0
    192
    views

    Open Shoulder Fracture-Dislocation in an Active 70-Year-Old Patient

    A 70-year-old male patient presents to a trauma center with a shoulder fracture-dislocation and large open defect over the lateral shoulder, sustained in a collision between his vehicle and a dump truck. What is the best initial treatment for this patient, and what are his long-term expectations?

    Authors

    Daniel E. Davis, MD, and Matthew L. Ramsey, MD

    Introduction

    Dislocations of the glenohumeral joint are the most common large joint dislocations in the body. [1] Anterior inferior shoulder dislocation is typically associated with a concomitant tear of the anterior inferior labrum (Bankart lesion). Bony injuries may also occur, with the most common being anterior glenoid rim fracture and Hill-Sachs defects of the posterior superior greater tuberosity. [2,3] These deformities of the greater tuberosity may even result in an isolated greater tuberosity fractures or more advanced proximal humerus fractures, which are reported in approximately 30% of dislocations. [3]

    Much less frequently described are associated coracoid process fractures, which occur in approximately 1% of fracture-dislocations. The majority are incidentally found as minimally or non-displaced fractures after non-operative management of a dislocation. Multiple case reports have described fixing the coracoid fracture or transferring the fragment, depending on the patient’s symptoms. [4-9] In a report by Davis and Lazarus in the Rothman Institute Grand Rounds on ICJR.net, an acute coracoid fracture was transferred to the anterior glenoid to restore stability. [10]

    RELATED: Acute Coracoid Fracture with Recurrent Traumatic Anterior Glenohumeral Instability

    This current case describes a 70-year-old man who sustained an anterior inferior glenohumeral dislocation with a glenoid fracture, a minimally displaced coracoid fracture, and a large open defect through the deltoid muscle. The case discusses the final treatment and outcome after initial irrigation and debridement.

    Case Presentation

    A 70-year-old man was on the way to the gym when a dump truck ran through a stop sign and struck his vehicle on the driver’s side. Fortunately, he was restrained by his seat belt. He was brought to the trauma center for an evaluation due to complaints of neck pain and significant left shoulder pain. He had an obvious large skin defect over the left shoulder.

    Physical Examination

    • Significant pain in the left shoulder; unable to put the shoulder through passive or active range of motion secondary to pain
    • Full-thickness skin defect of the lateral left shoulder, with exposed muscle and laceration of the underlying muscle of the deltoid
    • Axillary function difficult to assess secondary to overlying soft tissue injury
    • No tenderness about the elbow, wrist, or hand
    • Neurovascular exam distally within normal limits in median, ulnar, and radial nerve distributions

    Imaging

    Three views of the left shoulder were obtained, which demonstrated an anterior inferior glenohumeral dislocation and minimally displaced superior scapular body fracture.

    Figure 1. Initial radiographs obtained in the trauma evaluation demonstrating anterior dislocated humerus and minimally displaced superior scapular body fracture.

    The shoulder was reduced in the trauma center. An axillary view radiograph showed appropriate reduction of the shoulder, an anterior glenoid rim fracture, and a displaced fracture fragment, likely from the coracoid process.

     

    Figure 2. Post-reduction radiographs demonstrate a reduced glenohumeral joint on the anteroposterior imaging. Axillary lateral views demonstrate reduction of the joint with an anterior glenoid rim fracture and a displaced fracture fragment from the coracoid process.

    A CT scan was then performed of the left shoulder to more fully evaluate the bony deficits. A large Hill-Sachs defect was identified, as well as an anterior inferior glenoid rim fracture and displaced coracoid fracture. The humerus was found to be well located and centered on the glenoid.

     

     

    Figure 3. Images from the CT scan demonstrate the large Hill-Sachs defect (top left), the anterior inferior glenoid fracture (top right), the displaced coracoid fracture (bottom left), and a 3D reconstruction of the joint (bottom right).

    Diagnosis

    • Left shoulder traumatic dislocation with glenoid and coracoid fractures and a large open defect through the deltoid muscle

    Treatment

    Due to the open nature of the injury, immediate operative treatment was indicated for irrigation and debridement of the wound. The patient was also started on intravenous antibiotics immediately on presentation to the trauma center.

    We discussed whether acute management of the fractures and dislocation sequelae would be necessary. Options for acute management include open reduction internal fixation, coracoid transfer, remplissage of the Hill-Sachs defect, grafting of the defect, partial arthroplasty of the defect, and reverse total shoulder arthroplasty.

    Open Reduction Internal Fixation

    Internal fixation could be used to reduce and fix the coracoid and glenoid fractures, restoring the native anatomy.

    Disadvantages

    • Immediate hardware implantation in the setting of an open injury could increase the risk of infection.
    • Glenoid fragment may not be large enough to create instability, even with the Hill-Sachs defect.

    Coracoid Transfer

    The acute coracoid fracture could be used as a graft to transfer in a Bristow-Latarjet-type fashion to add more bone to the anterior glenoid and create stability through the sling effect.

