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Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases
hjury Vol. 29, No. 7, pp. 525-528, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020.1383/98 $19.00+0.00
ELSEVIER
PII: SOO20-1383(98)00124-7
Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases Mehmet
Demirhan,
Sercan Akpinar,
Ata Can Atalar, Senol Akman
and Yilmaz Akalin
Department of Orthopaedics and Traumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergoneclosed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8years (range38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the inju y. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 1244 active external rotation averaged 29” and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder. 0 1998 Elsevier Science Ltd. All rights reserved.
Injury, Vol. 29, No. 7, 525-528, 1998
Introduction Although iatrogenic displacement of the humeral neck fracture in fracture-dislocation of the shoulder is rare, the choice of treatment is difficult. Open reduction and internal fixation had been reported to cause avascular necrosis and severe collapse of the humeral head’. Humeral head replacement has been successfully used for patients with four-part proximal humeral fractures, selected three-part fractures and comminuted articular surface fractures of the humeral head. We are unaware of any reported
application of this technique for iatrogenically displaced humeral head fracture-dislocations. This report, therefore, is the first study about primary replacement of the humeral head in the iatrogenically displaced fracture dislocations of the shoulder.
Patients and methods In this study, we reviewed six patients with an average age of 52.8 years (range 38-72 years) with humeral head replacement due to iatrogenically displaced shoulder fracture dislocations. Three were women and three were men. Three patients fell onto their outstretched arms from a standing position and the other three patients had traffic accidents. Anterior dislocation of the shoulder with fractures of the greater tuberosity and anatomical neck was the original injury in all cases (Figure 1). A closed reduction was attempted in other medical centres but when it was realised that the humeral head was displaced, these patients were referred to us (Figure 2). Surgery was performed in all cases with the patient in the beach chair position with the arm prepped and draped free. Exposure was obtained through a standard delto-pectoral incision and the anterior deltoid was mobilised and retracted laterally, leaving the origin and insertion intact. The tuberosity fragments were identified and the interval between the supraspinatus and subscapularis tendons was accessed. Meticulous dissection of the humeral head was done because of the close proximity of the humeral head to the neurovascular structures. After the humeral head was removed, the prosthesis was inserted in 30” to 40” of retroversion. Methylmethacrylate fixation was used in all patients. The tuberosities were securely reattached to the humeral shaft, to each other and to the fin of the prosthesis with heavy non-absorbable suture (No. 5 Ethibond”). The extremity of the patient was placed in a sling and prophylactic antibiotics were given for 48 h.
526
Injury:
International
The average time between injury and surgery was 9.3 days (range 2-30 days). Three Biomet modular prostheses (Biomet, Warsaw, IN), three Neer II prostheses (Kirschner Medical, Fair Lawn, NJ) were used (Figure 3). Physical therapy was begun on the second postoperative day. This therapy consisted of passive range of motion of the shoulder for forward flexion, external rotation to neutral rotation and internal rotation to the chest wall. Passive range of motion was gradually progressed as tolerated, active range of motion was begun on the sixth week. Strengthening exercises were instituted at 3 months. All patients participated in a supervised therapy program for up to 1 year (Figure 4).
Journal
of the Care of the Injured
Vol. 29, No. 7,199s
forward flexion averaged 124”, active external rotation averaged 29” and internal rotation average to the second lumbar vertebra. Four patients were able to do activities at shoulder level without difficulty
Results The average follow-up period was 30.2 months (range 12-55 months). Evaluation of the patients has been made according to the American Shoulder and Elbow Surgeons criteria. Pain, range of motion, strength, function and patient satisfaction were recorded. All radiographs were also reviewed. In five of the patients, all pain was diminished. Only one patient had slight pain after vigorous activity. Active
Figure 1. Plain radiograph demonstrating non-displaced fracture of the humeral neck associated with anterior dislocation and greater tuberosity fracture.
Figure 2. Plain radiograph ment of the humeral neck.
showing
Figure 3. Plain operatively.
of the patient
radiograph
iatrogenic
displace-
4 years post-
Demirhan et al.: Primary replacement of the humeral head
and two patients could do overhead little or no difficulty (Table I).
activities
with
Discussion Approximately 85 per cent of proximal humeral fractures are undisplaced or minimally displaced and are well treated with non-operative methods. However, displaced fractures require closed reduc-
Figure 4. Forward flexion and external rotation of the patient on the fourth post-operative year.
