Osteochondral split depression fracture of humeral head without shoulder dislocation in an adult: A case report

1 Introduction

Proximal humerus fractures (PHF) are common in the elderly and generally belong to the displaced or split variety involving tuberosities and metaphysis. Sometimes head can get split fractured along with shoulder dislocation. The common mode of injury is fall on outstretched hand; less common fall on shoulder and direct impact injury.

PHF associated with shoulder dislocation is not uncommon and has varied path gnomic presentations. Hill-Sachs lesion is the most common type of injury usually associated with traumatic anterior dislocation of shoulder joint, with an incidence of 45 %–90 %.¹ In contrast to the more commonly reported Hill- Sachs lesion, there is Reverse Hill-Sachs lesion, that has been reported with posterior dislocation of the shoulder joint.

There are only limited number of cases in the literature pertaining to isolated osteochondral fracture of the humeral head without shoulder dislocation. This case refers to a split depression type of humeral head fracture following injury by direct impact on the shoulder joint.

The patient was informed that the data would be used for study purpose and would be submitted for publication, and all the proceedings have been done after obtaining informed consent from the patient for the same.

2 Case report

A 22 year old male, right hand dominant, presented to casualty following skid and fall from bike and sustaining direct impact to the right shoulder. Initial examination revealed pain around the right shoulder and movements of the right shoulder were painfully restricted. There were no external injuries. Distal pulses were well felt,there was no sensory deficit in the upper limb.

Standard anteroposterior radiograph of the shoulder was taken. A depression fracture was noted in the right humeral head. The shoulder joint congruity was maintained. CT scan revealed comminuted fracture of the humeral head involving anterolateral aspect; the fracture had both split element and depressed element [Fig. 1]. The depression was about 6mm at the maximum point. There was no subluxation or dislocation of the joint in the CT scan.

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Fig. 1 Axial (left) and three dimensional reconstruction (right) CT of right shoulder joint showing split element in addition to the depressed fragment.

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Surgical procedure: The surgery was performed under interscalene brachial block anesthesia. Standard delto-pectoral approach was used. The glenohumeral joint was exposed after subscapularis tenotomy. The split and depressed elements as noted in the CT scan were identified in the anterolateral aspect of the humeral head surface. The split displaced osteochondral fragment was reduced to the humeral head and fixed with Herbert screw. The depression element was lateral to the split element. With C arm guidance, a window was marked in the lateral cortex of proximal humerus to reach the desired area of depression. A 2 × 2 cm cortical window was made, bone punch was introduced through the window. Gentle hammering was done and the osteochondral fragment was pushed up. The elevation was assessed from the articular side, gradual punching was done and complete reduction of the depressed fragment was achieved. The reduction and congruity of the humeral head was confirmed under image intensifier and was found to be satisfactory. To support the depressed fragment the bone punch path was filled with synthetic bone graft [Fig. 2]. The wound was closed in layers.

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Fig. 2 Anteroposterior radiograph of the right shoulder showing depressed fracture of the humeral head (left) , and immediate post operative radiograph showing fixation of the humeral head with headless screws and bone punch path filled with synthetic bone graft (right).

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The patient was kept on shoulder immobilizer for a period of 4 weeks. Supervised physiotherapy was begun after 4 weeks of surgery. The patient was followed up at regular intervals with X-rays taken every 4 weeks [Fig. 3]. The fracture had healed by 12 weeks. Physiotherapy was continued for 16 weeks by which time, he achieved full range of movements at shoulder joint [Fig. 4].

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Fig. 3 Anteroposterior radiograph of the right shoulder at the end of 6 months showing maintained humeral head congruency and healed fracture.

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Fig. 4 Clinical photograph of the patient showing shoulder range of movement at the end of 6 months follow up.

