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The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process—a series of six cases
ARTICLE IN PRESS J Shoulder Elbow Surg (2017) ■■, ■■–■■
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process—a series of six cases Fabian Plachel, MDa,b,1, Jakob E. Schanda, MDc,1, Reinhold Ortmaier, MDa, Alexander Auffarth, MDa, Herbert Resch, MDa, Robert Bogner, MDa,* a
Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria Institute of Tendon and Bone Regeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria c Department of Trauma Surgery, AUVA Trauma Center Meidling, Vienna, Austria b
Background: A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature. Methods: All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with “triple dislocation fracture” (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up. Results: Surgery was determined individually according to the radiologic findings, patient’s age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean ConstantMurley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred.
This study was approved by Ethikkommission Land Salzburg: 415-EP/73/577-2015 (08.09.2015). *Reprint requests: Robert Bogner, MD, Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstraße 48, A-5020 Salzburg, Austria. E-mail address: [email protected] (R. Bogner). 1 These authors contributed equally to this work. 1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.01.022
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F. Plachel et al. Conclusions: A “triple dislocation fracture,” especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a firsttime traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results. Level of evidence: Level IV; Case Series; Treatment Study © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Anterior shoulder dislocation; glenoid fracture; greater tuberosity fracture; coracoid process fracture; surgery; functional outcome
With an overall incidence rate between 24 and 56 per 100.000 person-years, the glenohumeral joint reveals the highest dislocation rate of all joints.23,42 Depending on the injury mechanism, bony lesions of the glenoid (5%-56%) and HillSachs lesions (65%-71%) have been reported to be one of the most frequent pathologies after a first-time traumatic shoulder dislocation.2,13,15,38,41 Isolated fractures of the greater tuberosity are reported in approximately 30%14 and fractures of the coracoid process in 0.8% to 2%.17,25 A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after a traumatic shoulder dislocation is a rare event. To our knowledge, only 1 (conservatively treated) patient has been reported in the literature.36 We present a series of 6 patients with “triple dislocation fracture” (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process) who underwent surgical treatment.
Material and methods Study population We retrospectively screened the patient records of the Department of Orthopaedics and Traumatology of the Paracelsus Medical University Salzburg between 1998 and 2013 for first-time traumatic anterior shoulder dislocations with associated fractures of the glenoid rim, greater tuberosity, and coracoid process. Among the 2068 patients with anterior shoulder dislocation treated during the study period, we identified 6 patients (0.3%; 1 female, 5 male) with triple dislocation fracture. Demographic data, including sex, age at surgery and latest follow-up, and affected side and handedness, are reported in Table I. The mean age at index surgery was 60 years (range,
Table I
37-85 years) and at final follow-up was 65 years (range, 49-89 years). The injury mechanisms were a simple fall (n = 4), a skiing accident (n = 1), and a traffic accident (n = 1).
Patient care Standardized radiographs in 3 planes (true anterior-posterior view, scapular Y view, axial view) and computed tomography (CT) scans, including a 3-dimensional (3D) reconstruction were performed preoperatively in all patients to determine the associated fractures (Figs. 1 and 2). Glenoid rim fractures were then classified according to Scheibel et al.35 Surface area of the best-fit circle and defect size were measured by means of 3D en face views according to Baudi et al.5 Greater tuberosity fractures were subdivided into displaced/ undisplaced and comminuted/not comminuted. Displacement was defined as incongruity of >5 mm in CT scans. Coracoid process fractures were classified according to Ogawa et al.28 The decision concerning the surgical treatment of the glenoid, the greater tuberosity, and the coracoid process depended primarily on the radiologic findings: The glenoid in every patient with fragment displacement was treated operatively to ensure glenohumeral stability. The greater tuberosity was refixed in case of displacement >5 mm. The coracoid process was surgically treated in case of fractures type I according to Ogawa and type II when displaced (Table II). All patients underwent surgery under general anesthesia in the beach chair position. The method of reduction of the glenoid fracture depended on the classification according to Scheibel et al35: 3 patients underwent open reduction and internal fixation with 2.7mm cannulated screws (Fig. 3), 2 patients underwent arthroscopic screw fixation, and 1 patient underwent an Eden-Hybinette procedure (Table II). The greater tuberosity fractures were operatively treated in 4 patients. In case of comminution, percutaneous screw fixation was performed using 2.7-mm cannulated screws, because
Baseline data and follow-up period of all patients
Patient
Sex
Affected side
Dominant arm
Age at index surgery
Age at final follow-up
Follow-up duration
(y)
(y)
(mo)
1 2 3 4 5 6
Male Male Female Male Male Male
Left Left Left Right Left Right
Right Right Left Right Left Right
37 67 63 40 85 66
49 69 65 43 89 71
147 27 29 38 50 63
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Figure 1 Patient 2: (A) A computed tomography scan of the left shoulder, coronal view, shows a displaced fracture of the greater tuberosity. Three-dimensional reconstructions of computed tomography scans of the left shoulder show (B) a fracture of the anterior glenoid rim (type 1b) and (C) a displaced fracture of the coracoid process (type II). 1 large fragment could be identified and the periosteum was intact (Fig. 4). When the fragment was intact, tension band wiring was performed (Fig. 3, Table II). Patient 2 underwent an additional supraspinatus tendon repair using 1 suture anchor (Fig. 2). The fractures of the coracoid process were operatively treated in 2 patients by means of tension band wiring (Fig. 3), and a cannulated screw along with a washer was used in 1 patient (Table II). After surgery, the affected shoulder was immobilized in a sling for 4 weeks. Passive movement exercises were allowed until pain threshold from the beginning. After sling removal, active abduction up to 90° was allowed. Heavy manual work and sports were allowed after 8 to 10 weeks. To ensure anatomic reduction of the fractures and correct positioning of the osteosynthesis, all patients underwent standard radiographs in 2 planes immediately after surgery (Fig. 4). In case of bony glenoid augmentation or reconstruction, CT scans were done on the first postoperative day (Fig. 4).
