulder: Diagnosis, Surgical Pathology and Treatment
Fracture-Dislocations of the Shoulder Diagnosis, Surgical Pathology and TreatInent CARLO SCUDERI, M.D., PH.D., F.A.C.S.*
FRACTURE-DISLOCATION of the shoulder is caused by violence of a severe degree. The dislocation occurs first by an abduction mechanism, then as the force continues after the head has become displaced, the humerus fractures. The fracture usually occurs at the surgical neck, rarely at the anatomical neck, and mayor may not be associated with comminution. By necessity any trauma severe enough to produce this bony injury will likewise produce extensive soft tissue injuries which will be described later. Complete recovery of function cannot be anticipated. Moderate to severe loss of abduction and external rotation cannot be avoided. Should one obtain 60 to 70 per cent return of these movements, the surgical result should be considered excellent. Few cases ever regain this percentage of functional return. All of the other motions of the shoulder except adduction will have lesser percentages of loss. DIAGNOSIS
The history of the case gives a clue to the diagnosis. The patient as a rule sustains this type of injury from a severe trauma, such as falling down stairs, off a ladder or scaffold or he has been involved in a serious automobile accident. The patient, if conscious and not inebriated at the time, will inform you that he heard the bone break. Immediately thereafter he had severe pain and complete loss of use of the arm. On examination, one finds the shoulder markedly swollen, especially in the infraclavicular area with flattening of the lateral aspect. On palpation the glenoid cavity is found to be empty and the head of the humerus is palpable anteriorly and medially or inferiorly to the glenoid. I have never seen a posterior fracture-dislocation of the shoulder, although this could well occur. Crepitation is readily elicited on the slightest motion.
* Attending Surgeon, Cook County Hospital; Chairman of Department of Orthopedic Surgery, St. Elizabeth's, Alexian Brother's and Columbus Hospitals; Clinical Associate Professor of Orthopedic Surgery, University of Illinois Col/ege of Medicine, Chicago. 169
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Carlo Scuderi
Usually passive congestion of the hand and forearm is present because of the interference to venous return caused by axillary pressure. X-rays not only clinch the diagnosis, but permit one to see readily the extent of the bony injury. Differential Diagnosis
In the differential diagnosis one must keep in mind the following traumatic etiologic causes of painful, swollen shoulders, each of which, in addition to pain and swelling, causes moderate to marked restriction of shoulder motion: 1. 2. 3. 4.
Simple shoulder dislocations Acromioclavicular separation Rupture of the supraspinatus tendon Avulsion fracture of the greater tuberosity of the humerus
A careful history, physical examination and x-ray study should eliminate any possible element of error as to the correct diagnosis. SURGICAL PATHOLOGY
The capsule of the glenoid cavity invariably suffers a longitudinal tear nferiorly and medially or a stellate tear anteriorly, where the capsule is thicker. The long head of the biceps tendon is usually completely torn free from the bicipital groove and lies somewhat anteriorly and lateral to the head of the humerus. On several occasions, I have seen the tendon frayed, but never completely torn, and resting with two completely separated ends. The rotator cuff with the important supraspinatus tendon mayor may not remain partially attached to the head of the humerus, provided that the fracture is through the surgical neck. In some cases it has been found completely torn loose and remains free in the posterior superior aspect of the joint. The brachial artery, vein and brachial plexus lie immediately adjacent to the bony lesions and could readily be damaged, especially by the sharp spicules of the proximal end of the distal fragment. Fortunately these complications are rare, and with the exception of a temporary paresis of one or more of the nerve trunks, I have observed no permanent damage to the brachial plexus. Perforations of the brachial artery and veins could readily occur from this mechanism, but this has never been found at operation. Probably in the time interval between the accident and operation the perforations have clotted and healed sufficiently to keep the blood in a closed circuit. Fractures of the surgical neck of the humerus with some obliquity of the fracture are the most common injuries. The head is found either subcoracoid or infraclavicular and either completely free or still having
Fracture-Dislocations of the Shoulder
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some capsular attachment on the medial border. It is invariably surrounded by a great deal of free blood or numerous blood clots. The head usually remains with the articular surface pointing medially and cephalad. A true fracture through the anatomical neck is rare. A portion of the surgical neck is commonly found somewhere along its fracture margin. The proximal end of the distal fragment usually has a sharp point and is found embedded in either the anterior deltoid or pectoralis major fibers. This interposition must be liberated before any form of therapy can be instituted. If any comminution exists, it is as a rule a few smaller fragments of bone of no real significance. It is uncommon to see large independent fragments such as one frequently sees in fractures of the shaft of the femur and tibia. In .old fracture-dislocations a great deal of fibrosis occurs, making this region a mass of scar tissue with obscured anatomical details. It is in these cases that the surgical correction is fraught with many dangers, because the important axillary structures can readily be cut or damaged by pressure before the errors are recognized. NONOPERATIVE TREATMENT
