Schwerwiegende Komplikation nach perkutan-transaxillärer Verschraubung einer Glenoidfraktur

Anatomic healing after non-operative treatment of a large, displaced anterior glenoid rim fracture after primary traumatic anterior shoulder dislocation – a case report

Background

Large, displaced anterior glenoid rim fractures after primary traumatic anterior shoulder dislocation are usually managed by surgical stabilization. Although there is little evidence supporting surgical management, it is often preferred over non-operative treatment. This case report describes non-operative management of such large, displaced anterior glenoid rim fracture with CT- and MRI-based documentation of anatomical healing of the fracture fragment, a finding that has not been described previously.

Case presentation

This case report describes a 49-year-old male, right-hand dominant, carpenter, who had a left-sided primary anterior shoulder dislocation after a fall while skiing. Initial plain radiographs showed a reduced glenohumeral joint with a large, displaced anterior glenoid rim fracture. CT-evaluation showed a centered humeral head, and as per our institutional protocol, non-operative management was initiated. Longitudinal radiographic assessment at 2 weeks, 4.5 months and 12 months showed reduction of the initially severely displaced fracture fragment. MRI- and CT-evaluation after 12 months confirmed anatomical healing of the fragment. At final follow-up, the patient was highly satisfied, although the healing process was complicated by posttraumatic frozen shoulder, which has had almost fully resolved after 12 months.

Conclusions

Given that the glenohumeral joint is concentrically reduced, large (displaced) anterior glenoid rim fractures after traumatic primary shoulder dislocation can be successfully treated non-operatively, with the potential of anatomical fracture fragment healing. Therefore, it remains subject to conservative treatment at our institution and surgical stabilization is reserved for patients with a decentered humeral head or persistent glenohumeral instability.

Nonoperative Treatment of Anterior Glenoid Rim Fractures After First-Time Traumatic Anterior Shoulder Dislocation: A Study with 9-Year Follow-up

Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis.

METHODS

In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years).

RESULTS

Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work.

CONCLUSIONS

Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Reduction of glenoid rim fractures after primary shoulder dislocation in external rotation]

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

Arthroscopic screw fixation of large anterior glenoid fractures

Ten patients after traumatic shoulder dislocation with resulting instability due to an acute anterior glenoid fracture involving at least 21 percent of the glenoid length were treated by arthroscopic screw fixation of the fragment. The average fragment size measured 26.2% of the glenoid length. Pre- and postoperative radiographic evaluations were performed with three-dimensional CT scans. A cannulated titanium screw system was used for fragment fixation. All ten patients were followed up radiographically and, by evaluation of the Rowe score, clinically after a minimum of 2 years. At follow-up the Rowe score averaged 94 points. According to the rating scale, seven patients had an excellent result, two patients a good result, and one, fair result. In all patients CT scan confirmed that the fracture had healed in an anatomical position. One patient had one episode of traumatic redislocation with a positive apprehension test at follow up. In one case, removal of the screw was necessary due to mechanical impingement. We recommend this arthroscopic technique allowing for closed reduction and internal screw fixation of large anterior glenoid fractures, ensuring anatomical fracture healing and gleno-humeral joint stability.

Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder

The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (> 5 mm), displaced (> 2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint. After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one. Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph.