JORT Journal

1.      Introduction

Posterior glenohumeral dislocations account for 1-4% of all glenohumeral dislocations and are occasionally associated with fractures[1].Richard and Clarke originally described two types of humeral head fractures: humeral head impression fractures, or enoche fractures, andthe less common head-splitting fractures[1].Head-splitting fractures are extremely rare injuries that are most commonly a result of high-energy trauma such as a direct fall onto the shoulder with humeral head impaction on the glenoid. On review of the current literature, preserving the humeral head with ORIF when possible is the preferred technique in young patients with glenohumeral fracture-dislocations[2].This case report describes our experience in treating a young man who sustained a humeral head-splitting fracture with associated posterior glenohumeraldislocation from a high-energydirt bike accident. Surgical management involved attemptedclosed reduction followed by minimally invasive open reduction and internal fixation (ORIF) with cannulated screws to stabilize the fracture. Since few orthopaedic surgeons have experience in treating these fracture-dislocations with few examples present in the literature, our case report may be a valuable resource for future treatment of humeral head-splitting fractures with associated glenohumeral subluxation or dislocation[1-4].

2.      Case Description

A 32-year-old male presented to an outside emergency department after falling from his dirt bike and landing on his face and bilateral shoulders. His chief compliant wasbilateral shoulder pain. Gross deformity of both shoulders was observed on physical exam.Neurovascular status was determined to be intact. Initial outside radiographs demonstrated a left shoulder anterior dislocation as well as a right shoulder proximal humerus fracture-dislocation (Figure1).

Attempted closed reduction was performed under conscious sedation. The left shoulder was reduced; however, the right shoulder closed reduction was unsuccessful. CT scan revealed a displaced coronal split of the humeral headinvolving the articular surface and impaction on the posterior glenoid rim. (Figure 2).

The patient was then transferred to our institution for surgical management.After initial evaluation, the patient was informed of the risks, benefits, and alternatives and elected to proceed with closed versus open reduction and possible internal fixation of the right shoulder. The patient was brought to the operating room and a closed reduction was first attempted. The reduction maneuver involved internal rotation and axial tractionto disimpact the humeral head from the glenoid which achieved an audible pop. Fluoroscopic images confirmed glenohumeralreduction, however, the fracture was seen to be highly unstable (Figure 3)

Therefore, minimally invasive open reduction and internal fixation was performed. Under x-ray guidance a reduction clamp was applied to reduce the fracture anatomically. Five Kirschner wires (K-wires) were passed across the fracture site in a posterior to anterior direction, being careful not to enter the glenohumeral joint. Three 6.5 mm partially threaded cannulated screws of appropriate length were thenpassed over the wires and tightened into place with good purchase. Two additional 4.5 mm partially threaded cannulated screws were placed, one in a slightly oblique orientation, perpendicular to the fracture line. The K-wires were removed, and range of motion assessed under fluoroscopy. The fracture appeared well reduced and stable with no intra-articular hardware penetration(Figure 4).

The incision siteswere closed, and the arm was placed in an abduction sling. At two weeks follow up, the patient reported improvement but residual shoulder pain and stiffness. Pendulum exercises were initiated, however the patient was lost to future follow-up.

3.      Discussion

Humeral head splitting fractures with associated dislocations are extremely rare and usually occur in younger patients who have beensubjected to high-energy trauma. These fractures can be difficult to diagnose, and three radiographic views are usually recommended for accurate diagnosis⁵. Even with correct recognition, no best method exists for treating these injuries.Reported fixation techniques have included minimally invasive percutaneous screws, ORIF with locking or non-locking plate and screw constructs, and arthroplasty[2,6].Hemiarthroplasty as well astotal and reverseshoulder arthroplasty remain important treatment options because of the possibility of avascular necrosis of the humeral head[7,8]. However, this is not preferred for younger patients if the humeral head can be preserved because of long term poor results in patients who have undergoneshoulder arthroplasty prior to 50 years of age[9].Preservation of the humeral head, when possible, should be a primary focus for orthopaedic surgeons when treating head-splitting fractures in young patients.

4.      Conclusion

There are currently very few case reports in the literature regarding posterior dislocations with associated humeral head splitting fractures. Our case reported technique involves use of closed reduction and minimally invasive ORIF with percutaneous cannulated screws for treating such fracture-dislocations in a young patient. In conclusion, good results can be achieved with this technique, avoiding the need for arthroplasty in young patients. Future studies should be performed to investigate mid and long-term outcomes of this technique in young patients. 

Figure 3: Intra-operative fluoroscopy showing successful closed reduced with residual fracture instability.

Figure 4: Fluoroscopic final images demonstrating anatomic fracture reduction with cannulated screw fixation.

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2.       Rockwood CA Jr and Wirth MA (1996) Subluxations and dislocations about the glenohumeral joint. In: Rockwood CA, Bucholz RW, Green DP, Heckman JD, eds. Rockwood and Green’s fractures in adults. 4th edn. Philadelphia: Lippincott-Raven 1996:1221-1227.

3.       Swamy G and Schemitsch EH (1998) Humeral head fracture dislocation: case report and review of the literature. Journal of Trauma and Acute Care Surgery44: 377-380.

4.       Robinson CM, Khan LA, Akhtar MA (2006) Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br 88:502-508.

5.       Chesser TJ, Langdon IJ, Ogilvie C, Sarangi PP, Clarke AM (2001) Fractures involving splitting of the humeral head. Bone & Joint Journal83:423-426.

6.       Gavaskar AS and Tummala NC (2015) Locked plate osteosynthesis of humeral head–splitting fractures in young adults. Journal of shoulder and elbow surgery24:908-914.

7.       Walch G, Boileau P, Martin B, Dejour H (1990) Unreduced posterior luxations and fractures-luxations of the shoulder: à propos 30 cases. Rev ChirOrthopReparatriceAppar Mot 76: 546-558.

8.       Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. Journal of shoulder and elbow surgery13:427-433.

9.       Sperling JW, Cofield RH, Rowland CM (1998) Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less: longterm results. J Bone Joint Surg 80:464-473.