N onoperative treatment is preferable to surgical intervention but is successful in only a small percentage of cases. These are cases treated early in which the patients are not very muscular and have a widely torn capsule so that the head can be pushed through the tear and back into the glenoid cavity. A deep anesthesia should be used, preferably with curare for muscular relaxation. Abduction traction is used by pulling on the arm to free the distal fragment from any soft tissue interposition and also to remove the distal fragment from the path which the head must traverse to get back into the glenoid cavity. If one is fortunate, by direct pressure on the head in the axilla and careful manipUlation the head can be gotten back into the glenoid cavity. Then the problem simply becomes one of treating a fracture of the surgical neck of the humerus. One of the Italian orthopedic schools treated these cases by disregarding the dislocation but lining up the fracture and keeping it in position until it healed. Then either a closed manipulation was tried or the dislocation was left as it was. Although I do not share the enthusiasm of some orthopedic men for this procedure, I have seen some old unreduced dislocations of the shoulder that after a number of years regained almost normal range of motion, much to the embarrassment of those who predicted a frozen, useless shoulder unless a surgical procedure was undertaken. I have found myself in this embarrassing situation on one to two occasions.
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Carlo Scuderi Fig. 104 I'95lTlON ~ , TIif. .....TIi:NT
Fig. 105 Fig. 106 Fig. 104. The patient is placed in a semisitting position with a sandbag under the shoulder and the head turned to the opposite side for anesthesia. Fig. 105. The Cubbins incision has been most successful in the author's hands. The incision follows the border of the acromium forward to the outer third of the clavicle, then down between the deltoid and pectoralis muscles. The cephalic vein is found between these muscles and retracted medially or ligated if cut. Slight cross markings are made at the time of the incision so as to insure correct approximation of the skin edges at the end of the operation. Fig. 106. The deltoid is dissected from the clavicle and acromium subperiosteally and is then reflected posteriorly and inferiorly. OPERATIVE TREATMENT
Immediate active treatment of this condition offers the best chance of success. Every patient is entitled to one effort at closed manipulation under surgical anesthesia with x-ray control, the patient being informed ahead of time that if the shoulder cannot be reduced by the closed method, the surgeon will immediately proceed with open reduction.
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Fig. 107. The typical displacement of a fracture-dislocation through the surgical neck of the humerus. The head is countersunk so as to bring the level of the fixation screw below the cartilage level. B, The long screw with wide threads holds the fractured head segment in apposition with the shaft of the humerus.
In 1934, Cubbins, Callahan and Scuderi! reported the use of the Cubbins incision for the approach to fracture-dislocations of the shoulder. Since that time I have tried various other surgical approaches, but never with as much success. I now use the Cubbins incision exclusively for this condition. For those interested it would be worth their while to read the original article. The patient is placed in a semi-sitting position with a sandbag under the shoulder as shown in Figure 104. The arm and shoulder are prepared so the arm can be freely moved during the operation. The head is turned towards the normal shoulder from which side the anesthesia is given. An S-shaped incision is used (Fig. 105). It follows the acromium forward to the outer third of the clavicle, then down between the deltoid and pectorialis major muscles. The cephalic vein is found between these muscles and retracted medially or ligated if cut. Then the anterior twothirds of the deltoid is dissected subperiosteally from the clavicle and acromium and turned outward and downward (Fig. 106). This rapidly brings one down to the lesions caused by the fracture-dislocation. Good
i i 174
Carlo Scuderi
Fig. 108. When a relatively large noncomminuted proximal fragment exists a blade plate is probably the best method of reattaching the head. A blade plate, with the blade not longer than 1 to 1% inches, depending on the size of the proximal fragment, is inserted into the head. Care must be taken that it does not perforate the cartilage of the joint. B, The postoperative fixation by this method is very firm, but it requires a head that. is not associated with comminution, fissure fractures, or osteoporosis of advanced age.
hemostasis is essential, as this is a highly vascular area and good visibility is imperative. The handling of the fracture-dislocation now depends on the pathologic changes present and the experience of the surgeon. The following three things must be done if any semblance of success is expected. 1. Postoperative reduction and maintenance of the head in the glenoid. 2. Reduction of the fracture and maintenance of redudion by internal fixation. 3. Reattachment of the supraspinatous tendon and reapposition of the biceps tendon in the bicipital groove. In four cases I have successfully held the small head fragment to the shaft by a large screw inserted through the head into the medullary canal of the humerus, the screw being countersunk below the cartilage level (Fig. 107). When the head fragment with the surgical neck is large
I' Fracture-Dislocations of the Shoulder
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Fig. 109. A, A comminuted fracture of the head either at the surgical or anatomical neck had best be treated either by a stem prosthesis or a complete removal of the head position. B, The removal of the head segment creates a flail joint not free of pain, and is not to be recommended except as a last resort in this type of surgery of the shoulder.
a blade plate has been used with uniform success. The plate must have a blade not longer than 1 to 1Y2 inches, otherwise it will perforate the articular cartilage (Fig. 108). In both of the above procedures the biceps tendon is utilized either as in a Nicola or Roberts procedure to prevent recurrence of the dislocation. In recent years the substitution prosthesis of the head has been in vogue for the replacement of the comminuted head fractures. I have had little experience with it to date. In one case so treated in 1955, the result was classed as fair. The shoulder could not be voluntarily abducted beyond about 60 degrees. The other motions were all curtailed but the movements were painless. The cases seen in which the prosthesis was installed by other men have all been about as successful. Nothing takes the place of the patient's own bone. One must realize that where a prosthesis is indicated the damage to tissue and bone is extensive and therefore any improvement over the preoperative stage is on the positive side of the ledger.
Carlo Scuderi
176
Years ago complete removal of the head was a standard procedure in fracture-dislocation, with a suturing of the rotator cuff, to the best of one's ability, to the proximal portion of the humeral shaft (Fig. 109). At best, this creates a flail joint with pain on motion. I have been very unhappy about my cases so treated and never have shared the enthusiasm of colleagues whose cases I happened to see and examine. This procedure should be classed as the least desirable of the methods described. POSTOPERATIVE CARE
When a screw is inserted through the head to hold it on the shaft of the humerus, or a blade plate for firm fixation of the fragments, one not only has to contend with the fracture but also with the avoidance of a recurrent dislocation. Hence immobilization for a minimum of six weeks is necessary. A shoulder spica is used postoperatively, with the arm in about 45 degrees of abduction and 25 degrees of forward flexion. When the cast is removed, circumduction exercises associated with daily physical therapy consisting of heat and massage are used to build up muscle strength and also gain the maximum shoulder motion. Later, pulley exercises and abduction wheel motion exercises are given. Optimum motion in the shortest possible time after healing of the fracture is the goal. When a substitution prosthesis is used, then of course active use is recommended as soon as the soft tissues heal, which takes a minimum of three to four weeks. The period of convalescence is shorter than when one must wait for a fracture to heal. About the same period of time and type of exercise and physical therapy are recommended for complete removal of the head as for the substitution prosthesis. REFERENCE 1. Cubbins, W. R, Callahan, J. J. and Scuderi, C.: The Reduction of Old or Irreducible Dislocations of the Shoulder Joint. Surg., Gynec. & Obst. 58: 129-135 (Feb.) 1934.
