Rev. bras. ortop. vol.52 número2

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

report

Intrathoracic

fracture-dislocation

of

the

humerus

–

case

report

and

literature

review

夽

Wilson

Carlos

Sola

Junior

,

Paulo

Sérgio

dos

Santos

b_{UniversidadeFederaldoParaná,HospitaldeClínicas,Curitiba,PR,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17March2016 Accepted2May2016

Availableonline5February2017

Keywords: Dislocations Shoulderfractures Shoulderjoint Humeralhead Hemiarthroplasty

a

b

s

t

r

a

c

t

Shoulderfracture-dislocationsareuncommon.Thoseassociatedwithintrathoracic disloca-tionareveryrareconditions,resultingfromhigh-energytrauma;usually,theaffectedlimb isinanabductionposition.InBrazil,thereisonlyonereportofateenagerwithdisplacement oftheepiphysisintothechestcavity;thepresentisthefirstadultpatientreportof intratho-racicdislocationofthehumerus.Theauthorspresentthecaseofapatientfemale,aged56 years,whowashitbymotorcycleandthrownapproximately5metersaway.Shewas res-cuedonsitewiththoracic,pelvic,andrightupperlimbtrauma.Herchestwasdraineddueto pneumothoraxandmultiplefracturesofribs;shewasdiagnosedwithfracture-dislocation infourparts,withintrathoracicdislocationofthehumeralhead.Displacedforearmbones fracturewasalsodiagnosed;theolecranon,scaphoid,andischiopubicfractureswerenot displaced.Thepatientunderwentajointprocedurewithacardiothoracicsurgeryteamto removethehumeralheadthroughthoracotomyandchestdrainage;subsequently,apartial arthroplastyofthehumeruswasperformed,withgraftfromthehumeralheadand fixa-tionofforearmfractures.Conservativetreatmentwaschosenfortheotherfractures.After threemonths,allfractureswerehealedwithgradualfunctionalimprovement.Thepatient remainedinphysiotherapyandorthopedicmonitoring,havingbeendischargedfromthe thoracicsurgery;inaseveredepressiveepisode,thepatient committedsuicideafter11 monthsofthetrauma.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedatHospitalXV,Curitiba,PR,Brazil. ∗ _{Correspondingauthor.}

E-mail:solajr@gmail.com(W.C.SolaJunior).

http://dx.doi.org/10.1016/j.rboe.2017.01.005

Palavras-chave: Luxac¸ões Fraturasdoombro Articulac¸ãodoombro Cabec¸adoúmero Hemiartroplastia

r

e

s

u

m

o

Asfraturasluxac¸õesdoombrosãoincomuns;aquelasassociadascomdeslocamento intra-torácicosãocondic¸õesmuitorarasedecorrentesdetraumasdealtaenergia,nosquaiso membroacometidogeralmenteestánumaposic¸ãodeabduc¸ão.NoBrasil,existeapenaso relatodeumadolescentecomdeslocamentodaepífiseparaointeriordacaixatorácica. Esseéoprimeirorelatodepacienteadultocomluxac¸ãointratoracicadeumero.