    Disadvantages

    • Hardware implantation would be required, which, again, could add to the infection potential in the setting of an open injury.
    • The coracoid fracture in this case is distal to the elbow and, thus, is smaller than a standard Latarjet graft. It may not restore an adequate amount of glenoid bone.

    Hill-Sachs Defect Management

    Different techniques may be used to fill the defect in order to reduce the risk of an engaging creating further instability:

    • Remplissage: Tenodesis of the rotator cuff tendon into the Hills-Sachs defect
    • Bone graft: Humeral head allograft to fill the defect with bone
    • Arthroplasty: Small, partial cap-type arthroplasty to fill the defect

    Disadvantages

    • Implanted anchors, bone graft, or an arthroplasty would be concerning for potential future infection in the setting of an open injury.

    Reverse Shoulder Arthroplasty

    Given the patient’s age, a reverse shoulder arthroplasty would bypass the need to address bony defects of the glenoid or humerus. The reverse arthroplasty could provide stability, as well as the option of performing a procedure in the acute or delayed setting.

    Disadvantages

    • Acute implantation would not be advised given the open nature of the injury.
    • The integrity and function of the deltoid muscle could not be determined in the acute injury setting.

    These options were discussed with the patient and the decision was made to perform serial irrigation and debridement procedures until only viable tissue with a healthy soft tissue envelope remained. The goal was to obtain soft tissue closure and skin coverage prior to performing a definitive stabilization procedure.

    The plan was to irrigate and debride necrotic tissue, close the deltoid muscle, obtain soft tissue coverage with plastic surgery, and address bony deformity or fracture after complete healed soft tissue coverage.

    Procedure

    • The patient was taken to the operating room and positioned in a well-padded beach chair positioner. General anesthesia was induced.
    • Inspection of the left shoulder revealed a full-thickness skin defect laterally, with exposed deltoid muscle and a small skin bridge in the defect (Figure 4).

    Figure 4. Intraoperative image demonstrated the full-thickness skin defect.

    • Longitudinal transection of the deltoid between the anterior and middle head was observed.
    • Exploration was performed to identify the axillary nerve, which did not appear to be transected.
    • Twitch of the anterior and middle heads of the deltoid muscle was observed when the deltoid muscle heads were tested.
    • Utilizing the defect in the deltoid, the deep shoulder was explored. The glenohumeral joint space was not violated and had an intact rotator cuff and rotator interval.
    • The shoulder was taken through a range of motion and was stable with external rotation. While adducted, however, the Hill-Sachs defect engaged and the shoulder dislocated with abduction and external rotation. The dislocation was reduced.
    • The wound was then copiously irrigated with 6 liters of normal saline.
    • A negative pressure wound therapy (NPWT) closure system was used to close and cover the wound.
    • Two days later, the patient was returned to the operating room for repeat irrigation and debridement.
    • The skin bridge laterally was found to be necrotic and was debrided, as were necrotic skin edges. Non-viable muscle was also identified and debrided.
    • The wound was again irrigated with 6 liters of normal saline.
    • The anterior and middle heads of the deltoid were then approximated and closed with polydioxanone suture (Figure 5).

    Figure 5. Intraoperative image demonstrating closure of the anterior and middle heads of the deltoid.

    • An NPWT closure system was again used to cover the defect.
    • The patient was referred to plastic surgery, where a split-thickness skin graft was used for definitive coverage over the deltoid muscle laterally.

    Postoperative Course

    The patient was placed in an abduction sling with instruction to remain in the sling at all times except for showering and changing clothes, for which he was permitted to rest his arm at the side. He was instructed to avoid any abduction and external rotation motion out of concern of recurrent dislocation.

    2-Week Postoperative Visit

    The patient was seen in the office for evaluation of his wound. The NPWT closure system was in place and the patient had an appointment for follow-up with plastic surgery for definitive coverage.

    Range of motion was deferred in the shoulder with the intent to again avoid dislocation. Ultimate management of his shoulder was again deferred until the wound was closed and well healed.

    2-Month Postoperative Visit

    The patient’s next postoperative visit was delayed slightly due to the COVID-19 pandemic. Since his last visit, he had received a split-thickness skin graft to cover his lateral wound, which was well incorporated and healed.

    On neurovascular exam, his sensation was intact in the axillary distribution in the anterior, middle, and posterior distribution, with the exception of the grafted area. He had activation of all 3 heads of the deltoid. He had active forward elevation to approximately 45°, passive forward elevation to 90°, and passive external rotation with the arm at the side of 30°.

    A CT scan demonstrated a reduced glenohumeral joint with a large Hill-Sachs defect, stable displacement of the coracoid fragment, and appropriate interval healing of the glenoid fracture (Figure 6).

     

    Figure 6. CT scan demonstrating reduced glenohumeral joint with a large Hill-Sachs defect, stable displacement of the coracoid fragment, and appropriate interval healing of the glenoid fracture.

    The abduction sling was discontinued at this time and the patient was taught how to perform passive and active assisted forward elevation and external rotation, with instruction to avoid abducted external rotation. Formal physical therapy was not able to be performed due to pandemic restrictions at the time.