104 S. Michigan Boulevard Chicago 3, Illinois
FRACTURE-DISLOCATION of the shoulder is caused by violence of a severe degree. The dislocation occurs first by an abduction mechanism, then as the force continues after the head has become displaced, the humerus fractures. The fracture usually occurs at the surgical neck, rarely at the anatomical neck, and mayor may not be associated with comminution. By necessity any trauma severe enough to produce this bony injury will likewise produce extensive soft tissue injuries which will be described later. Complete recovery of function cannot be anticipated. Moderate to severe loss of abduction and external rotation cannot be avoided. Should one obtain 60 to 70 per cent return of these movements, the surgical result should be considered excellent. Few cases ever regain this percentage of functional return. All of the other motions of the shoulder except adduction will have lesser percentages of loss. DIAGNOSIS
The history of the case gives a clue to the diagnosis. The patient as a rule sustains this type of injury from a severe trauma, such as falling down stairs, off a ladder or scaffold or he has been involved in a serious automobile accident. The patient, if conscious and not inebriated at the time, will inform you that he heard the bone break. Immediately thereafter he had severe pain and complete loss of use of the arm. On examination, one finds the shoulder markedly swollen, especially in the infraclavicular area with flattening of the lateral aspect. On palpation the glenoid cavity is found to be empty and the head of the humerus is palpable anteriorly and medially or inferiorly to the glenoid. I have never seen a posterior fracture-dislocation of the shoulder, although this could well occur. Crepitation is readily elicited on the slightest motion.
* Attending Surgeon, Cook County Hospital; Chairman of Department of Orthopedic Surgery, St. Elizabeth's, Alexian Brother's and Columbus Hospitals; Clinical Associate Professor of Orthopedic Surgery, University of Illinois Col/ege of Medicine, Chicago. 169
170
Carlo Scuderi
Usually passive congestion of the hand and forearm is present because of the interference to venous return caused by axillary pressure. X-rays not only clinch the diagnosis, but permit one to see readily the extent of the bony injury. Differential Diagnosis
In the differential diagnosis one must keep in mind the following traumatic etiologic causes of painful, swollen shoulders, each of which, in addition to pain and swelling, causes moderate to marked restriction of shoulder motion: 1. 2. 3. 4.
Simple shoulder dislocations Acromioclavicular separation Rupture of the supraspinatus tendon Avulsion fracture of the greater tuberosity of the humerus
A careful history, physical examination and x-ray study should eliminate any possible element of error as to the correct diagnosis. SURGICAL PATHOLOGY
The capsule of the glenoid cavity invariably suffers a longitudinal tear nferiorly and medially or a stellate tear anteriorly, where the capsule is thicker. The long head of the biceps tendon is usually completely torn free from the bicipital groove and lies somewhat anteriorly and lateral to the head of the humerus. On several occasions, I have seen the tendon frayed, but never completely torn, and resting with two completely separated ends. The rotator cuff with the important supraspinatus tendon mayor may not remain partially attached to the head of the humerus, provided that the fracture is through the surgical neck. In some cases it has been found completely torn loose and remains free in the posterior superior aspect of the joint. The brachial artery, vein and brachial plexus lie immediately adjacent to the bony lesions and could readily be damaged, especially by the sharp spicules of the proximal end of the distal fragment. Fortunately these complications are rare, and with the exception of a temporary paresis of one or more of the nerve trunks, I have observed no permanent damage to the brachial plexus. Perforations of the brachial artery and veins could readily occur from this mechanism, but this has never been found at operation. Probably in the time interval between the accident and operation the perforations have clotted and healed sufficiently to keep the blood in a closed circuit. Fractures of the surgical neck of the humerus with some obliquity of the fracture are the most common injuries. The head is found either subcoracoid or infraclavicular and either completely free or still having
Fracture-Dislocations of the Shoulder
171
some capsular attachment on the medial border. It is invariably surrounded by a great deal of free blood or numerous blood clots. The head usually remains with the articular surface pointing medially and cephalad. A true fracture through the anatomical neck is rare. A portion of the surgical neck is commonly found somewhere along its fracture margin. The proximal end of the distal fragment usually has a sharp point and is found embedded in either the anterior deltoid or pectoralis major fibers. This interposition must be liberated before any form of therapy can be instituted. If any comminution exists, it is as a rule a few smaller fragments of bone of no real significance. It is uncommon to see large independent fragments such as one frequently sees in fractures of the shaft of the femur and tibia. In .old fracture-dislocations a great deal of fibrosis occurs, making this region a mass of scar tissue with obscured anatomical details. It is in these cases that the surgical correction is fraught with many dangers, because the important axillary structures can readily be cut or damaged by pressure before the errors are recognized. NONOPERATIVE TREATMENT
