Presentation
Chest pain and deformity with shortness of breath after a high-speed motor vehicle accident.
Patient Data
Comminuted displaced fracture of the left humeral head and proximal shaft.
Comminuted fracture of the left humerus. The humeral head is displaced into the left upper hemithorax abutting the aortic arch. Comminuted fracture of the left clavicle, left transverse process of T1 and the 1st and 2nd ribs. Suspected fractures are seen involving 3rd ,4th and 5th ribs. Soft tissue hematoma with surgical emphysema involving the left shoulder and upper chest wall. Moderate hemothorax is on the left side. Patchy shadowing is seen involving the left lung more marked in upper lobe most likely representing contusions.
Annotated Images
Intraoperative photos
The left humeral head fragments after extraction from the left hemithorax.
Case Discussion
The patient presented to the ER after lateral impaction during a high-speed motor vehicle accident. He was conscious, tachypneic and had a deformity of the left shoulder. Peripheral pulses and nerves are intact except the axillary nerve could not be assessed due to severe pain. After the CT, the patient was transferred to the ICU for further management of hemodynamics. An anterolateral thoracotomy was performed to extract the migrated head of the left humerus that lay adjacent to the aortic arch. A 4-5 cm left apical pulmonary laceration was repaired for hemostasis. After a full recovery, the patient underwent a split-thickness graft on the left hand, left clavicle and olecranon fixation and was transferred to another center for hemiarthroplasty.
Although extremely rare, intrathoracic displacement of a fractured humeral head can be initially missed due to other serious injuries in the region, can be a life-threatening condition and in need of urgent surgical intervention.
The case is courtesy of Dr Mounther Al Daradkah, Chest Surgery Consultant, RCMC.
Thanks to Dr Hatem Mahmoud Hanafi for supplying the photo.
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