bilateral proximal humerus fractures 800

Case Report: Bilateral Proximal Humerus Fractures

Case Introduction

A 20-something year old male with a history of polycythemia vera on apixaban, right above knee amputation, and seizure disorder presents with bilateral shoulder pain. The patient adamantly denies any trauma or etiology of his pain. He states the right is worse than the left and he denies any other complaints.
On physical exam, his heart rate is 132 and his other vital signs are stable. He has significant ecchymosis of his right shoulder. He is unable to move or range either shoulder and his strength and neurovascular exam is grossly normal from his elbow down.
Initial radiographs of the right shoulder demonstrates a comminuted humeral head fracture with posterior displacement of the primary fragment. His left shoulder demonstrates a minimally displaced surgical neck fracture of the proximal humerus, possibly subacute. Orthopedics was consulted and he was admitted to the hospital.

Case Discussion

Proximal humerus fractures include fractures to the humeral head and neck. They are sometimes reductively termed “shoulder fractures”. They represent 4-5% of all fractures and are most commonly seen in geriatric patients.[1]Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin Orthop Relat Res. 1975;(112):250–3. Their frequency increases as we age and they are more commonly seen in women than men.[2]Bengner U, Johnell O, Redlund-Johnell I. Changes in the incidence of fracture of the upper end of the humerus during a 30-year period. A study of 2125 fractures. Clin Orthop Relat Res. … Continue reading

Right shoulder: comminuted humeral head fracture with posterior displacement of the primary fragment

Left Shoulder: minimally displaced surgical neck fracture of the proximal humerus, possibly subacute
The etiology is more commonly low energy after a fall. This is your typical elderly patient with osteopenia/ osteoporosis and these are usually minimally displaced. In moderate or high energy mechanisms, the patient is typically younger and there is more displacement.
The anatomy of the shoulder is worth reviewing briefly. The humerus has both an anatomic neck (fused physis) and a surgical neck, which is the weakest area and most commonly fractured. Both the anterior and posterior humeral circumflex arteries are present here and vulnerable. The axillary nerve courses inferior to the humeral head. The pectoralis major and rotator cuff muscles can occasionally cause an avulsion fracture of the lesser or greater tuberosity, respectively. Additionally associated injuries include glenohumeral dislocations, AC joint separation, scapular fractures, clavicle fractures and distal radius fractures.
Illustration of fracture patterns of the proximal humerus.[3]
Patients can typically describe the injury pattern, unlike the case with our patient. They will endorse pain, swelling, bruising and loss of range of motion. Less commonly, neurovascular symptoms can be present. Thus it is important to examine the entire arm with particular attention placed on the axillary nerve. Patients will be tender to palpation around the proximal humerus, often with swelling and bruising. Range of motion is restricted secondary to pain.
Radiographs are sufficient to make the diagnosis. CT and MRI are not often necessary but can be used to better evaluate osseous injuries and soft tissue injuries respectively. Historically, the Neer classification was used to classify the fracture, however more recently the AO classification has become the standard. Both are radiographic classification systems.
There is no clear, evidence based consensus for management of many of these fractures. Most are uncomplicated and can be treated conservatively. The presumption is that nondisplaced fractures will heal and patients will regain much or most of their shoulder function.
A four-part fracture of the proximal humerus was treated initially by plate fixation. The reduction was incorrect, and a severe tuberosity and humeral head malunion occurred (a). It was treated by reverse arthroplasty, and as a proximal humeral bone loss was found intraoperatively, an allograft and a long humeral stem were used. The allograft was placed around the proximal body of the prosthesis in the greater tuberosity area and fixed with a cable wire around the graft and the inner humerus. The prosthesis dislocated and was not stable upon adding an extension to the humeral neck component (b). Therefore, it had to be revised and converted to a hemiarthroplasty with a larger head cover (c). We could observe the allograft incorporated into the prosthesis 2 years later (d)[4]Martinez, Angel Antonio, et al. “The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus.” Journal of Orthopaedic Science 17.2 … Continue reading
Indications for nonoperative management include most cases with minimal displacement, displacement less than 5 mm and patients who are poor surgical candidates. They can start in a sling or shoulder immobilizer but begin early range of motion at 1 or 2 weeks. Indications for surgical management depend in part on the patient age and comorbidities but generally includes 2-part surgical neck fractures, any 3- or 4-part fractures and displaced greater tuberosity fractures. Surgical options also vary but include closed reduction with percutaneous pinning, open reduction and internal fixation, intramedullary nail and finally arthroplasty.
Rehabilitation includes a 3-phase protocol that starts with early passive range of motion, progression to active range of motion and resistance exercises, and then advance to stretching and strengthening programs.[5]Hodgson, Steve. “Proximal humerus fracture rehabilitation.” Clinical Orthopaedics and Related Research® 442 (2006): 131-138. Complications include axillary nerve injury, avascular necrosis, malunion, nonunion, rotator cuff tear, proximal biceps tendon tear, adhesive capsulitis and glenohumeral arthritis.

Case Conclusion

Further traumatic evaluation identified stable vertebral body fractures of T7 and T8 without any retropropulsion or cord impingement. Eventually, the patient admitted to significant alcohol use and could not describe any trauma that might have occurred. He also reported a history of abuse. During his initial hospitalization, the decision was made to delay surgical repair given his coagulopathy and significant soft tissue swelling in the right shoulder. Approximately 3 months later, after clearance from hematology, he underwent right shoulder hemiarthroplasty. At his most recent follow up, the patient is continuing to undergo post op physical therapy and is doing fairly well, however his range of motion and strength are still quite limited.

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