N onoperative treatment is preferable to surgical intervention but is successful in only a small percentage of cases. These are cases treated early in which the patients are not very muscular and have a widely torn capsule so that the head can be pushed through the tear and back into the glenoid cavity. A deep anesthesia should be used, preferably with curare for muscular relaxation. Abduction traction is used by pulling on the arm to free the distal fragment from any soft tissue interposition and also to remove the distal fragment from the path which the head must traverse to get back into the glenoid cavity. If one is fortunate, by direct pressure on the head in the axilla and careful manipUlation the head can be gotten back into the glenoid cavity. Then the problem simply becomes one of treating a fracture of the surgical neck of the humerus. One of the Italian orthopedic schools treated these cases by disregarding the dislocation but lining up the fracture and keeping it in position until it healed. Then either a closed manipulation was tried or the dislocation was left as it was. Although I do not share the enthusiasm of some orthopedic men for this procedure, I have seen some old unreduced dislocations of the shoulder that after a number of years regained almost normal range of motion, much to the embarrassment of those who predicted a frozen, useless shoulder unless a surgical procedure was undertaken. I have found myself in this embarrassing situation on one to two occasions.
t
I
i
172
Carlo Scuderi Fig. 104 I'95lTlON ~ , TIif. .....TIi:NT
Fig. 105 Fig. 106 Fig. 104. The patient is placed in a semisitting position with a sandbag under the shoulder and the head turned to the opposite side for anesthesia. Fig. 105. The Cubbins incision has been most successful in the author's hands. The incision follows the border of the acromium forward to the outer third of the clavicle, then down between the deltoid and pectoralis muscles. The cephalic vein is found between these muscles and retracted medially or ligated if cut. Slight cross markings are made at the time of the incision so as to insure correct approximation of the skin edges at the end of the operation. Fig. 106. The deltoid is dissected from the clavicle and acromium subperiosteally and is then reflected posteriorly and inferiorly. OPERATIVE TREATMENT
Immediate active treatment of this condition offers the best chance of success. Every patient is entitled to one effort at closed manipulation under surgical anesthesia with x-ray control, the patient being informed ahead of time that if the shoulder cannot be reduced by the closed method, the surgeon will immediately proceed with open reduction.
ti
I'
". Fracture-Dislocations of the Shoulder
173
Fig. 107. The typical displacement of a fracture-dislocation through the surgical neck of the humerus. The head is countersunk so as to bring the level of the fixation screw below the cartilage level. B, The long screw with wide threads holds the fractured head segment in apposition with the shaft of the humerus.
In 1934, Cubbins, Callahan and Scuderi! reported the use of the Cubbins incision for the approach to fracture-dislocations of the shoulder. Since that time I have tried various other surgical approaches, but never with as much success. I now use the Cubbins incision exclusively for this condition. For those interested it would be worth their while to read the original article. The patient is placed in a semi-sitting position with a sandbag under the shoulder as shown in Figure 104. The arm and shoulder are prepared so the arm can be freely moved during the operation. The head is turned towards the normal shoulder from which side the anesthesia is given. An S-shaped incision is used (Fig. 105). It follows the acromium forward to the outer third of the clavicle, then down between the deltoid and pectorialis major muscles. The cephalic vein is found between these muscles and retracted medially or ligated if cut. Then the anterior twothirds of the deltoid is dissected subperiosteally from the clavicle and acromium and turned outward and downward (Fig. 106). This rapidly brings one down to the lesions caused by the fracture-dislocation. Good
i i 174
Carlo Scuderi
Fig. 108. When a relatively large noncomminuted proximal fragment exists a blade plate is probably the best method of reattaching the head. A blade plate, with the blade not longer than 1 to 1% inches, depending on the size of the proximal fragment, is inserted into the head. Care must be taken that it does not perforate the cartilage of the joint. B, The postoperative fixation by this method is very firm, but it requires a head that. is not associated with comminution, fissure fractures, or osteoporosis of advanced age.