527
tion or open reduction and internal fixation. Other fractures including four-part fractures or fracturedislocations, head-splitting fractures and impression fractures involving more than 45 per cent of the humeral head require prosthetic replacement of the humeral head. The majority of non-displaced fractures of the proximal humerus are treated non-operatively. Should there be an undisplaced fracture of the humeral neck associated with a dislocation of the shoulder, the risk of displacement of the fracture is very high with closed reduction methods. This iatrogenie displacement of the humeral head is rare, De Mourgues et al. reported four cases, Ferkel et al. two cases and Hersche and Gerber seven cases’“. Although all fracture-dislocations were anterior with greater tuberosity fractures, Hersche and Gerber also reported two posterior fracture-dislocations with lesser tuberosity fractures and one anterior fracturedislocation with fractures of both tuberosities’. Hersche and Gerber reduced four cases under optimal relaxation and fluoroscopy control, but they caused moderate to severe displacement of the fracture in all four cases. In addition, they performed in situ fixation of the neck fracture before gentle reduction in one patient. They were also able to prevent the displacement but not the avascular necrosis of the humeral head. They suggested, that both the anterior circumflex arcuate artery and the intraosseous anastomoses might have been injured even in the absence of iatrogenic displacement of the humeral head. Hersche and Gerber reported avascular necrosis and severe collapse of the head in all six of their cases that were treated with open reduction and internal fixation’. When only four-part fractures are analysed, hemiarthroplasty emerges as the superior treatment option. An analysis of nine series in the literature of true four-part fractures treated with primary humeral head replacement shows that of 171 four-part fractures, 136 (80 per cent) achieved satisfactory or better results%“. Furthermore, humeral head replacement as a salvage procedure after loss of reduction, malunion or avascular necrosis of failed open reduction internal fixation is more technically demanding and less predictable in outcome than primary humeral head replacement’0J2-15. We have treated onIy one patient in this manner and observed deep prosthetic infection which resulted in removal of the prosthesis. We found that pain relief is predictable, but the functional outcome of humeral head replacement depends on the co-operation and motivation of the patient. These findings are similar to-those previously reported in the literature7-9,‘6J7. Motor strength around the shoulder is dependent on many factors including pre-operative strength, quality of tuberosity reattachment and rotator cuff repair and post-operative rehabilitation. Strength in our cases was excellent with an average of 4 on a 0-5 manual muscle testing scale. Although one patient had radiographic finding suggestive of loosening as
528
Injury:
International
Journal
of the Care of the Injured
Vol. 29, No. 7,1998
Table I. Patient demographics Patient no. 1 2 3 4 5 6 AFE:
active
Age
Sex
Fracture
42 64 72 61 40 38
M M F M F F
3-part 3-part d-part 3-part 3-part 3-part
forward
elevation,
ER: external
Arthroplasty time (days) ___~.
Prosthesis
7 6 3 8 2 30 rotation,
Biomet Neer II Neer II Biomet Neer II Biomet IR: internal
Follow-up (month) 14 48 55 12 34 12
AFE (“)
ER (“)
IR
110 140 120 116 128 130
26 34 25 28 32 29
L4 Th 12 L2 L2 L3 Ll
Function Shoulder Overhead Shoulder Shoulder Shoulder Overhead
level level level level
rotation.
demonstrated circumferential lucency between bone and cement interface, this did not affect the pain relief and the functional outcome of the patient. We did not observe any radiological finding of heterotopic ossification in any of our cases. Primary humeral head replacement for acute iatrogenitally displaced fracture-dislocations of the shoulder effectively relieves pain. Functional outcomes are dependent on the age, sex, co-operation and motivation of the patient. With a meticulously performed surgical technique and a rigorous supervised physical rehabilitation, better results are obtained than open reduction and internal fixation of the proximal humerus.
References 1 Hersche 0. and Gerber C. Iatrogenic displacement of fracture-dislocations of the shoulder. I Bone Joint Surg 1993; 76-B: 30. 2 De Mourgues G., Razemon J. P. and Leclair H. P. etal. Les fractures-luxations de l’epaule. Rev Chiv Orthop 1965; 51: 151. 3 Ferkel Rd., Hedley A. K. and Eckardt J. J. Anterior fracture-dislocations of the shoulder: pitfalls in treatment. J Trauma 1984; 24: 363. 4 Kraulis J. and Hunter G. The results of prosthetic replacement in fracture-dislocations of upper end of the humerus. lrzjuty 1977; 8: 129. 5 Kristiansen B. and Christiansen S. W. Proximal humeral fractures. Acta Orthop Stand 1987; 58: 124. 6 Marotte J. H., Lord G. and Banuel P. L’arthroplastie de Neer dans le fractures et fractures-luxations complexes de l’epaule: apropos de 12~0s. Chirurgie 1978; 104: 816. 7 Neer II C. S. Displaced proximal humerus fractures, Part II. I Bone Joint Surg 1970; 52A: 1090.