Osautoresapresentamumcasodepacientefemininade56anos,atropeladapor moto-cicletaearremessadaemtornodecincometrosdedistância.Foisocorridanolocalcom traumatorácico,pélvicoedomembrosuperiordireito.Teveotóraxdrenadodevidoa pneu-motóraxemúltiplasfraturasdearcoscostaiserecebeuodiagnósticodefraturaluxac¸ão emquatropartescomdeslocamentointratorácicodacabec¸aumeral.Foramdiagnosticadas fraturadeossosdoantebrac¸odesviadaefraturasdoolécrano,doescafoideedosramos isquiopúbicossemdesvios.Apacientefoisubmetidaaprocedimentocirúrgicoconjunto comumaequipedecirurgiacardiotorácicapararetiradadacabec¸aumeralpormeiode tora-cotomiaedrenagemtorácica;posteriormente,umaartroplastiaparcialdoúmerofoifeita, comenxertiaprovenientedacabec¸aumeral,alémdefixac¸ãodasfraturasdoantebrac¸o.Nas demaisfraturas,optou-seportratamentoconservador.Apóstrêsmeses,todasasfraturas apresentavam-seconsolidadascommelhoriagradualdasfunc¸ões.Apacientepermaneceu emacompanhamentofisioterápicoeortopédicoerecebeualtadacirurgiatorácica.Dentro deumquadrodepressivograve,cometeusuicídio11mesesapósotrauma.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Fracture-dislocationsofthe humerusare relatively uncom-mon.Whenassociatedwithintrathoracicdisplacement,they areextremelyrareandpotentiallyfatal.Thecasesdescribedin theliteraturehaveincommonhigh-energytraumainvolved, thepositionofthelimb(predominantlyinabduction),andlack ofagegrouppredilection.Penetrationofthehumeralheadinto thethoraciccavityisduetothefragilitybetweentheupper ribs,whichfacilitatesmigration.Theseverityofthecondition stemsmainlyfrompulmonaryinvolvementandthenumerous injuriesfrequentlyobservedinthistypeoflesion.

TheauthorsdescribethefirstcaseintheBrazilianliterature ofanadultpatientwithanintrathoracicfracture-dislocation ofthehumerus,afterbeingrunoverbyamotorcycle.

Case

report

A female patient, 56 year-old, right-handed, was struck by a motorcycle and tossed five meters away; the mobile emergency careservice (Servic¸o de AtendimentoMóvel de Urugência[SAMU])teamprovidedpre-hospitalcareandshe wastakentothepublichospital.Physicalexaminationshowed a severely polytraumatized, hypotensive, and tachypneic patient,withcervical andright upperlimbimmobilization; she presentedlarge edema in the right shoulder, a defor-mity in the forearm, and ipsilateral elbow. At admission, neurologicaland vascular examinationwere normal. After

Fig.1–Radiographoftherightshoulder,showinga

complexfractureoftheproximalhumeruswith

intrathoracicmigrationofthehumeralhead.

Fig.2–(A)Chestcomputedtomography(CT):axialsection

showingthehumeralheadindirectcontactwiththe

pulmonaryparenchyma;(B)chestCT:3Dreconstruction.

Ribfracturesandcephalicmigrationintothepulmonary

cavityareobserved.

achievedashoulderrangeofmotionof100degreesofanterior elevation,30degreesofexternalrotation,andinternalrotation atthelevelofL1.Elevenmonthsaftertheinitialtraumaand inaseveredepressivestate,shecommittedsuicide.

Fig.3–Transoperativeimageofthethoracotomyfor

removalofthehumeralhead.

Discussion

Reportsofintrathoracicfracture-dislocationofthehumerus are extremely scarce in the literature. After an extensive reviewin the maindatabase, only24 articles (20 ofwhich inEnglish)reporting patientswiththis typeoflesionwere retrieved.West1_{wasoneofthefirstauthorswhoreportedthis} typeofatypicalpresentationinanadultpatient,whosuffered afallfromheight.Othersimilarinjuryreportsweredescribed byGlessner,2_{in1961,andbyPattel,}3_{in1963,whosepatients} underwent fracturereductionandfixationwithsatisfactory results.In bothcases,patientswereelderly withlow func-tional demand.Watson-Jones4 _{alsodescribed thecaseofa} patientwithfracture-dislocationandremotemigrationofthe head,butwithnofurtherdetails.

