A 68-year-old woman presented to the emergency department with right shoulder and chest wall pain after falling down 12 stairs. Awake and alert, the patient was bruised and tender in the right shoulder and unable to move her right arm because of pain. Her respiratory rate and effort were normal. In accordance with the abnormal chest radiograph result ( Figure 1 ), computed tomography (CT) was performed to better characterize the injury ( Figure 2 ).
Diagnosis
Four-part comminuted right proximal humerus fracture-dislocation with humeral head impaction into the thoracic cavity. The patient underwent right-sided video-assisted thorascopic surgery, with removal of the humeral head from the thoracic cavity, evacuation of the hemothorax, and right shoulder hemiarthroplasty.
Intrathoracic displacement of the humeral head is a rare complication of high-energy trauma. The majority of cases involve a 4-part humeral head fracture, as with this patient. Four-part fractures carry a high risk of avascular necrosis and usually require hemiarthroplasty. The mechanism of humeral head dislocation into the thorax is unclear. It is postulated that the dislocation occurs when an extreme external force is applied while the shoulder is in abduction, causing an anterior or inferior displacement of the humeral head medially into the thoracic cavity. The humeral shaft is then leveraged against the ribs, resulting in the humeral head’s being trapped in the chest. Associated thoracic injuries are similar to any penetrating chest trauma—rib fractures, pneumothorax, hemothorax, and hemopneumothorax—and often require urgent intervention.
For the diagnosis and teaching points, see page 619.
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