Clinical and radiologic follow-up examination At the final follow-up, the clinical outcome was measured using the Constant-Murley Score (CMS), Simple Shoulder Test (SST), and Subjective Shoulder Value (SSV). Patient satisfaction was classified as “very satisfied,” “satisfied,” “good,” and “dissatisfied.” Clinical examination was performed in the outpatient clinic by an experienced resident. Range of motion in active and passive anterior flexion, abduction, and internal and external rotation was measured. The strength of the affected side was assessed using an IDO isometer (Innovative Design Orthopaedics Limited, Redditch, Worcestershire, UK) with the arm in 90° abduction. All patients underwent radiographic evaluation in 3 planes (true anterior-posterior view, scapular Y view, axial view) to assess bony union and position of the osteosynthesis. The mean follow-up time was 59 months (minimum, 27; maximum, 147 months). No patient was lost during follow-up.
Results Revision surgery was necessary in 2 patients. Patient 1 needed repeat osteosynthesis of the coracoid process after 7 days because of loss of reduction (screw removal, reduction using
Figure 2 Patient 4: (A) A plain radiograph of the right shoulder shows a displaced and highly comminuted fracture of the greater tuberosity. The fracture of the coracoid process and the size of the glenoid rim defect are not easily seen. (B) A computed tomography scan of the right shoulder, axial view, shows the displaced and highly comminuted fracture of the greater tuberosity and an undisplaced fracture of the coracoid process (type II). Threedimensional reconstructions of computed tomography scans of the right shoulder show (C) a displaced fracture of the anterior glenoid rim (type 1c) and (D) a displaced and highly comminuted fracture of the greater tuberosity, undisplaced fracture of the coracoid process (type II).
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Table II
Radiographic findings and surgical techniques
Patient
Surgical approach
Glenoid fracture Radiologic findings*
Surgical treatment
Radiologic findings†
Surgical treatment
Radiologic findings‡
Surgical treatment
1
Deltopectoral
None
Displaced, not comminuted
3
Displaced, not comminuted
Tension band wiring (anterolateral)§ Tension band wiring
4
Deltopectoral
5
Arthroscopic
Displaced, highly comminuted with 1 large fragment and intact periosteum Displaced, slightly comminuted
Screw fixation (percutaneous) Screw fixation
6
Arthroscopic, deltopectoral
Not displaced, not comminuted
None
• Type II • Displaced • Type II • Displaced • Type II • Not displaced • Type II • Not displaced • Type II • Not displaced • Type I • Displaced
Screw fixation
Deltopectoral, anterolateral Deltopectoral
Eden-Hybinette graft Screw fixation (deltopectoral) Screw fixation
Not displaced, not comminuted
2
• Ic • 28% • Ib • 15% • Ib • 37% • Ic • 20% • Ib • 25% • Ib • 19%
Screw fixation Screw fixation (arthroscopic)
Coracoid process fracture
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Screw fixation
Greater tuberosity fracture
Tension band wiring None None None Tension band wiring (deltopectoral)
* Classification according to Scheibel et al35: Type I: acute fracture type, subdivided into a: bony Bankart-lesion, b: solitaire glenoid rim fracture, c: multifragmentary glenoid rim fracture; Type II: chronic fracture type in extra-anatomical position (non-union); Type III: glenoid bone defect without fragment, subdivided into a: <25% glenoid defect size, b: >25% glenoid defect size. Glenoid defect size (in %) determined with the Pico method.5 † Displacement >5 mm, comminution. ‡ Classification according to Ogawa et al28: Type I: posterior of the attachment of the coracoclavicular ligaments; Type II: anterior of the attachment of the coracoclavicular ligaments. § Patient 2 underwent additional repair of the supraspinatus tendon during the index surgery.
F. Plachel et al.
ARTICLE IN PRESS The “triple dislocation fracture”
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Figure 3 Patient 2: (A) A plain radiograph of the left shoulder, 1 month after the index surgery, shows anatomic reduction of the fractures of the anterior glenoid rim, greater tuberosity, and coracoid process, screw fixation of the anterior glenoid rim, tension band wiring of the greater tuberosity, and additional repair of the supraspinatus tendon using 1 suture anchor. (B) A plain radiograph of the left shoulder, 3 months after the index surgery, shows correct positioning of the osteosynthesis. (C) A plain radiograph of the left shoulder, 24 months after the index surgery, shows bony healing of the fractures of the anterior glenoid rim, greater tuberosity, and coracoid process, and broken tension band wiring of the greater tuberosity without impairment of the glenohumeral joint.
a trabecular bone screw, and additional tension band wiring). Patient 2 underwent repeat osteosynthesis of the greater tuberosity after 5 days because of loss of reduction (new tension band wiring). At the final follow-up, the mean abduction was 133° (range, 90°-180°), and the mean anterior flexion was 138° (range, 90°-180°). The mean CMS was 72 points (range, 42-98 points), the mean SST was 9 points (range, 5-12 points), and the mean SSV was 72% (range, 40%-95%). Four patients rated their outcome as “very satisfied” and 2 as “satisfied.” No patient reported recurrent shoulder instability.
