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Fracture-dislocation of the shoulder with intrathoracic displacement of the humeral head

1995; Elsevier BV; Volume: 26; Issue: 9 Linguagem: Inglês

10.1016/0020-1383(95)00120-x

1879-0267

T. Kenneth Kaar, John Jeremy Rice, G. B. Mullan,

Shoulder Injury and Treatment

A 79-year-old woman presented with right shoulder and chest pain following a fall down three steps. The clinical findings included tachypnoea, subcutaneous emphysema on the right side of the chest and tender swelling in the region of the right shoulder. There was no evidence of neurovascular deficit in the right upper limb. An antero-posterior radiograph of the chest showed fracture of the right third to fifth ribs, haemopneumothorax and a four part fracture-dislocation of the proximal right humerus with inferomedial displacement of the head. A lateral radiograph (Figtrre I) of the right shoulder demonstrated anterior displacement of the humeral head. An antero-posterior projection showed the humeral head obscured by the fractured ribs. Computerized tomography (CT) of the thorax (Figure2) confirmed the intra-thoracic position of the head of the humerus. The patient was initially resuscitated with intravenous fluids and oxygen by mask. A right-sided chest drain was inserted and drained 600ml blood immediately. This improved her respiratory embarrassment considerably. The patient was managed in the intensive care unit. She developed a right lower lobe pneumonia and a mini-tracheostomy tube was inserted to permit bronchial toilet. Her condition improved enough within three days to permit management on a surgical ward. A collar and cuff were applied on the right-hand side and shoulder range-ofmotion exercises were gradually introduced as the patient’s pain permitted. The patient was discharged four weeks after admission. Six months following her injury, the patient complained of mild-moderate pain associated with extremes of right shoulder movements; she had no respiratory symptoms. She could dress independently but had to brush her hair using her left hand. She could actively abduct her right shoulder to 40”. Her pain was reproduced by passive abduction of the shoulder to 90”. An anteroposterior radiograph (Figure 3) showed complete resolution of her pneumonia, but persistence of the humeral head in the right middle zone. The patient died two years after this injury, from an unrelated illness.