A 34-year-old right-hand dominant Greek woman, presented at the Upper Limb Clinic of the Hospital complaining of persisting pain and stiffness in her right shoulder. The symptoms began 3 months earlier after a fall on her outstretched hand from a height of approximately 3 metres. The patient reported that the initial clinical assessment in the local emergency department and the anteroposterior radiograph of the right shoulder did not reveal any significant abnormality and a diagnosis of shoulder sprain and contusion was established. Pain medication was prescribed and a sling was applied for 10 days. After that time, the patient was re-examined and physical therapy with active and passive shoulder and upper limb exercises was commenced. As there was no improvement in pain and shoulder mobility, she was finally referred to our clinic for a second opinion and further evaluation.
On physical examination, her shoulder looked flattened anteriorly and both acromion and coracoid processes appeared to be prominent at the anterior part of the shoulder. There was an internal rotation deformity of 30° and any effort to passively or actively move the glenohumeral joint was extremely painful. Forward elevation of 40°, no external rotation and inability to completely supinate the forearm were also identified. The patient did not have any neuromuscular deficit and her medical history was unremarkable in terms of previous injuries in the shoulder region or other medical comorbidities. The anteroposterior radiograph of the right shoulder illustrated the marked internal rotation of the proximal humerus and the typical "lightbulb sign". The greater and lesser tuberosities were fractured and displaced from each other and from the humeral head. A further undisplaced fracture line at the anatomic neck of the proximal humerus was also evident (Figure 1A). Because of the inherent patient difficulty to abduct the arm, an axillary view was not performed. The transthoracic lateral roentgenogram showed posterior extrusion of the humeral head from the glenoid fossa (Figure 1B). Furthermore, the computed tomography (CT) scan clearly delineated the locked posterior shoulder dislocation with the large anteromedial head defect (50% of the articular surface) and the comminuted fractures of both tuberosities (Figure 1C).
According to these findings, open reduction and reconstruction of the proximal humerus was considered necessary. Under general anaesthesia, the patient was placed in a beach chair position and the glenohumeral joint was assessed via a deltopectoral approach. The axillary nerve was palpated to ascertain its position but it was not mobilised. The long head of the biceps was still intact and both tuberosities were localised and circumferentially released from the newly formed granulation tissue and immature callus. As the capsule was torn and detached along with the lesser tuberosity, mobilisation of the bone fragment in a "trap-door" manner allowed easy access and visualisation of the glenohumeral joint. The humeral head was found to be dislocated posteriorly, the posterior labrum was pulled out from the glenoid and a layer of fibrous tissue covered the glenoid cavity (Figure 2A). After meticulous removal of the scar tissue, the glenoid articular cartilage looked to be in good condition and the humeral head was reduced using long Darrach retractors in combination with extra-articular pressure. However, the joint was unstable even with a few degrees of internal rotation. Using three Panalok RC (Mitek Products, Ethicon) absorbable anchors with number-2 polyester braided sutures, the posterior capsule and labrum were repaired to the posterior glenoid rim. The large reverse Hill-Sachs lesion was addressed with transfer of the fractured lesser tuberosity and its attached subscapularis muscle to the anteromedial defect according to McLaughlin's technique modified by Hawkins et al. . Aiming to restore the sphericity of the humeral head and enhance the healing process, the bone bed of the defect was augmented with demineralised bone matrix allograft (Grafton® DBM Putty, Osteotech, Eatontown, NJ) and stable fixation of the lesser tuberosity was achieved with two partially threaded 4.0 mm titanium screws (Figure 2B). The greater tuberosity and anatomic neck fractures were subsequently stabilised using three screws of the same type. Repair of the rotator interval was the last step performed and routine closure of the wound over a drain was achieved.
Postoperatively, the extremity was placed in a sling with the shoulder in neutral rotation and slight abduction. At 4 weeks, passive shoulder and pendulum exercises were initiated and the patient was advised to use the sling for another 4 weeks. At 8 weeks, a more aggressive physical therapy with active assisted range-of-motion and strengthening exercises was instituted as plane X-rays showed maintenance of joint congruency and early signs of bone healing. Despite the instructions for examination at regular intervals, the patient did not return for follow-up until two and a half years postoperatively. She reported that her shoulder was totally painless without any limitations during daily activities. She could actively elevate and abduct her arm 150° and 120°, respectively. In internal rotation, she reached the L2 vertebra and external rotation was 40°. Plane radiographs (Figure 3A) and CT scan (Figure 3B) confirmed a good clinical result and absence of devascularisation or instability of the humeral head.