Inthe1990s,Wirthetal.5 _{andSimpsonetal.}6_described cases ofyounger patientswho suffered motorvehicle acci-dent,oneofwhomwasstruckandtossedforapproximately six meters, amechanism similar tothe present case. Har-manetal.7_{reportedacaseofa56-year-oldpatient,thevictim} of a rollover, with intrathoracic fracture-dislocation of the humeruswithseverecomminution,whounderwentremoval oftheheadfromthethoraciccavity,followedby hemiarthro-plasty. Theonly articleretrieved in the Brazilianliterature reportedthecaseofa14-year-oldfemalepatientwithafixed intrathoracic fracture-dislocation,whose six-year follow-up indicated an excellent functional outcome, despite partial avascularnecrosis.8

Fig.4–RadiographintrueanteroposteriorandNeerprofileforpostoperativecontrolofshoulderarthroplastywithlocal

humeralheadgraft.

Fig.5–Six-monthpostoperativeradiographsshowingfractureandtubercleconsolidation.

Inthepresentcase,theprobabletraumaenergyassociated withtheabductedpositionofthearmcontributedtosevere comminutionofthefractureandintrathoracicdisplacement of the humeral head. Moreover, the other fractures are evidence of the dissipation of this energy throughout the upperlimb.Performing a single, combined procedure with

prevented adequate rehabilitation. Unfortunately, the patient’s depression worsened further and culminated in suicideoneyearaftertheaccident.

The combined procedure, in which cardiothoracic and orthopedicsurgery were performed forthe removal ofthe humeralheadfollowedbyhemiarthroplasty,waseffectiveand withoutcomplicationsintheshort-term,whichisin agree-mentwiththescarceliteratureonsuchlesions.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. WestEF.Intrathoracicdislocationofthehumerus.JBoneJoint SurgBr.1949;31(1):61.

2. GlessnerJRJr.Intrathoracicdislocationofthehumeralhead.J BoneJointSurgAm.1961;43:428–30.

3. PatelMR,PardeeML,SingermanRC.Intrathoracicdislocation oftheheadofthehumerus.JBoneJointSurgAm.

1963;45:1712–4.

4. Watson-JonesR.Fracturesandjointinjuries.4thed. Edinburgh:Livingstone;1956.

5. WirthMA,JensenKL,AgarwalA,CurtisRJ,RockwoodCAJr. Fracture-dislocationoftheproximalpartofthehumeruswith retroperitonealdisplacementofthehumeralhead.Acase report.JBoneJointSurgAm.1997;79(5):763–6.

6.SimpsonNS,SchwappachJR,TobyEB.Fracture-dislocation ofthehumeruswithintrathoracicdisplacementofthe humeralhead.Acasereport.JBoneJointSurgAm.1998;80(6): 889–91.

7.HarmanBD,MillerNG,ProbeRA.Intrathoracichumeralhead fracture-dislocation.JOrthopTrauma.2004;18(2):112–5.

8.GuiottiFilhoJ,BorgesACW,LeiteMC.Fraturaepifisióliseda extremidadeproximaldoúmerocomluxac¸ãointratorácica: relatodecaso.RevBrasOrtop.2008;43(1/2):48–52.

9.Jun-SongW,Jing-YuD,Zhi-QiangW,FangG,Xiang-JinL. Intrathoracicdisplacementofthehumeralheadinatrauma patient.IndianJOrthop.2012;46(5):596–8.

10.GaloisL,SiatJ,ReibelN,ValentinS,GasnierJ,MainardD. Intra-thoracicfracture-dislocationofthehumeralhead:a casereportandreviewoftheliterature.RevChirOrthop ReparatriceApparMot.2007;93(8):854–8.

11.LiuHH,LeeYH,YangSW,WongCY.Fractureoftheproximal humeruswithintrathoracicdislocationofthehumeralhead. JTrauma.2007;63(2):E37–9.

12.BoyerP,AlsacJM,EttoriMA,LesècheG,HutenD.Four-part fractureafterintrathoracicdisplacementofthehumeral head:acasereportandreviewoftheliterature.ArchOrthop TraumaSurg.2007;127(8):651–4.

13.WieslerER,SmithAM,ShiltJS.Humeralhead

fracture-dislocationintothethoracicoutlet:casereportand reviewoftheliterature.JShoulderElbowSurg.

2004;13(5):576–9.