8 Neer II C. S. and McIlveen S. J. Replacement de la tete humerale avec reconstruction -des ‘tuberosities et de la coiffe dan les fractrues desplacees a 4 fragments. Resultats actuels et techniques. Rev Chir Orthop Suppf II 1988; 74: 31. 9 Stableforth P. G. W. Four-part fractures of the neck of the humerus. J Bone Joint Surg 1984; 66B: 104. 10 Tanner M. W. and Cofield R. H. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop 1983; 179: 116. 11 Willems W. J. and Lim T. E. A. Neer arthroplasy for humeral fractures. Acta Orthop Stand 1985; 56: 394. 12 Fourrier I?. and Martini M. Post-traumatic avascular necrosis of the humeral head. Int Orthop 1977; 1: 187. 13 Norris T. R., Green A. and McGuigan F. X. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995; 4: 271. 14 Schai P., Imhoff A. and Preiss S. Cominuted humeral head fractures: a multicenter analysis. J Shoulder Elbow slug 1995; 4: 319. M. and Brostrom L. A. Shoulder 15 Zyto K., Kronberg function after displaced fractures of the proximal humerus. J Shoulder Elbow Surg 1995; 4: 331. 16 Goldman R. T., Koval K. J. and Cuomo F. etal. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995; 4: 81. 17 Neer II C. S. and McIlveen S. J. Recent results and techniques of prosthetic for four-part proximal humerus fractures. Orthop Trans 1986; 10: 475.
Paper accepted 10 May 1998. Requests for reprints should be addressed to: Dr Mehmet Demirhan, Department of Orthopaedics and Traumatology, Istanbul School of Medicine, Istanbul University, 34390 Topkapi, Istanbul, Turkey.
ELSEVIER
PII: SOO20-1383(98)00124-7
Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases Mehmet
Demirhan,
Sercan Akpinar,
Ata Can Atalar, Senol Akman
and Yilmaz Akalin
Department of Orthopaedics and Traumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergoneclosed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8years (range38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the inju y. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 1244 active external rotation averaged 29” and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder. 0 1998 Elsevier Science Ltd. All rights reserved.
Injury, Vol. 29, No. 7, 525-528, 1998
Introduction Although iatrogenic displacement of the humeral neck fracture in fracture-dislocation of the shoulder is rare, the choice of treatment is difficult. Open reduction and internal fixation had been reported to cause avascular necrosis and severe collapse of the humeral head’. Humeral head replacement has been successfully used for patients with four-part proximal humeral fractures, selected three-part fractures and comminuted articular surface fractures of the humeral head. We are unaware of any reported
application of this technique for iatrogenically displaced humeral head fracture-dislocations. This report, therefore, is the first study about primary replacement of the humeral head in the iatrogenically displaced fracture dislocations of the shoulder.
Patients and methods In this study, we reviewed six patients with an average age of 52.8 years (range 38-72 years) with humeral head replacement due to iatrogenically displaced shoulder fracture dislocations. Three were women and three were men. Three patients fell onto their outstretched arms from a standing position and the other three patients had traffic accidents. Anterior dislocation of the shoulder with fractures of the greater tuberosity and anatomical neck was the original injury in all cases (Figure 1). A closed reduction was attempted in other medical centres but when it was realised that the humeral head was displaced, these patients were referred to us (Figure 2). Surgery was performed in all cases with the patient in the beach chair position with the arm prepped and draped free. Exposure was obtained through a standard delto-pectoral incision and the anterior deltoid was mobilised and retracted laterally, leaving the origin and insertion intact. The tuberosity fragments were identified and the interval between the supraspinatus and subscapularis tendons was accessed. Meticulous dissection of the humeral head was done because of the close proximity of the humeral head to the neurovascular structures. After the humeral head was removed, the prosthesis was inserted in 30” to 40” of retroversion. Methylmethacrylate fixation was used in all patients. The tuberosities were securely reattached to the humeral shaft, to each other and to the fin of the prosthesis with heavy non-absorbable suture (No. 5 Ethibond”). The extremity of the patient was placed in a sling and prophylactic antibiotics were given for 48 h.
526
Injury:
International
The average time between injury and surgery was 9.3 days (range 2-30 days). Three Biomet modular prostheses (Biomet, Warsaw, IN), three Neer II prostheses (Kirschner Medical, Fair Lawn, NJ) were used (Figure 3). Physical therapy was begun on the second postoperative day. This therapy consisted of passive range of motion of the shoulder for forward flexion, external rotation to neutral rotation and internal rotation to the chest wall. Passive range of motion was gradually progressed as tolerated, active range of motion was begun on the sixth week. Strengthening exercises were instituted at 3 months. All patients participated in a supervised therapy program for up to 1 year (Figure 4).
Journal
of the Care of the Injured
Vol. 29, No. 7,199s
forward flexion averaged 124”, active external rotation averaged 29” and internal rotation average to the second lumbar vertebra. Four patients were able to do activities at shoulder level without difficulty
Results The average follow-up period was 30.2 months (range 12-55 months). Evaluation of the patients has been made according to the American Shoulder and Elbow Surgeons criteria. Pain, range of motion, strength, function and patient satisfaction were recorded. All radiographs were also reviewed. In five of the patients, all pain was diminished. Only one patient had slight pain after vigorous activity. Active
Figure 1. Plain radiograph demonstrating non-displaced fracture of the humeral neck associated with anterior dislocation and greater tuberosity fracture.
Figure 2. Plain radiograph ment of the humeral neck.
showing
Figure 3. Plain operatively.
of the patient
radiograph
iatrogenic
displace-
4 years post-
Demirhan et al.: Primary replacement of the humeral head
and two patients could do overhead little or no difficulty (Table I).
activities
with
Discussion Approximately 85 per cent of proximal humeral fractures are undisplaced or minimally displaced and are well treated with non-operative methods. However, displaced fractures require closed reduc-
Figure 4. Forward flexion and external rotation of the patient on the fourth post-operative year.
527
tion or open reduction and internal fixation. Other fractures including four-part fractures or fracturedislocations, head-splitting fractures and impression fractures involving more than 45 per cent of the humeral head require prosthetic replacement of the humeral head. The majority of non-displaced fractures of the proximal humerus are treated non-operatively. Should there be an undisplaced fracture of the humeral neck associated with a dislocation of the shoulder, the risk of displacement of the fracture is very high with closed reduction methods. This iatrogenie displacement of the humeral head is rare, De Mourgues et al. reported four cases, Ferkel et al. two cases and Hersche and Gerber seven cases’“. Although all fracture-dislocations were anterior with greater tuberosity fractures, Hersche and Gerber also reported two posterior fracture-dislocations with lesser tuberosity fractures and one anterior fracturedislocation with fractures of both tuberosities’. Hersche and Gerber reduced four cases under optimal relaxation and fluoroscopy control, but they caused moderate to severe displacement of the fracture in all four cases. In addition, they performed in situ fixation of the neck fracture before gentle reduction in one patient. They were also able to prevent the displacement but not the avascular necrosis of the humeral head. They suggested, that both the anterior circumflex arcuate artery and the intraosseous anastomoses might have been injured even in the absence of iatrogenic displacement of the humeral head. Hersche and Gerber reported avascular necrosis and severe collapse of the head in all six of their cases that were treated with open reduction and internal fixation’. When only four-part fractures are analysed, hemiarthroplasty emerges as the superior treatment option. An analysis of nine series in the literature of true four-part fractures treated with primary humeral head replacement shows that of 171 four-part fractures, 136 (80 per cent) achieved satisfactory or better results%“. Furthermore, humeral head replacement as a salvage procedure after loss of reduction, malunion or avascular necrosis of failed open reduction internal fixation is more technically demanding and less predictable in outcome than primary humeral head replacement’0J2-15. We have treated onIy one patient in this manner and observed deep prosthetic infection which resulted in removal of the prosthesis. We found that pain relief is predictable, but the functional outcome of humeral head replacement depends on the co-operation and motivation of the patient. These findings are similar to-those previously reported in the literature7-9,‘6J7. Motor strength around the shoulder is dependent on many factors including pre-operative strength, quality of tuberosity reattachment and rotator cuff repair and post-operative rehabilitation. Strength in our cases was excellent with an average of 4 on a 0-5 manual muscle testing scale. Although one patient had radiographic finding suggestive of loosening as
528
Injury:
International
Journal
of the Care of the Injured
Vol. 29, No. 7,1998
Table I. Patient demographics Patient no. 1 2 3 4 5 6 AFE:
active
Age
Sex
Fracture
42 64 72 61 40 38
M M F M F F
3-part 3-part d-part 3-part 3-part 3-part
forward
elevation,
ER: external
Arthroplasty time (days) ___~.
