Metastatic pathological fracture of the surgical neck of humerus during manipulation under anaesthesia for adhesive capsulitis

Abstract

Introduction

We report a case of an iatrogenic neck of humerus fracture sustained during MUA, following arthroscopic capsular release, for a diagnosis of frozen shoulder. The patient was subsequently diagnosed as having shoulder girdle metastatic disease.

Case history

A 70 years old lady presented with a 4 month history of severe progressive pain in the right shoulder. The patient had had breast cancer treated 18 years with subsequent local recurrence 10 years after her original diagnosis. Examination of her right shoulder revealed bony tenderness and decreased range of motion in all directions. Shoulder X-ray showed osteopaenia. Conservative treatment for a diagnosis of frozen shoulder failed to alleviate her pain and she was offered arthroscopic capsular release and MUA. During the manipulation she sustained iatrogenic neck of humerus fracture. A bone scan showed diffuse osteoblastic activity due to the acute fracture. Conservative management of the fracture was initiated with close clinical follow-up with serial shoulder X-rays. A lytic lesion was noted in the humeral head 3 months after the operation. MRI was performed at this stage, showing a large metastatic deposit with extensive extra osseous soft tissue spread. She underwent excision of the proximal humerus with the overlying deltoid muscle and insertion of a spacer.

Conclusion

We would recommend having a low threshold for extensive imaging if there is a strong suspicion of metastatic disease. Shoulder MRI scan and biopsy in addition to bone scan and plain film should be performed to rule out malignancy before proceeding to any surgical intervention.