hemostasis is essential, as this is a highly vascular area and good visibility is imperative. The handling of the fracture-dislocation now depends on the pathologic changes present and the experience of the surgeon. The following three things must be done if any semblance of success is expected. 1. Postoperative reduction and maintenance of the head in the glenoid. 2. Reduction of the fracture and maintenance of redudion by internal fixation. 3. Reattachment of the supraspinatous tendon and reapposition of the biceps tendon in the bicipital groove. In four cases I have successfully held the small head fragment to the shaft by a large screw inserted through the head into the medullary canal of the humerus, the screw being countersunk below the cartilage level (Fig. 107). When the head fragment with the surgical neck is large
I' Fracture-Dislocations of the Shoulder
175
Fig. 109. A, A comminuted fracture of the head either at the surgical or anatomical neck had best be treated either by a stem prosthesis or a complete removal of the head position. B, The removal of the head segment creates a flail joint not free of pain, and is not to be recommended except as a last resort in this type of surgery of the shoulder.
a blade plate has been used with uniform success. The plate must have a blade not longer than 1 to 1Y2 inches, otherwise it will perforate the articular cartilage (Fig. 108). In both of the above procedures the biceps tendon is utilized either as in a Nicola or Roberts procedure to prevent recurrence of the dislocation. In recent years the substitution prosthesis of the head has been in vogue for the replacement of the comminuted head fractures. I have had little experience with it to date. In one case so treated in 1955, the result was classed as fair. The shoulder could not be voluntarily abducted beyond about 60 degrees. The other motions were all curtailed but the movements were painless. The cases seen in which the prosthesis was installed by other men have all been about as successful. Nothing takes the place of the patient's own bone. One must realize that where a prosthesis is indicated the damage to tissue and bone is extensive and therefore any improvement over the preoperative stage is on the positive side of the ledger.
Carlo Scuderi
176
Years ago complete removal of the head was a standard procedure in fracture-dislocation, with a suturing of the rotator cuff, to the best of one's ability, to the proximal portion of the humeral shaft (Fig. 109). At best, this creates a flail joint with pain on motion. I have been very unhappy about my cases so treated and never have shared the enthusiasm of colleagues whose cases I happened to see and examine. This procedure should be classed as the least desirable of the methods described. POSTOPERATIVE CARE
When a screw is inserted through the head to hold it on the shaft of the humerus, or a blade plate for firm fixation of the fragments, one not only has to contend with the fracture but also with the avoidance of a recurrent dislocation. Hence immobilization for a minimum of six weeks is necessary. A shoulder spica is used postoperatively, with the arm in about 45 degrees of abduction and 25 degrees of forward flexion. When the cast is removed, circumduction exercises associated with daily physical therapy consisting of heat and massage are used to build up muscle strength and also gain the maximum shoulder motion. Later, pulley exercises and abduction wheel motion exercises are given. Optimum motion in the shortest possible time after healing of the fracture is the goal. When a substitution prosthesis is used, then of course active use is recommended as soon as the soft tissues heal, which takes a minimum of three to four weeks. The period of convalescence is shorter than when one must wait for a fracture to heal. About the same period of time and type of exercise and physical therapy are recommended for complete removal of the head as for the substitution prosthesis. REFERENCE 1. Cubbins, W. R, Callahan, J. J. and Scuderi, C.: The Reduction of Old or Irreducible Dislocations of the Shoulder Joint. Surg., Gynec. & Obst. 58: 129-135 (Feb.) 1934.
104 S. Michigan Boulevard Chicago 3, Illinois