    5-Month Postoperative Visit

    The patient returned for evaluation of the shoulder with a primary complaint of stiffness and pain, most significantly at the end ranges of motion, not through mid-range.

    On exam, he had active and passive forward elevation to 80° and active and passive external rotation to 30°. Internal rotation was to the mid-lumbar spine. He had a negative abdominal compression test. Due to restrictions of the soft tissues, he was unable to achieve full abduction and external rotation.

    The patient had slight atrophy of the anterior deltoid; however, sensation was intact in the anterior axillary distribution and there was 4 of 5 strength in the deltoid. Radiographs demonstrated a well-reduced joint with appropriate interval healing of the glenoid fracture.

    Although our previous discussions with the patient had centered on surgical intervention of the shoulder, they were largely focused on concerns of recurrent instability. Because he had become appropriately stiff without pain and no arthritic changes, the decision was made to try a course of formal physical therapy to increase range of motion and decrease the stiffness-related pain.

    6½-Month Postoperative Visit

    The patient returned after 6 weeks of physical therapy and demonstrated very positive gains. His stiffness-related pain had improved, as had his range of motion. Active and passive forward elevation was to 150°, external rotation was to 40°, and internal rotation was to the upper lumbar spine, with no weakness in any direction. The patient was happy with his progress and planned to continue with physical therapy.

    Conclusion

    Despite a severely traumatic injury to the left shoulder, including an open fracture-dislocation, the patient was able to avoid further operative intervention to treat stability or pain. After it was clear that there were no signs of infection and the open skin defect was treated, we still had concerns about continued instability, pain, or post-traumatic joint changes. However, the patient was able to recover through a prolonged immobilization and subsequent physical therapy to regain a stable and pain-free shoulder at 6 months after injury.

    The patient was counseled about the possibility of further arthritic changes. He will continue to be followed so that we can intervene if these changes occur.

    Author Information

    Daniel E. Davis, MD, MS, is an orthopaedic surgeon with The Rothman Institute, Philadelphia, Pennsylvania, specializing in the treatment of shoulder and elbow conditions. He is also the Shoulder Section Editor for Rothman Institute Grand Rounds on ICJR.net. Matthew L. Ramsey, MD, is Chief of The Rothman Orthopaedic Institute’s Shoulder & Elbow Division and a board certified shoulder and elbow specialist. 

    Disclosures: The authors have no disclosures relevant to this article.

    References

    1. Streubel PN, Krych AJ, Simone JP, Dahm DL, Sperling JW, Steinmann SP, et al. Anterior glenohumeral instability: a pathology-based surgical treatment strategy. J. Am. Acad. Orthop. Surg. 2014 May;22(5):283–294. doi:10.5435/JAAOS-22-05-283
    2. Longo UG, Loppini M, Rizzello G, Romeo G, Huijsmans PE, Denaro V. Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: a systematic review. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2014 Feb;22(2):392–414. doi:10.1007/s00167-013-2403-5
    3. Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J. Bone Joint Surg. Am. 2012 Jan 4;94(1):18–26. doi:10.2106/JBJS.J.01795
    4. Allagui M, Aloui I, Hammouda I, Koubaa M, Abbadi A, Hamdi MF, et al. [Pseudarthrosis of the coracoid process after dislocation of the shoulder]. Chir. Main. 2009 Dec;28(6):363–366. doi:10.1016/j.main.2009.08.013
    5. Cottias P, le Bellec Y, Jeanrot C, Imbert P, Huten D, Masmejean EH. Fractured coracoid with anterior shoulder dislocation and greater tuberosity fracture–report of a bilateral case. Acta Orthop. Scand. 2000 Feb;71(1):95–97. doi:10.1080/00016470052943982
    6. Garcia-Elias M, Salo JM. Non-union of a fractured coracoid process after dislocation of the shoulder. A case report. J. Bone Joint Surg. Br. 1985 Nov;67(5):722–723.
    7. Plachel F, Schanda JE, Ortmaier R, Auffarth A, Resch H, Bogner R. The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases. J. Shoulder Elbow Surg. 2017 Sep;26(9):e278–e285. doi:10.1016/j.jse.2017.01.022
    8. Saragaglia D, Picard F, Gérard P, Tourne Y, Leroy JM. [Anterior instability of the shoulder associated with fracture of the coracoid process. Apropos of 3 cases]. Rev. Chir. Orthop. Reparatrice Appar. Mot. 1994;80(7):651–655.
    9. Subramanian AS, Khalik MA, Shah MM. Isolated fracture of the coracoid process associated with unstable shoulder. ANZ J. Surg. 2007 Mar;77(3):188–189. doi:10.1111/j.1445-2197.2006.04005.x
    10. Acute Coracoid Fracture with Recurrent Traumatic Anterior Glenohumeral Instability | International Congress for Joint Reconstruction [Internet]. [cited 2020 Sep 7]; available at https://icjr.net/articles/acute-coracoid-fracture-with-recurrent-traumatic-anterior-glenohumeral-instability