Discussion We present the functional and radiologic outcomes of a series of 6 patients with triple dislocation fracture, a combined fracture of the anterior glenoid rim, greater tuberosity, and coracoid process after traumatic anterior shoulder dislocation. Only 1 report of a patient with this rare injury pattern has been published until now. Bony lesions of the glenoid rim are common after anterior shoulder dislocation, with an incidence of between 5% and 56%.13,38 Rowe et al32 even reported rates up to 73%. Nevertheless, glenoid rim fractures are overlooked in approximately 20% if only radiographs in 2 planes are performed. Therefore, CT scans and 3D reconstructions to determine the defect size of the glenoid should be performed as a routine procedure after first-time shoulder dislocations.3 No unequivocal treatment recommendations in favor of conservative or surgical treatment exist. In the past, glenoid rim fractures have been mainly treated conservatively. Maquieira et al24 investigated 14 patients with large, displaced glenoid rim fractures after a first-time traumatic shoulder dislocation and described satisfactory results after conservative
treatment. The same holds true for open or arthroscopic surgical treatment.8,33,37 In general, decisions concerning conservative or operative treatment depend on factors such as fragment size, amount of dislocation, position of the humeral head (centered or subluxation), and the patient’s age, general state of health, and personal demands. Nevertheless, glenoid rim fixation should be considered in any case to prevent possible recurrent glenohumeral instability. In case of chronic fracture types, bony glenoid augmentation such as Latarjet procedure, J-Bone graft, or iliac crest bone grafts could be performed.4,21,30,34,35 Greater tuberosity fractures occur in up to 30% after anterior shoulder dislocation.14 Platzer et al31 reported significantly better results in operative vs. conservative treatment in case of greater tuberosity displacement >5 mm. Recommendation for surgery exists even in case of displacement >3 mm.14 To determine the extent of dislocation, plain radiographs in external rotation and plain radiographs with a 15° caudal tilt are suggested.29 However, if the indication for surgical treatment is based on radiologic findings in millimeter increments, CT scans are crucial, because determining the exact extent of displacement may be difficult only using plain radiographs. Numerous surgical techniques for reduction of the greater tuberosity are reported, including open reduction and internal fixation, tension band wiring, percutaneous screw fixation, transosseous suture fixation, and arthroscopic double-row fixation.7,11,12,16,22 Up to now, there is no consensus on which technique is preferable. The decision should be made individually considering the radiologic findings (amount of displacement, comminuted, etc). Because fractures of the coracoid process after traumatic shoulder dislocation are rare (0.8%-2%),17,25 only a few case reports have been published.6,10,20,36,40 Coracoid fractures can easily be missed on standard radiographs.19,26 Therefore, CT
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Figure 4 Patient 4: (A) A plain radiograph of the right shoulder, 1 day after surgery, shows anatomic reduction of the anterior glenoid rim and screw refixation, a highly comminuted fracture of the greater tuberosity with 1 large fragment, and intact periosteum, anatomically reduced using a 2.7-mm cannulated screw. (B) A 3-dimensional reconstruction of a computed tomography scan of the right shoulder, 1 day after surgery, shows anatomic reduction of the anterior glenoid rim and screw refixation, a highly comminuted fracture of the greater tuberosity, anatomic reduction and screw refixation, and an undisplaced fracture of the coracoid process (type II). (C) A plain radiograph of the right shoulder, 1 month after surgery, shows unchanged positioning of the osteosynthesis compared with the postoperative radiograph in panel A. (D) A plain radiograph of the right shoulder, 48 months after surgery, shows bony healing of the fractures of the anterior glenoid rim and the greater tuberosity and unchanged positioning of the osteosynthesis compared with the previous scans in panels A, B, and C.
F. Plachel et al. reduction of the coracoid process can be done by screw fixation, plates, or tension band wiring.1,27 The only published patient with a triple dislocation fracture was treated conservatively.36 Surgery was performed in all of our patients to ensure long-term joint stability and prevent secondary arthropathy.9,18,20,27 Surgical treatment was assessed individually according to the preoperative radiologic findings (Table II). The patient reported by te Slaa et al,36 a 73-year-old woman, had a stable shoulder 6 months after injury. She reached 89 points in the CMS and anterior flexion of 140°, but still reported mild pain.36 The mean follow-up period in our series was 59 months (range, 27-147 months; Table I). The mean CMS of our patients was 72 points (range, 42-98 points), and mean anterior flexion was 138° (range, 90°180°; Table III). Three patients, patients 3, 4, and 5, reached excellent results in the CMS (91-98 points), with a physiologic anterior flexion (160°-180°, Table III). These 3 patients were “very satisfied” with the treatment. Three patients (patients 1, 2, and 6) reached poorer results in the CMS (range, 42-51 points; Table III). Patients 1 and 2 had to undergo revision surgery in the first week after the index operation due to loss of reduction of the greater tuberosity and the coracoid process. Both patients were “satisfied” at the final follow-up. Patient 6 had by far the poorest outcome in the clinical examination and all shoulder scores (Table III). He reported reduced range of motion, which could be explained by post-traumatic degeneration of the rotator cuff, because asymptomatic tears occur in 23% to 51% of elderly patients.39 Nevertheless, the patient was “very satisfied” with the treatment because he did not report any pain during the entire follow-up period. The retrospective design of our study and the small sample size are limiting factors. However, considering the scarcity of the investigated injury pattern (0.3% of all anterior shoulder dislocations between 1998 and 2013 in a level A trauma center) and that only 1 patient has been reported until now, our study is the first to report the functional outcome of triple dislocation fracture after surgical intervention.