Prosthesis
7 6 3 8 2 30 rotation,
Biomet Neer II Neer II Biomet Neer II Biomet IR: internal
Follow-up (month) 14 48 55 12 34 12
AFE (“)
ER (“)
IR
110 140 120 116 128 130
26 34 25 28 32 29
L4 Th 12 L2 L2 L3 Ll
Function Shoulder Overhead Shoulder Shoulder Shoulder Overhead
level level level level
rotation.
demonstrated circumferential lucency between bone and cement interface, this did not affect the pain relief and the functional outcome of the patient. We did not observe any radiological finding of heterotopic ossification in any of our cases. Primary humeral head replacement for acute iatrogenitally displaced fracture-dislocations of the shoulder effectively relieves pain. Functional outcomes are dependent on the age, sex, co-operation and motivation of the patient. With a meticulously performed surgical technique and a rigorous supervised physical rehabilitation, better results are obtained than open reduction and internal fixation of the proximal humerus.
References 1 Hersche 0. and Gerber C. Iatrogenic displacement of fracture-dislocations of the shoulder. I Bone Joint Surg 1993; 76-B: 30. 2 De Mourgues G., Razemon J. P. and Leclair H. P. etal. Les fractures-luxations de l’epaule. Rev Chiv Orthop 1965; 51: 151. 3 Ferkel Rd., Hedley A. K. and Eckardt J. J. Anterior fracture-dislocations of the shoulder: pitfalls in treatment. J Trauma 1984; 24: 363. 4 Kraulis J. and Hunter G. The results of prosthetic replacement in fracture-dislocations of upper end of the humerus. lrzjuty 1977; 8: 129. 5 Kristiansen B. and Christiansen S. W. Proximal humeral fractures. Acta Orthop Stand 1987; 58: 124. 6 Marotte J. H., Lord G. and Banuel P. L’arthroplastie de Neer dans le fractures et fractures-luxations complexes de l’epaule: apropos de 12~0s. Chirurgie 1978; 104: 816. 7 Neer II C. S. Displaced proximal humerus fractures, Part II. I Bone Joint Surg 1970; 52A: 1090.
8 Neer II C. S. and McIlveen S. J. Replacement de la tete humerale avec reconstruction -des ‘tuberosities et de la coiffe dan les fractrues desplacees a 4 fragments. Resultats actuels et techniques. Rev Chir Orthop Suppf II 1988; 74: 31. 9 Stableforth P. G. W. Four-part fractures of the neck of the humerus. J Bone Joint Surg 1984; 66B: 104. 10 Tanner M. W. and Cofield R. H. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop 1983; 179: 116. 11 Willems W. J. and Lim T. E. A. Neer arthroplasy for humeral fractures. Acta Orthop Stand 1985; 56: 394. 12 Fourrier I?. and Martini M. Post-traumatic avascular necrosis of the humeral head. Int Orthop 1977; 1: 187. 13 Norris T. R., Green A. and McGuigan F. X. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995; 4: 271. 14 Schai P., Imhoff A. and Preiss S. Cominuted humeral head fractures: a multicenter analysis. J Shoulder Elbow slug 1995; 4: 319. M. and Brostrom L. A. Shoulder 15 Zyto K., Kronberg function after displaced fractures of the proximal humerus. J Shoulder Elbow Surg 1995; 4: 331. 16 Goldman R. T., Koval K. J. and Cuomo F. etal. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995; 4: 81. 17 Neer II C. S. and McIlveen S. J. Recent results and techniques of prosthetic for four-part proximal humerus fractures. Orthop Trans 1986; 10: 475.
Paper accepted 10 May 1998. Requests for reprints should be addressed to: Dr Mehmet Demirhan, Department of Orthopaedics and Traumatology, Istanbul School of Medicine, Istanbul University, 34390 Topkapi, Istanbul, Turkey.