Traumatic shoulder fracture-dislocation in a child: An innovative method of closed reduction

Introduction

Traumatic shoulder dislocation is rarely seen in children. ¹ Fractures around the shoulder joint in young children tend to occur through the growth plate because of its relative weakness, and Salter-Harris type 1 and 2 injuries are commonly seen around the shoulder. ² A combination of a fracture with dislocation is extremely rare and treatment is always challenging. In most cases, open reduction is chosen in order to fix the fracture and to get a stable reduction of the joint.^2,3 We present the case of a six-year-old girl with a shoulder dislocation and proximal humerus metaphysis fracture, treated by closed reduction using a joystick method and fixation by two intramedullary K-wires achieving a good anatomical reduction of the fracture and shoulder joint with excellent clinical results. There are no previous reports of treatment of fracture-dislocations of the shoulder in children by a closed method using the joystick technique.

Case report

A six-year-old girl was a back-seat passenger (not wearing a seat belt) involved in a car accident when the car collided with a barrier on the road. She presented with severe pain and gross swelling of the right shoulder and physical examination revealed a palpable humeral head anteriorly. She was able to feel and move all her fingers; there was no external wound and injury to any other part of the body. A radiograph confirmed anterior shoulder dislocation with a severely displaced fracture of the neck of the humerus (Figure 1(a) and (b)). After preoperative preparations, the patient was taken to the operating room where a trial of a closed reduction under fluoroscopy was not successful. OPEN IN VIEWER

After making a 4-cm incision on the posterolateral aspect of the distal arm, a 3.5 mm drill hole was expanded with an awl, so that a 2 mm K-wire could be inserted into the medullary cavity of the humerus with the help of T handle under the guidance of intra-operative fluoroscopy (Figure 2(a) and (b)). The sharp tip of the wire was excised and bent 15 degrees. Under fluoroscopy, an attempt to reduce the fracture by a technique like the Metaizeau method ⁴ was tried but was unsuccessful. OPEN IN VIEWER

Under screening, a further 2 mm K-wire was centered in the dislocated humeral head through the middle of the deltoid muscle and used as a joystick (Figure 2(c) and (d)). By manoeuvring both wires, successful reduction of the fracture was achieved (Figure 2(e)). Once the fracture was reduced, the humeral head spontaneously slipped easily into the socket, and a second intramedullary K-wire of similar size was inserted to achieve steadiness (Figure 2(f)). The stability of the fracture and joint was assessed by continuous screening. Postoperatively, the shoulder was immobilized by U slab and a sling. At six weeks, K wires and U-slab were removed, and the patient was allowed mobilisation in a sling for two weeks. Follow-up at 12 weeks showed excellent clinical and radiological results (Figure 3(a) to (d)). OPEN IN VIEWER

There was no sign of avascular necrosis at one-year follow-up and the child had a full range of pain-free movement (Figure 2(g)).

Discussion

Shoulder dislocations are rare in children, and few cases are reported in the literature and are associated with proximal humerus fracture in most cases. Nelson et al. ⁵ reviewed 220 children, with an average age of nine years, with a fractured proximal humerus and identified no associated dislocations. There are 14 published cases of true shoulder dislocation combined with a fracture of the proximal humerus (Table 1). Most fractures occur through physeal plate, as it is considered the weakest area of the humerus. ⁶ Four cases were classified as Salter-Harris Type 1, four were Type 2 and two cases belong to Type 3.

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Table 1.

Combination of shoulder dislocation with fracture proximal humerus in children: Literature review.

No.	Year	Author	Age/sex	Associated injury with dislocation	Surgical approach: open/closed reduction	Method of fixation of the fracture	Follow-up	Outcome
1	1982	Nicastro and Adair 9	32 months /F	Epiphysis separation (SH 1)	Open	One K-wire	2 years	Uneventful
2	1992	Gregg-Smith and White 10	12 years/F	Fracture epiphysis (SH 3)	Open	One K-wire	4 months	Uneventful
3	1994	Obremskey and Routt 1	11 years/F	Fracture Metaphysis with ep displacement (SH 2)	Closed	Reduction done after two weeks when the fracture became sticky and moved as one piece. Immobilization done by shoulder sling	8 months	Axillary Nerve-recovered in six weeks
4	1997	Wang et al. 11	10 years/M	Fracture epiphysis (SH 3)	Open	Two screws	2 years	AVN but revascularized
5	2003	Winmoon et al. 12	2 years /M	Epiphysis separation (SH 1)	Closed	Two K-wires	30 months	Uneventful
6	2007	Lee et al. 13	16 years /M	Fracture epiphysis (SH 3)	Open	Three Steinmann pins	16 months	Uneventful
7	2010	Nugpok et al. 14	3 years/F	Epiphysis separation (SH 1)	Open	Two K-wires	1 year	Uneventful
8	2013	Gupta et al. 15	3 years/M	Epiphysis separation (SH 1)	Closed	Three K-wires	1 year	Uneventful
9	2013	Azevedo et al. 6	6 years/M	Fracture metaphysis with no epiphyseal involvement	Open	Two K-wires	5 year	Uneventful
10	2013	Isik et al. 2	7 years/F	Fracture metaphysis with ep displacement (SH2)	Open	Two K-wires	6 months	Uneventful
11	2014	Jonghun et al. 7	5 years/F	Fracture metaphysis with no epiphyseal involvement	Open	Four K-wires	1 year	Uneventful
12	2015	Hong et al. 16	9 years/F	Fracture metaphysis with ep displacement (SH2)	Open	Four K-wires	I year	Uneventful
13	2017	Jin et al. 3	6 years/F	Fracture metaphysis with no epiphyseal involvement	Open	Two intramedullary elastic nails	2 year	Uneventful
14	2017	Fannouch et al. 8	10 years/F	Fracture metaphysis with no epiphyseal involvement	Closed	Two TENS	4 months	Uneventful

Fractures on the proximal humerus not involving the physis are even rarer.

In four cases of fracture-dislocation shoulder where the physeal plate was not involved,^3,6–8 only one was treated by closed reduction of the dislocation with intramedullary fixation of the fracture.

Closed reduction of fracture and dislocation is always difficult. Jin et al. ³ attempted closed reduction with an elastic stable intramedullary nail (ESIN) but failed and had to perform the open reduction. Isik et al. ² reported dislocation with a fracture in a similar age group and claimed excellent results only after open reduction, but the patient took a longer time to achieve full function. Fannouch et al. ⁸ reported the satisfactory radiological union and full function after closed reduction and intramedullary pinning. We failed to get a reduction of the fracture by this method, so inserted another K-wire in the center of the humeral head and used it as a joystick to reduce the fracture. The fracture was easily reduced anatomically by manoeuvring both wires under fluoroscopy. Once the fracture reduced, the humeral head went easily into the socket. The key to managing dislocation with a fracture is the reduction of the fracture. We found this method to be relatively easier to reduce the fracture, allowing the head to move into the socket without any resistance. To our knowledge, this method has not been previously reported in the literature.

Conclusion

We recommend using this joystick technique when a closed reduction of the fracture-dislocation of the shoulder fails. It is effective and quick and provides excellent long-term outcome.