Conclusion
scans, including 3D reconstruction, are recommended to precisely assess the indication for surgery. According to Ogawa et al,28 all type I fractures (dorsal of the coracoclavicular ligaments) should be surgically treated. Type II fractures (fractures of the coracoid process ventral of the coracoclavicular ligaments) can be treated conservatively. However, the tension of the conjoined tendons can cause the tip of the coracoid process to be displaced downward, leading to subcoracoid impingement.20,27 Therefore, type II fractures with a displacement of >5 mm should be treated surgically to prevent pseudoarthrosis or malunion. Surgical
Early CT scans with 3D reconstruction, as well as a precise clinical examination after traumatic shoulder dislocation, is strongly recommended to estimate the injury pattern and associated pathologies. The fixation of the multiple bony injuries in the triple dislocation fracture may be considered when there is risk for recurrent instability, rotator cuff dysfunction, or coracoid impingement based on prior classification and treatment recommendation for the individual fracture components. The goal of fixation in these complex fractures is to ensure a stable glenohumeral joint, maximize function, and minimize risk of secondary arthropathy.
ARTICLE IN PRESS The “triple dislocation fracture” Table III Patient
1 2 3 4 5 6 Mean
7
Clinical examination and objective outcome at final follow-up Abduction
(in °) 110 90 170 160 180 90 133
Constant-Murley Score*
Anterior flexion
Pain
Activity
Mobility
Strength
Strength
Total
Simple Shoulder Test†
Subjective Shoulder Value
(in °) 140 90 170 160 180 90 138
12 15 15 13 15 13 14
9 14 20 20 20 12 16
26 16 40 40 38 14 29
4 6 16 25 25 6 14
(in kg) 2 3 8 12 14 3 7
51 51 91 98 98 42 72
5 8 11 12 12 5 9
(%) 40 60 95 90 95 50 72
Patient satisfaction‡
Satisfied Satisfied Very satisfied Very satisfied Very satisfied Very satisfied
* Minimum, 0 points; maximum, 100 points, subdivided into pain: minimum. 0 points; maximum, 15 points; activity: minimum, 0 points; maximum, 20 points; mobility: minimum, 0 points; maximum, 40 points; strength: minimum, 0 points; maximum, 25 points. † Minimum, 0 points; maximum, 12 points. ‡ Classified as “very satisfied,” “satisfied,” “good,” or “dissatisfied.”
Disclaimer 10.
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
11.
12.
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F. Plachel et al. tuberosity fractures? Clin Orthop Relat Res 2016;474:1269-79. http://dx.doi.org/10.1007/s11999-015-4663-5 Liavaag S, Svenningsen S, Reikerås O, Enger M, Fjalestad T, Pripp AH, et al. The epidemiology of shoulder dislocations in Oslo. Scand J Med Sci Sports 2011;21:e334-40. http://dx.doi.org/10.1111/j.1600-0838 .2011.01300.x Maquieira GJ, Espinosa N, Gerber C, Eid K. Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder. J Bone Joint Surg Br 2007;89:1347-51. http://dx.doi .org/10.1302/0301-620X.89B10.19273 McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II. A comparative study. J Trauma Acute Care Surg 1967;7:191201. Ogawa K, Ikegami H, Takeda T, Watanabe A. Defining impairment and treatment of subacute and chronic fractures of the coracoid process. J Trauma 2009;67:1040-5. http://dx.doi.org/10.1097/TA.0b013e318184205c Ogawa K, Matsumura N, Ikegami H. Coracoid fractures: therapeutic strategy and surgical outcomes. J Trauma Acute Care Surg 2012;72:E206. http://dx.doi.org/10.1097/TA.0b013e31822af54e Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures of the coracoid process. J Bone Joint Surg Br 1997;79:17-9. Parsons BO, Klepps SJ, Miller S, Bird J, Gladstone J, Flatow E. Reliability and reproducibility of radiographs of greater tuberosity displacement. A cadaveric study. J Bone Joint Surg Am 2005;87:58-65. http://dx.doi.org/10.2106/JBJS.C.01576 Plachel F, Heuberer P, Schanda J, Pauzenberger L, Kriegleder B, Anderl W. [All-arthroscopic J-bone grafting in chronic anterior shoulder instability with glenoid bone loss]. Obere Extrem 2016;11:119-25. http://dx.doi.org/10.1007/s11678-015-0321-5 [in German] Platzer P, Thalhammer G, Oberleitner G, Kutscha-Lissberg F, Wieland T, Vécsei V, et al. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma 2008;65:843-8. http://dx.doi.org/10.1097/01.ta.0000233710.42698 .3f
32. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978;60:1-16. 33. Scheibel M, Hug K, Gerhardt C, Krüger D. Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures. J Shoulder Elbow Surg 2016;25:781-90. http://dx.doi.org/10 .1016/j.jse.2015.09.012 34. Scheibel M, Kraus N, Diederichs G, Haas NP. Arthroscopic reconstruction of chronic anteroinferior glenoid defect using an autologous tricortical iliac crest bone grafting technique. Arch Orthop Trauma Surg 2008;128:1295-300. http://dx.doi.org/10.1007/ s00402-007-0509-2 35. Scheibel M, Kraus N, Gerhardt C, Haas NP. [Anterior glenoid rim defects of the shoulder]. Orthopade 2009;38:41-8, 50-3. http://dx.doi.org/10 .1007/s00132-008-1354-x 36. te Slaa RL, Verburg H, Marti RK. Fracture of the coracoid process, the greater tuberosity, and the glenoid rim after acute first-time anterior shoulder dislocation: a case report. J Shoulder Elbow Surg 2001;10:489-92. 37. Tauber M, Moursy M, Eppel M, Koller H, Resch H. Arthroscopic screw fixation of large anterior glenoid fractures. Knee Surg Sports Traumatol Arthrosc 2008;16:326-32. http://dx.doi.org/10.1007/s00167-007-0437-2 38. Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg 2004;13:279-85. http://dx.doi.org/10.1016/j.jse.2004.01.008 39. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9. 40. Wong-Pack WK, Bobechko PE, Becker EJ. Fractured coracoid with anterior shoulder dislocation. J Can Assoc Radiol 1980;31:278-9. 41. Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy 2007;23:985-90. http://dx.doi.org/10 .1016/j.arthro.2007.05.009 42. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am 2010;92:542-9. http://dx.doi.org/10.2106/JBJS.I.00450
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ORIGINAL ARTICLE
The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process—a series of six cases Fabian Plachel, MDa,b,1, Jakob E. Schanda, MDc,1, Reinhold Ortmaier, MDa, Alexander Auffarth, MDa, Herbert Resch, MDa, Robert Bogner, MDa,* a
Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria Institute of Tendon and Bone Regeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria c Department of Trauma Surgery, AUVA Trauma Center Meidling, Vienna, Austria b
Background: A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature. Methods: All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with “triple dislocation fracture” (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up. Results: Surgery was determined individually according to the radiologic findings, patient’s age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean ConstantMurley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred.
This study was approved by Ethikkommission Land Salzburg: 415-EP/73/577-2015 (08.09.2015). *Reprint requests: Robert Bogner, MD, Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstraße 48, A-5020 Salzburg, Austria. E-mail address: [email protected] (R. Bogner). 1 These authors contributed equally to this work. 1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.01.022
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F. Plachel et al. Conclusions: A “triple dislocation fracture,” especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a firsttime traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results. Level of evidence: Level IV; Case Series; Treatment Study © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Anterior shoulder dislocation; glenoid fracture; greater tuberosity fracture; coracoid process fracture; surgery; functional outcome
With an overall incidence rate between 24 and 56 per 100.000 person-years, the glenohumeral joint reveals the highest dislocation rate of all joints.23,42 Depending on the injury mechanism, bony lesions of the glenoid (5%-56%) and HillSachs lesions (65%-71%) have been reported to be one of the most frequent pathologies after a first-time traumatic shoulder dislocation.2,13,15,38,41 Isolated fractures of the greater tuberosity are reported in approximately 30%14 and fractures of the coracoid process in 0.8% to 2%.17,25 A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after a traumatic shoulder dislocation is a rare event. To our knowledge, only 1 (conservatively treated) patient has been reported in the literature.36 We present a series of 6 patients with “triple dislocation fracture” (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process) who underwent surgical treatment.
Material and methods Study population We retrospectively screened the patient records of the Department of Orthopaedics and Traumatology of the Paracelsus Medical University Salzburg between 1998 and 2013 for first-time traumatic anterior shoulder dislocations with associated fractures of the glenoid rim, greater tuberosity, and coracoid process. Among the 2068 patients with anterior shoulder dislocation treated during the study period, we identified 6 patients (0.3%; 1 female, 5 male) with triple dislocation fracture. Demographic data, including sex, age at surgery and latest follow-up, and affected side and handedness, are reported in Table I. The mean age at index surgery was 60 years (range,
Table I
37-85 years) and at final follow-up was 65 years (range, 49-89 years). The injury mechanisms were a simple fall (n = 4), a skiing accident (n = 1), and a traffic accident (n = 1).
Patient care Standardized radiographs in 3 planes (true anterior-posterior view, scapular Y view, axial view) and computed tomography (CT) scans, including a 3-dimensional (3D) reconstruction were performed preoperatively in all patients to determine the associated fractures (Figs. 1 and 2). Glenoid rim fractures were then classified according to Scheibel et al.35 Surface area of the best-fit circle and defect size were measured by means of 3D en face views according to Baudi et al.5 Greater tuberosity fractures were subdivided into displaced/ undisplaced and comminuted/not comminuted. Displacement was defined as incongruity of >5 mm in CT scans. Coracoid process fractures were classified according to Ogawa et al.28 The decision concerning the surgical treatment of the glenoid, the greater tuberosity, and the coracoid process depended primarily on the radiologic findings: The glenoid in every patient with fragment displacement was treated operatively to ensure glenohumeral stability. The greater tuberosity was refixed in case of displacement >5 mm. The coracoid process was surgically treated in case of fractures type I according to Ogawa and type II when displaced (Table II). All patients underwent surgery under general anesthesia in the beach chair position. The method of reduction of the glenoid fracture depended on the classification according to Scheibel et al35: 3 patients underwent open reduction and internal fixation with 2.7mm cannulated screws (Fig. 3), 2 patients underwent arthroscopic screw fixation, and 1 patient underwent an Eden-Hybinette procedure (Table II). The greater tuberosity fractures were operatively treated in 4 patients. In case of comminution, percutaneous screw fixation was performed using 2.7-mm cannulated screws, because
Baseline data and follow-up period of all patients
Patient
Sex
Affected side
Dominant arm
Age at index surgery
Age at final follow-up
Follow-up duration
(y)
(y)
(mo)
1 2 3 4 5 6
Male Male Female Male Male Male
Left Left Left Right Left Right
Right Right Left Right Left Right
37 67 63 40 85 66
49 69 65 43 89 71
147 27 29 38 50 63
ARTICLE IN PRESS The “triple dislocation fracture”
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Figure 1 Patient 2: (A) A computed tomography scan of the left shoulder, coronal view, shows a displaced fracture of the greater tuberosity. Three-dimensional reconstructions of computed tomography scans of the left shoulder show (B) a fracture of the anterior glenoid rim (type 1b) and (C) a displaced fracture of the coracoid process (type II). 1 large fragment could be identified and the periosteum was intact (Fig. 4). When the fragment was intact, tension band wiring was performed (Fig. 3, Table II). Patient 2 underwent an additional supraspinatus tendon repair using 1 suture anchor (Fig. 2). The fractures of the coracoid process were operatively treated in 2 patients by means of tension band wiring (Fig. 3), and a cannulated screw along with a washer was used in 1 patient (Table II). After surgery, the affected shoulder was immobilized in a sling for 4 weeks. Passive movement exercises were allowed until pain threshold from the beginning. After sling removal, active abduction up to 90° was allowed. Heavy manual work and sports were allowed after 8 to 10 weeks. To ensure anatomic reduction of the fractures and correct positioning of the osteosynthesis, all patients underwent standard radiographs in 2 planes immediately after surgery (Fig. 4). In case of bony glenoid augmentation or reconstruction, CT scans were done on the first postoperative day (Fig. 4).
Clinical and radiologic follow-up examination At the final follow-up, the clinical outcome was measured using the Constant-Murley Score (CMS), Simple Shoulder Test (SST), and Subjective Shoulder Value (SSV). Patient satisfaction was classified as “very satisfied,” “satisfied,” “good,” and “dissatisfied.” Clinical examination was performed in the outpatient clinic by an experienced resident. Range of motion in active and passive anterior flexion, abduction, and internal and external rotation was measured. The strength of the affected side was assessed using an IDO isometer (Innovative Design Orthopaedics Limited, Redditch, Worcestershire, UK) with the arm in 90° abduction. All patients underwent radiographic evaluation in 3 planes (true anterior-posterior view, scapular Y view, axial view) to assess bony union and position of the osteosynthesis. The mean follow-up time was 59 months (minimum, 27; maximum, 147 months). No patient was lost during follow-up.
Results Revision surgery was necessary in 2 patients. Patient 1 needed repeat osteosynthesis of the coracoid process after 7 days because of loss of reduction (screw removal, reduction using
Figure 2 Patient 4: (A) A plain radiograph of the right shoulder shows a displaced and highly comminuted fracture of the greater tuberosity. The fracture of the coracoid process and the size of the glenoid rim defect are not easily seen. (B) A computed tomography scan of the right shoulder, axial view, shows the displaced and highly comminuted fracture of the greater tuberosity and an undisplaced fracture of the coracoid process (type II). Threedimensional reconstructions of computed tomography scans of the right shoulder show (C) a displaced fracture of the anterior glenoid rim (type 1c) and (D) a displaced and highly comminuted fracture of the greater tuberosity, undisplaced fracture of the coracoid process (type II).
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Table II
Radiographic findings and surgical techniques
Patient
Surgical approach
Glenoid fracture Radiologic findings*
Surgical treatment
Radiologic findings†
Surgical treatment
Radiologic findings‡
Surgical treatment
1
Deltopectoral
None
Displaced, not comminuted
3
Displaced, not comminuted
Tension band wiring (anterolateral)§ Tension band wiring
4
Deltopectoral
5
Arthroscopic
Displaced, highly comminuted with 1 large fragment and intact periosteum Displaced, slightly comminuted
Screw fixation (percutaneous) Screw fixation
6
Arthroscopic, deltopectoral
Not displaced, not comminuted
None
• Type II • Displaced • Type II • Displaced • Type II • Not displaced • Type II • Not displaced • Type II • Not displaced • Type I • Displaced
Screw fixation
Deltopectoral, anterolateral Deltopectoral
Eden-Hybinette graft Screw fixation (deltopectoral) Screw fixation
Not displaced, not comminuted
2
• Ic • 28% • Ib • 15% • Ib • 37% • Ic • 20% • Ib • 25% • Ib • 19%
Screw fixation Screw fixation (arthroscopic)
Coracoid process fracture
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Screw fixation
Greater tuberosity fracture
Tension band wiring None None None Tension band wiring (deltopectoral)
* Classification according to Scheibel et al35: Type I: acute fracture type, subdivided into a: bony Bankart-lesion, b: solitaire glenoid rim fracture, c: multifragmentary glenoid rim fracture; Type II: chronic fracture type in extra-anatomical position (non-union); Type III: glenoid bone defect without fragment, subdivided into a: <25% glenoid defect size, b: >25% glenoid defect size. Glenoid defect size (in %) determined with the Pico method.5 † Displacement >5 mm, comminution. ‡ Classification according to Ogawa et al28: Type I: posterior of the attachment of the coracoclavicular ligaments; Type II: anterior of the attachment of the coracoclavicular ligaments. § Patient 2 underwent additional repair of the supraspinatus tendon during the index surgery.
F. Plachel et al.
ARTICLE IN PRESS The “triple dislocation fracture”
5
Figure 3 Patient 2: (A) A plain radiograph of the left shoulder, 1 month after the index surgery, shows anatomic reduction of the fractures of the anterior glenoid rim, greater tuberosity, and coracoid process, screw fixation of the anterior glenoid rim, tension band wiring of the greater tuberosity, and additional repair of the supraspinatus tendon using 1 suture anchor. (B) A plain radiograph of the left shoulder, 3 months after the index surgery, shows correct positioning of the osteosynthesis. (C) A plain radiograph of the left shoulder, 24 months after the index surgery, shows bony healing of the fractures of the anterior glenoid rim, greater tuberosity, and coracoid process, and broken tension band wiring of the greater tuberosity without impairment of the glenohumeral joint.
a trabecular bone screw, and additional tension band wiring). Patient 2 underwent repeat osteosynthesis of the greater tuberosity after 5 days because of loss of reduction (new tension band wiring). At the final follow-up, the mean abduction was 133° (range, 90°-180°), and the mean anterior flexion was 138° (range, 90°-180°). The mean CMS was 72 points (range, 42-98 points), the mean SST was 9 points (range, 5-12 points), and the mean SSV was 72% (range, 40%-95%). Four patients rated their outcome as “very satisfied” and 2 as “satisfied.” No patient reported recurrent shoulder instability.
Discussion We present the functional and radiologic outcomes of a series of 6 patients with triple dislocation fracture, a combined fracture of the anterior glenoid rim, greater tuberosity, and coracoid process after traumatic anterior shoulder dislocation. Only 1 report of a patient with this rare injury pattern has been published until now. Bony lesions of the glenoid rim are common after anterior shoulder dislocation, with an incidence of between 5% and 56%.13,38 Rowe et al32 even reported rates up to 73%. Nevertheless, glenoid rim fractures are overlooked in approximately 20% if only radiographs in 2 planes are performed. Therefore, CT scans and 3D reconstructions to determine the defect size of the glenoid should be performed as a routine procedure after first-time shoulder dislocations.3 No unequivocal treatment recommendations in favor of conservative or surgical treatment exist. In the past, glenoid rim fractures have been mainly treated conservatively. Maquieira et al24 investigated 14 patients with large, displaced glenoid rim fractures after a first-time traumatic shoulder dislocation and described satisfactory results after conservative
treatment. The same holds true for open or arthroscopic surgical treatment.8,33,37 In general, decisions concerning conservative or operative treatment depend on factors such as fragment size, amount of dislocation, position of the humeral head (centered or subluxation), and the patient’s age, general state of health, and personal demands. Nevertheless, glenoid rim fixation should be considered in any case to prevent possible recurrent glenohumeral instability. In case of chronic fracture types, bony glenoid augmentation such as Latarjet procedure, J-Bone graft, or iliac crest bone grafts could be performed.4,21,30,34,35 Greater tuberosity fractures occur in up to 30% after anterior shoulder dislocation.14 Platzer et al31 reported significantly better results in operative vs. conservative treatment in case of greater tuberosity displacement >5 mm. Recommendation for surgery exists even in case of displacement >3 mm.14 To determine the extent of dislocation, plain radiographs in external rotation and plain radiographs with a 15° caudal tilt are suggested.29 However, if the indication for surgical treatment is based on radiologic findings in millimeter increments, CT scans are crucial, because determining the exact extent of displacement may be difficult only using plain radiographs. Numerous surgical techniques for reduction of the greater tuberosity are reported, including open reduction and internal fixation, tension band wiring, percutaneous screw fixation, transosseous suture fixation, and arthroscopic double-row fixation.7,11,12,16,22 Up to now, there is no consensus on which technique is preferable. The decision should be made individually considering the radiologic findings (amount of displacement, comminuted, etc). Because fractures of the coracoid process after traumatic shoulder dislocation are rare (0.8%-2%),17,25 only a few case reports have been published.6,10,20,36,40 Coracoid fractures can easily be missed on standard radiographs.19,26 Therefore, CT
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Figure 4 Patient 4: (A) A plain radiograph of the right shoulder, 1 day after surgery, shows anatomic reduction of the anterior glenoid rim and screw refixation, a highly comminuted fracture of the greater tuberosity with 1 large fragment, and intact periosteum, anatomically reduced using a 2.7-mm cannulated screw. (B) A 3-dimensional reconstruction of a computed tomography scan of the right shoulder, 1 day after surgery, shows anatomic reduction of the anterior glenoid rim and screw refixation, a highly comminuted fracture of the greater tuberosity, anatomic reduction and screw refixation, and an undisplaced fracture of the coracoid process (type II). (C) A plain radiograph of the right shoulder, 1 month after surgery, shows unchanged positioning of the osteosynthesis compared with the postoperative radiograph in panel A. (D) A plain radiograph of the right shoulder, 48 months after surgery, shows bony healing of the fractures of the anterior glenoid rim and the greater tuberosity and unchanged positioning of the osteosynthesis compared with the previous scans in panels A, B, and C.
F. Plachel et al. reduction of the coracoid process can be done by screw fixation, plates, or tension band wiring.1,27 The only published patient with a triple dislocation fracture was treated conservatively.36 Surgery was performed in all of our patients to ensure long-term joint stability and prevent secondary arthropathy.9,18,20,27 Surgical treatment was assessed individually according to the preoperative radiologic findings (Table II). The patient reported by te Slaa et al,36 a 73-year-old woman, had a stable shoulder 6 months after injury. She reached 89 points in the CMS and anterior flexion of 140°, but still reported mild pain.36 The mean follow-up period in our series was 59 months (range, 27-147 months; Table I). The mean CMS of our patients was 72 points (range, 42-98 points), and mean anterior flexion was 138° (range, 90°180°; Table III). Three patients, patients 3, 4, and 5, reached excellent results in the CMS (91-98 points), with a physiologic anterior flexion (160°-180°, Table III). These 3 patients were “very satisfied” with the treatment. Three patients (patients 1, 2, and 6) reached poorer results in the CMS (range, 42-51 points; Table III). Patients 1 and 2 had to undergo revision surgery in the first week after the index operation due to loss of reduction of the greater tuberosity and the coracoid process. Both patients were “satisfied” at the final follow-up. Patient 6 had by far the poorest outcome in the clinical examination and all shoulder scores (Table III). He reported reduced range of motion, which could be explained by post-traumatic degeneration of the rotator cuff, because asymptomatic tears occur in 23% to 51% of elderly patients.39 Nevertheless, the patient was “very satisfied” with the treatment because he did not report any pain during the entire follow-up period. The retrospective design of our study and the small sample size are limiting factors. However, considering the scarcity of the investigated injury pattern (0.3% of all anterior shoulder dislocations between 1998 and 2013 in a level A trauma center) and that only 1 patient has been reported until now, our study is the first to report the functional outcome of triple dislocation fracture after surgical intervention.
Conclusion
scans, including 3D reconstruction, are recommended to precisely assess the indication for surgery. According to Ogawa et al,28 all type I fractures (dorsal of the coracoclavicular ligaments) should be surgically treated. Type II fractures (fractures of the coracoid process ventral of the coracoclavicular ligaments) can be treated conservatively. However, the tension of the conjoined tendons can cause the tip of the coracoid process to be displaced downward, leading to subcoracoid impingement.20,27 Therefore, type II fractures with a displacement of >5 mm should be treated surgically to prevent pseudoarthrosis or malunion. Surgical
Early CT scans with 3D reconstruction, as well as a precise clinical examination after traumatic shoulder dislocation, is strongly recommended to estimate the injury pattern and associated pathologies. The fixation of the multiple bony injuries in the triple dislocation fracture may be considered when there is risk for recurrent instability, rotator cuff dysfunction, or coracoid impingement based on prior classification and treatment recommendation for the individual fracture components. The goal of fixation in these complex fractures is to ensure a stable glenohumeral joint, maximize function, and minimize risk of secondary arthropathy.
ARTICLE IN PRESS The “triple dislocation fracture” Table III Patient
1 2 3 4 5 6 Mean
7
Clinical examination and objective outcome at final follow-up Abduction
(in °) 110 90 170 160 180 90 133
Constant-Murley Score*
Anterior flexion
Pain
Activity
Mobility
Strength
Strength
Total
Simple Shoulder Test†
Subjective Shoulder Value
(in °) 140 90 170 160 180 90 138
12 15 15 13 15 13 14
9 14 20 20 20 12 16
26 16 40 40 38 14 29
4 6 16 25 25 6 14
(in kg) 2 3 8 12 14 3 7
51 51 91 98 98 42 72
5 8 11 12 12 5 9
(%) 40 60 95 90 95 50 72
Patient satisfaction‡
Satisfied Satisfied Very satisfied Very satisfied Very satisfied Very satisfied
* Minimum, 0 points; maximum, 100 points, subdivided into pain: minimum. 0 points; maximum, 15 points; activity: minimum, 0 points; maximum, 20 points; mobility: minimum, 0 points; maximum, 40 points; strength: minimum, 0 points; maximum, 25 points. † Minimum, 0 points; maximum, 12 points. ‡ Classified as “very satisfied,” “satisfied,” “good,” or “dissatisfied.”
Disclaimer 10.
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
11.
12.
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