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Posterior dislocation of the shoulder with ipsilateral humeral shaft fracture: a very rare injury
Copyright ELSEVIER
Injury Vol. 28, No. 2, pp. 150-152, 1997 0 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383197 $17.00 +O.OO
PII: SOO20-1383(96)00159-3
Posterior dislocation of the shoulder with ipsilateral humeral shaft fracture: a very rare injury S. Naresh, J. A. Chapman Department
of Orthopaedics,
and T. Muralidharan Royal Halifax Infirmary,
Halifax, UK
A third case of a posterior dislocation of the shoulder with ipsilatera1 humeral shaft fracture is described. It is recommended that this difficult management problem requires internal fixation of the humeral shaft fracture to allow control of the shoulder.0 1997 Elsevier Science Ltd.
injury, there being only 13 cases reported in the literature.‘-I0 Of these, only two dislocations were posterior.5,h A third case of posterior dislocation associated with a fracture of the shaft of the humerus is described. This combination of injuries presents a difficult management problem.
Injury,
Case report
Vol. 28, No. 2,150-152,1997
Introduction Posterior dislocation of the shoulder is constituting 2.1 per cent of all shoulder A combination of the fracture of the humerus with shoulder dislocation is
Figure
1. Fractured shaft of the humerus.
a rare injury dislocations. shaft of the a very rare
A 45-year-old man was riding his push-bike down a hill and ran into the side of a van. He did not have a clear recollection of the accident. He was noted to have a closed fracture of the shaft of the right humerus (Figure 1). The orthopaedic senior house officer was summoned and he insisted on an axillary view of the shoulder which had not been performed. This showed a posterior dislocation of the
Case reports deficit was shoulder joint (F&WY 2). No neurovascular noted at this time. A manipulation under anaesthetic was performed and it was noted that the shoulder relocated very easily but was extremely unstable. A ‘LJ’ slab was applied. Following the manipulation, the patient was noted to have a radial nerve palsy. Further X-rays showed that the dislocation had recurred. The fracture was, therefore, internally fixed with a Halder humeral nail”. This allows fixation of the fracture without any incisions around the shoulder. The dislocation was then reduced without difficulty and was stabilized by immobilizing the patient in a spica with the shoulder held in external rotation (Figure 3). He was then mobilized and went home. The patient was reviewed after 2 weeks and was progressing satisfactorily although understandably was having difficulty sleeping in the spica. He returned 2 weeks later to have the spica removed and by this time he had developed very marked swelling of the arm. His joints were mobilized with intensive physiotherapy. EMGs showed a severe radial nerve palsy which is now recovering. The fracture has healed satisfactorily and the shoulder is stable.
Discussion We report a third case of posterior dislocation of the shoulder in association with a fracture of the ipsilatera1 humeral shaft. There are 11 cases in the literature of anterior dislocation associated with a humeral shaft fracture. There is no consensus regarding the best form of treatment for these rare injuries. With regard to the dislocation, in ten cases including the one described here, the dislocation was reduced closed’-‘+“‘. In the two of these, a transcutaneous pin was required in the proximal fragmenP. In three cases, open reduction was required4,“,“‘. In
Figure 2. Axillary view showing posterior dislocation of the shoulder.
151
one case, no attempt at reduction was performed”. It has to be emphasized that great care is required when reducing a dislocation in the presence of a shaft fracture. In the two cases including the one described here a radial nerve palsy occurred after the reduction. With regard to the shaft fracture, five cases including the one described here were internally fixed*,8,9. One was treated with external fixation’, seven were treated closed and in one, the limb was amputated because of massive soft tissue injury”. Any dislocation should be reduced as soon as possible. This may not occur if the dislocation is missed. It is aIways emphasized that the hip must be assessed if there is a fracture of the shaft of the femur and it is felt that the same must apply to the shoulder in the presence of a fracture of the shaft of the humerus. Radiologically, an anterior dislocation of the shoulder is easily diagnosed whereas a posterior dislocation is notoriously easy to miss. Our patient is the first in whom a posterior dislocation of the shoulder in association with a shaft fracture has been diagnosed on the day of injury. In the first patient to be described with this combination of injuries, the dislocation was not noted until 5 weeks after injury5. The shaft fracture was allowed to heal and open reduction and stabilization with a bone block from the iliac crest was required. In the second patient, the posterior dislocation does not appear to have been diagnosed until 17 days after the accident when the patient was transferred to a different hospital because of severe soft-tissue injuries to the forearm and hand, for which an amputation was performed”. Closed reduction of the dislocation failed and no open reduction was attempted because of the infection.
152
Injury:
International
Journal
of the Care of the Injured
Vol. 28, No. 2,1997
Acknowledgement We thank Deborah Marsden for secretarial help.
References
Figure 3. Modified operative period.
spica to hold the reduction
in the post-
In our patient, the shoulder was reduced on the day of admission but it was extremely unstable and could not be controlled satisfactorily. The humeral shaft fracture was then internally fixed and the reduction could then be maintained with a spica, holding the arm in external rotation. It is not felt that it would have been possible to control the dislocation without internally fixing the fracture and it is felt that this is the treatment of choice in this rare combination of injuries. The lessons to be learnt from this case are: (1) always assess the shoulder in the presence of a humeral shaft fracture. This may require an axillary X-ray; (2) reduction of a dislocated shoulder in the presence of a humeral shaft fracture endangers the radial nerve; (3) internal fixation of a humeral shaft fracture is required to allow control of the reduction of a posterior dislocation of the shoulder.
1 Winderman A. Dislocation of the shoulder with the fracture of the shaft of the humerus (quoted in ref. 9). Bull Hasp Jt Dis Ortkop lnst 1940; 1: 23. 2 Bohler L. Die Tecknik der Knockenbruckbehandlung. Vienna: Maudrich, 1941 (quoted in ref. 9). 3 Gui L. Frutture e Lussazioni. Florence: Edizioni Sciemtifiche Institute Ortopedico Tuscano, 1957 (quoted in ref. 9). 4 Baker D. Fracture of the humeral shaft associated with ipsilateral fracture dislocation of the shoulder. ] Trrzuma 1971; 11: 532. JH. Posterior dislocation shoulder with 5 Kavanaugh ipsilateral humeral shaft fracture. Ch Ortkop Rel Res 1978; 131: 168. 6 Barquet A, Schimchak M, Carreras 0 et al. Dislocation of the shoulder with fracture of the ipsilateral shaft of the humerus. Injury 1985; 16: 300. 7 Sankaran-Kutty M and Sadat-Ali M. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Ovtkop Trauma Surg 1989; 108: 60. 8 Canosa I and Areste J. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Ortkop Trauma Surg
1994;
113:
347.
9 Calderone RR, Ghobadi F and Mclnerny V. Treatment of shoulder dislocation with ipsilateral humeral shaft fracture. Am J Ortkop 1995; 24: 173. 10 Kontakis GM, Galanakis IA and Steripoulos KA. Dislocation of the shoulder and ipsilateral fracture of the humeral shaft; case reports and literature review. 1 Trauma 1995; 39: 990. 11 Halder SC and Chapman JA. Proximal humeral fractures. A new internal fixation device. J Bone Joint Surg [Br] Suppl 1 1996; 78B: 61.
Paper accepted 7 October 1996. Requests for reprints should be addressed to: Mr. Naresh Kumar, 89 Bootham Park Court, Clarence Street, York Y03 7JT, UK.
Injury Vol. 28, No. 2, pp. 150-152, 1997 0 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383197 $17.00 +O.OO
PII: SOO20-1383(96)00159-3
Posterior dislocation of the shoulder with ipsilateral humeral shaft fracture: a very rare injury S. Naresh, J. A. Chapman Department
of Orthopaedics,
and T. Muralidharan Royal Halifax Infirmary,
Halifax, UK
A third case of a posterior dislocation of the shoulder with ipsilatera1 humeral shaft fracture is described. It is recommended that this difficult management problem requires internal fixation of the humeral shaft fracture to allow control of the shoulder.0 1997 Elsevier Science Ltd.
injury, there being only 13 cases reported in the literature.‘-I0 Of these, only two dislocations were posterior.5,h A third case of posterior dislocation associated with a fracture of the shaft of the humerus is described. This combination of injuries presents a difficult management problem.
Injury,
Case report
Vol. 28, No. 2,150-152,1997
Introduction Posterior dislocation of the shoulder is constituting 2.1 per cent of all shoulder A combination of the fracture of the humerus with shoulder dislocation is
Figure
1. Fractured shaft of the humerus.
a rare injury dislocations. shaft of the a very rare
A 45-year-old man was riding his push-bike down a hill and ran into the side of a van. He did not have a clear recollection of the accident. He was noted to have a closed fracture of the shaft of the right humerus (Figure 1). The orthopaedic senior house officer was summoned and he insisted on an axillary view of the shoulder which had not been performed. This showed a posterior dislocation of the
Case reports deficit was shoulder joint (F&WY 2). No neurovascular noted at this time. A manipulation under anaesthetic was performed and it was noted that the shoulder relocated very easily but was extremely unstable. A ‘LJ’ slab was applied. Following the manipulation, the patient was noted to have a radial nerve palsy. Further X-rays showed that the dislocation had recurred. The fracture was, therefore, internally fixed with a Halder humeral nail”. This allows fixation of the fracture without any incisions around the shoulder. The dislocation was then reduced without difficulty and was stabilized by immobilizing the patient in a spica with the shoulder held in external rotation (Figure 3). He was then mobilized and went home. The patient was reviewed after 2 weeks and was progressing satisfactorily although understandably was having difficulty sleeping in the spica. He returned 2 weeks later to have the spica removed and by this time he had developed very marked swelling of the arm. His joints were mobilized with intensive physiotherapy. EMGs showed a severe radial nerve palsy which is now recovering. The fracture has healed satisfactorily and the shoulder is stable.
Discussion We report a third case of posterior dislocation of the shoulder in association with a fracture of the ipsilatera1 humeral shaft. There are 11 cases in the literature of anterior dislocation associated with a humeral shaft fracture. There is no consensus regarding the best form of treatment for these rare injuries. With regard to the dislocation, in ten cases including the one described here, the dislocation was reduced closed’-‘+“‘. In the two of these, a transcutaneous pin was required in the proximal fragmenP. In three cases, open reduction was required4,“,“‘. In
Figure 2. Axillary view showing posterior dislocation of the shoulder.
151
one case, no attempt at reduction was performed”. It has to be emphasized that great care is required when reducing a dislocation in the presence of a shaft fracture. In the two cases including the one described here a radial nerve palsy occurred after the reduction. With regard to the shaft fracture, five cases including the one described here were internally fixed*,8,9. One was treated with external fixation’, seven were treated closed and in one, the limb was amputated because of massive soft tissue injury”. Any dislocation should be reduced as soon as possible. This may not occur if the dislocation is missed. It is aIways emphasized that the hip must be assessed if there is a fracture of the shaft of the femur and it is felt that the same must apply to the shoulder in the presence of a fracture of the shaft of the humerus. Radiologically, an anterior dislocation of the shoulder is easily diagnosed whereas a posterior dislocation is notoriously easy to miss. Our patient is the first in whom a posterior dislocation of the shoulder in association with a shaft fracture has been diagnosed on the day of injury. In the first patient to be described with this combination of injuries, the dislocation was not noted until 5 weeks after injury5. The shaft fracture was allowed to heal and open reduction and stabilization with a bone block from the iliac crest was required. In the second patient, the posterior dislocation does not appear to have been diagnosed until 17 days after the accident when the patient was transferred to a different hospital because of severe soft-tissue injuries to the forearm and hand, for which an amputation was performed”. Closed reduction of the dislocation failed and no open reduction was attempted because of the infection.
152
Injury:
International
Journal
of the Care of the Injured
Vol. 28, No. 2,1997
Acknowledgement We thank Deborah Marsden for secretarial help.
References
Figure 3. Modified operative period.
spica to hold the reduction
in the post-
In our patient, the shoulder was reduced on the day of admission but it was extremely unstable and could not be controlled satisfactorily. The humeral shaft fracture was then internally fixed and the reduction could then be maintained with a spica, holding the arm in external rotation. It is not felt that it would have been possible to control the dislocation without internally fixing the fracture and it is felt that this is the treatment of choice in this rare combination of injuries. The lessons to be learnt from this case are: (1) always assess the shoulder in the presence of a humeral shaft fracture. This may require an axillary X-ray; (2) reduction of a dislocated shoulder in the presence of a humeral shaft fracture endangers the radial nerve; (3) internal fixation of a humeral shaft fracture is required to allow control of the reduction of a posterior dislocation of the shoulder.
1 Winderman A. Dislocation of the shoulder with the fracture of the shaft of the humerus (quoted in ref. 9). Bull Hasp Jt Dis Ortkop lnst 1940; 1: 23. 2 Bohler L. Die Tecknik der Knockenbruckbehandlung. Vienna: Maudrich, 1941 (quoted in ref. 9). 3 Gui L. Frutture e Lussazioni. Florence: Edizioni Sciemtifiche Institute Ortopedico Tuscano, 1957 (quoted in ref. 9). 4 Baker D. Fracture of the humeral shaft associated with ipsilateral fracture dislocation of the shoulder. ] Trrzuma 1971; 11: 532. JH. Posterior dislocation shoulder with 5 Kavanaugh ipsilateral humeral shaft fracture. Ch Ortkop Rel Res 1978; 131: 168. 6 Barquet A, Schimchak M, Carreras 0 et al. Dislocation of the shoulder with fracture of the ipsilateral shaft of the humerus. Injury 1985; 16: 300. 7 Sankaran-Kutty M and Sadat-Ali M. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Ovtkop Trauma Surg 1989; 108: 60. 8 Canosa I and Areste J. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Ortkop Trauma Surg
1994;
113:
347.
9 Calderone RR, Ghobadi F and Mclnerny V. Treatment of shoulder dislocation with ipsilateral humeral shaft fracture. Am J Ortkop 1995; 24: 173. 10 Kontakis GM, Galanakis IA and Steripoulos KA. Dislocation of the shoulder and ipsilateral fracture of the humeral shaft; case reports and literature review. 1 Trauma 1995; 39: 990. 11 Halder SC and Chapman JA. Proximal humeral fractures. A new internal fixation device. J Bone Joint Surg [Br] Suppl 1 1996; 78B: 61.
Paper accepted 7 October 1996. Requests for reprints should be addressed to: Mr. Naresh Kumar, 89 Bootham Park Court, Clarence Street, York Y03 7JT, UK.