Management of a Complex, Comminuted Humeral Head and Neck Fracture
Kevin D. Plancher, MD
A 55-year-old male athlete who enjoys skiing, swimming, running, and weight lifting presented to the clinic with constant left shoulder pain from the mid-arm into the biceps. The patient injured his shoulder 6 days prior in a skiing accident in Colorado. He consulted an orthopaedic surgeon in Colorado and indicated that he had dislocated his left shoulder and fractured his greater tuberosity and glenoid. He was provided with a sling without a pillow and was instructed to follow-up with his orthopaedic surgeon. The patient reported that he was unable to sleep through the night due to the severe pain he experienced with all shoulder and elbow movements, and complained of sharp twinges of pain that started in his shoulder and ran down his arm. He presented to the clinic wearing a sling without an abduction pillow.
Physical examination revealed global tenderness to palpation and ecchymosis along the anterior deltoid and biceps muscles. Due to pain, a thorough assessment of the patient's active and passive range of motion was not conducted. Forward flexion was limited to 10° with severe pain, adduction to 10°, and internal rotation at the side to neutral. X-rays demonstrated a comminuted greater tuberosity and humeral head fracture with evidence of step off and displacement of approximately 2cm.
CT scan revealed a comminuted proximal humerus fracture involving the surgical neck with multiple fracture fragments (Figure 1a-c). The greater and lesser tuberosities were separate fragments. The fracture had some mild varus impaction and intra-articular extension into the inferomedial humeral head.
Figures 1a-c: CT images demonstrating a comminuted, varus-impacted proximal humerus fracture involving the surgical neck and greater and lesser tuberosities with inferomedial intra-articular humeral head extension.
MRI revealed extensive post-traumatic changes in the soft tissue surrounding the comminuted proximal humerus fracture. The rotator cuff tendons remained largely attached to their normal insertions despite the multiple bony fragments. Underlying tendinosis and articular-sided tears of the distal infraspinatus tendon were also noted. Evaluation of the joint capsule and labrum were limited due to the extensive edema in the soft tissues surrounding the shoulder.
Based on the comminuted and complex nature of the fracture, open reduction internal fixation with a proximal humerus plate was performed nine days after initial presentation to the clinic.
The patient was brought to the operating room and placed in the beach chair position with the arm placed in 45 degrees abduction. The shoulder was meticulously prepped and draped, and a 10-12 cm incision was made using a standard deltopectoral approach. The cephalic vein was mobilized medially and its deltoid branches were cauterized using a Bipolar. Hemostasis was obtained with a Bovie. The coracobrachialis appeared hemorrhagic upon visualization.
A deltoid retractor was placed under the deltoid and a blunt 90 degree retractor was used to retract the coracobrachialis. Upon further inspection, the long head of the biceps tendon (LHBT) appeared to be entwined in the shaft through the fracture, so it was freed. We then released the superior aspect of the pectoralis major insertion to improve visualization.
The biceps tendon was then traced proximally and to the level of the coracoacromial (CA) ligament, which was preserved. A Hohmann retractor was then inserted over the CA ligament and a Hawkins retractor was used to retract the pectoralis major. No. 2 FiberWire suture was then passed through the supra/infraspinatus and subscapularis near their attachments onto the greater and lesser tuberosities, respectively, to assist with fracture reduction.
The fractures were then debrided of interposed callus. A bone hook was used to reduce the shaft to the proximal humerus and sutures were tensioned to reduce the tuberosities to the humerus. A three-hole proximal humerus locking plate was then positioned 10mm distal to the insertion of the supraspinatus on the greater tuberosity, with the anterior border of the plate immediately lateral to the bicipital groove and provisionally secured with 2mm Kirschner wires. Orthogonal fluoroscopic images were taken to confirm plate position and fracture reduction. The tuberosity sutures were then passed through the plate, and the plate was subsequently fixed to the shaft with bicortical fixation. X-Rays were repeated. The locking screws were inserted using a threaded drill guide, followed by the remaining two distal cortical screws. The humerus was guided through external and internal rotation to ensure that it moved as one unit and that the plate did not impinge. The shoulder was then taken through internal and external rotation under live fluoroscopy to ensure that none of the screws were penetrating the humeral head articular surface.
The No. 2 FiberWire used to secure the tuberosities was then tensioned and tied. The wound was copiously irrigated with Bacitracin and a second dose of antibiotics was administered. The wound was closed in a multi-layered fashion using Vicryl and Monocryl suture, then Steri-Strips and dry sterile dressing were applied.
The patient was placed in an arm sling with an abduction pillow for the first two weeks postoperatively. Pendulum and passive range of motion exercises were initiated at two weeks until four weeks post-op. At post-op week four, active assisted range of motion exercises as well as scapular retraction and depression exercises, were initiated avoiding cross body adduction. Strengthening of the rotator cuff was commenced eight weeks postoperatively. Full range of motion, particularly emphasizing forward elevation and external rotation, as well as posterior capsular and anterior chest wall stretching exercises were progressed over weeks eight through twelve.
The patient reported minimal pain and stiffness in the first weeks following surgery, which improved with time. Thirteen weeks following surgery, the patient reported no pain with movement and demonstrated 145° forward flexion, 150° abduction, 85° external rotation at 90° abduction, 65° external rotation at the side, and internal rotation to L5. There was no evidence of impingement on Neer or Hawkins maneuvers. He was negative for painful arc of abduction and painful cross body adduction with 5/5 strength in the deltoid, rhomboid, supraspinatus, subscapularis, infraspinatus, trapezius, and teres as well as 5/5 strength in abduction and external rotation against resistance. The patient returned to swimming and skiing at this time. X-rays taken six months after surgery showed good consolidation of the previous fracture site, good alignment of the plate and seven screws, and no signs of loosening (Figure 2a-f).
One year following surgery, the patient’s excellent outcome was maintained with range of motion further improved to 170° forward flexion, 150° abduction, 90° external rotation at 90°, 65° external rotation at the side, and internal rotation to L5.
Figure 2a-f: X-rays taken six months after surgery showing good consolidation of the previous fracture site, good alignment of the plate and seven screws, and no signs of loosening.