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3 Discussion

Proximal humerus fractures are commonly known to occur in the older subset of individuals. The fracture was classified by Neer as 2 part, 3 part and 4 part fractures. Generally there is no dislocation of the head, it gets displaced into varus or valgus alignment.² PHF in younger subset of individuals occurs as a consequence of either direct impact to the shoulder joint or the more commoner, dislocation of the shoulder joint which results in the osteochondral fractures of the humeral head. Anterior shoulder dislocations frequently leads to depressed fractures of the humeral head commonly termed as Hill-Sachs lesion.¹ Other injury pattern following dislocation of the shoulder joint being reverse Hill-Sachs lesions seen in posterior dislocation and the Bony Bankart lesions.

The injury pattern seen in our patient doesn't fit into any of the classical classification systems used for proximal humerus fracture patterns. As the fracture is purely intra articular it should be classified as Neer's originally described type 6 type of injury. According to his description, displaced fractures of the articular surface falls into the group of fracture dislocations.³

It is commonly believed that proximal humerus osteochondral injuries are synonymous with Hill-Sachs lesions, which is caused by massive impaction of the humeral head against the glenoid. It is the typical manifestation of anterior shoulder dislocation. Other injury patterns like splitting fractures of the humeral head have also been reported in the literature. However, there is very little description of humeral head shearing osteochondral fractures of split depression type. To our knowledge there have only been 4 cases documented similar to the injury pattern seen in our patient. However our case stands out in comparison, as all the other 4 cases were associated with dislocation of the shoulder joint.

In a case reported by Choi et al.,⁴ he reported an osteochondral fracture of the medial part of greater tuberosity in a 12-year-old boy who was hurt while playing football. The MRI results revealed a superiorly displaced osteochondral fracture just anterior to the traditional Hill-Sachs lesion in addition to Bankart lesion and a torn anterior capsule, indicating a dislocation of the anterior shoulder. The fracture was immobilized and it recovered in five weeks. The patient resumed all activities, including participating in sports three months following the injury. The authors pointed out that dislocation with relocation has to be taken into consideration in these type of injuries.

In a case reported by Fandridis et al.,⁵ he described a 26 year old male who sustained an osteochondral fracture of the humeral head following a motor vehicle collision. Intra operatively the fragment was found in the axilla, hence the authors concluded that the fracture occurred secondary to traumatic posterior dislocation of shoulder. Additionally the authors also described posterior labro-capsular detachment which further supported the mode the injury. Fixation of the fragment was done using headless screws and at the end of 1 year the fracture was considered healed and the range of motion was comparable to the opposite side. Here posterior subluxation/dislocation was attributed to the fracture pattern.

Campbell et al.,⁶ described a posteriorly displaced osteochondral shear fracture of the humeral head which was likely due to dislocation and relocation. There was no associated labral pathology. The fragment was fixed using a headless screw and the patient regained full range of motion within 9 months.

Spross et al.,⁷ reported a case in a 23 year old male where he was diagnosed to have osteochondral shearing fracture of the humeral head following anterior dislocation of shoulder joint. Intra operatively Bankart lesion was seen. However the authors did not address the labral tear and the osteochondral fragment was reduced and fixed with three 2.4mm resorbable pins. At 3 months follow up the patient had recovered well and was able to perform his daily activities and sporting activities comparable to the pre injury phase.

In our patient, the osteochondral fracture had shear element and depressed element. For an anterior fracture of this nature, if at all dislocation had happened, it must be a significant posterior dislocation. Neither patient gave any history suggestive of dislocation and relocation, nor the radiographs showed any signs of dislocation. The split fragment was large enough for headless screw fixation. Other surgical options described for osteochondral humeral head fracture include bioabsorbable pin fixation, autograft or osteochondral allograft or even arthroplasty of the shoulder joint.

CRediT authorship contribution statement

B.R.J. Satishkumar: Dr. Lester Frank: MS(ortho), DNB (ortho), Perfomed the given technique, Wrote the paper, Data support, Dr. Suka Sekar: MS (ortho), DNB (ortho), Wrote the paper, Collected material regarding the related subject., Dr.

Guardian/Patient's consent

The above case report has been studied and prepared after obtaining consent from the patient for the use of radiographical and clinical pictures.

Ethical Statement

Ethical approval for the case report has been obtained.

Funding

No financial funding was done for the above case report.