Entrapment radiographs or CT- scan with 3D

Entrapment of the long head of the biceps tendon in proximalhumeral fractures is an exceedingly rare entity described in the literature infew cases of the pediatric population. Clinical presentation may be misleading,and the diagnosis of proximal humeral shoulder fractures with or without bicepstendon entrapment could be missed or uninterpreted on plane radiographs or CT-scan with 3D reconstruction. Interposition of the long head of the biceps incomplex proximal humeral fractures may be a challenge for proper anatomicalpercutaneous or open reduction of these fractures. The following case reportdescribes a case of a patient involved in a ski accident falling on anoutstretched arm with an atypical presentation of long head of the biceps LHBtendon entrapment in a multi-fragmentary depressed intra-articular proximalhumeral fracture. The patient underwent prompt surgical intervention.IntroductionFractures of the proximal humerus account for 5% of all fracturesand are the third most common fracture pattern occurring in individuals overthe age of 65.

The vast majorities of these fractures are relativelynon-displaced and can be successfully managed with non-operative means 1. In ad­dition to non-operative treatment, a broad spectrumof operative treatments are available, including open reduction and internalfixation (ORIF) with a variety of devices, hemiarthroplasty, and percutane­ousfixation 2.Some authors have expressed concern regarding interposedsoft tissue, such as the long head of the bicep tendon, in fractures of theproximal humerus in children.

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These same authors have offered this fear oftissue entrapment as the main reason for recommending open reduction3, 10 and 11.  We discuss an atypical presentation of a caseof an adult patient diagnosed with entrapment of the LHB in a complex proximalhumeral fracture after a ski injury.  CaseThis is the case of a 43 year old male patient that presented toour emergency department complaining of minimal pain and tenderness in his leftshoulder after sustaining a fall during skiing. The patient noted a high speeddown slope injury and falling on an outstretched hand with the shoulderabducted in 90 degrees on direct impact with the snow. The incident took placearound 6 hours prior to his presentation and he continued his day skiingnormaly with intermitent minimal stabbing pain over the lateral aspect of theaffected shoulder. He presented for assessment and management of severeshoulder pain.Upon inspection he had no swelling, edema, erythema or any ecchymosisover his left shoulder. Upon physical examination the patient had a full normalslightly painful range of motion of his left shoulder joint with moderatetenderness upon palpation of his left proximal humerus.

No neurovasculardeficits were associated with his injury. In the ED a standard Antero-Posteriorand lateral radiographs of the affected shoulder joint were done andsurprisingly showed a multi-fragmentary displaced humeral head fracture (Figure 1).CT-Scan with 3D reconstruction was ordered for further evaluation andpre-operative planning. The scan showed an acute comminuted, markedly displaced,vertically oriented fracture of the proximal humerus, extending from the mostsuperior aspect of the articular surface of the humeral head at its mid aspectand the lateral two thirds. The fracture lines also extended to involve thegreater tuberosity which was laterally displaced, the proximal humerusmetadiaphyseal junction at the humeral surgical neck and the floor of thebicipital tendon groove ( Figure 2-3).The patient was transferred to the operating room at once forplanned percutaneous fixation of his left proximal humerus fracture withKischner wires and cannulated screws. With the patient placed in the beachchair position, and after multiple failed trials of proper anatomic reductionand fixation the decision was taken to switch to an open technique. A miniincision deltopectoral approach to the proximal humerus was used.

Aftermultiple unsatisfactory extraarticular attempts of reduction of the fractureand anatomical realignment of the articular surface, a decision was taken toenter the joint and reduce the fracture fragments under direct vision. Properdissection and entry into the shouder joint was done through the rotator cuffinterval with proper retraction,while taking care not to breach the integrityof the cuff insertions. Surprisingly the LHB was found to be entrapped in thelongitudinal split  banana shapedfracture of the superior articular surface of the humeral head, extending fromthe bicipital groove anteriorly all the way posteriorly at the cartilage  bone interface (Figure 4). Anatomicalrealignment of the articular surface and freeing the entrapped LHB tendon wasimpossible, so the decision was taken to do a LHB tenotomy( Figure 5). Afterthe tenotomy was done, anatomical reduction of the fracture and the articularsurface was achieved and fixed with screws. Subsequently subpectoral tenodesisto restore the biceps function was done (Figure 6). His shoulder was immobilized for the first 3 weeks post operativelywith a proximal humerus shoulder immobilizer. After 3 weeks physical therapywas initiated starting with passive range of motion for 2 weeks and thenprogressing to active range of motion as tolerated without any bicepsstrengthening for the first 6 weeks.

  Thepatient presented 3 months after the surgery with full active and passive rangeof motion and near normal biceps muscle strength (Figure 7).DiscussionProximal humerus fractures, commonlyreferred to as “shoulder fractures,” typically involve the humeral head andneck. Because the proximal humerus serves as the insertion and origin formultiple muscles, the attachment of several ligaments, and shoulderarticulation, proper management of these fractures is essential to minimizemorbidity and maximize functional outcomes 7.The majority of PHFs are the result of low energy falls, areminimally displaced, and may be treated with sling immobilization and physicaltherapy.

However, in approximately 20% of fractures, surgery should beconsidered. The treating surgeon must have an understanding of the fracturepattern, the quality of the bone, other patient-related factors, and theexpanding range of reconstructive options 4. In the majority of casesstandard plain radiographs are sufficient to define the fracture pattern.Computed tomography CT can be used to evaluate for a head-splittingcomponent, better define the bone quality or the degree of comminution, and tofurther delineate the fracture configuration. The fracture pattern is animportant consideration when deciding upon treatment and predicting the risk ofosteonecrosis after proximal humeral fractures 4.Some proximal humerus fractures are irreducible, but there are onlya few reports in the literature of tissue interposition into the fracture site 5and 6.

The LHB tendon resides within a groove separating the greater andlesser tuberosities. The long head arises from the supraglenoid tubercle of thescapula and crosses the head of the humerus within the capsule of the shoulderjoint, exiting along the intertubercular sulcus joining with the short head.The tendon is retained in the bicipital groove by the transverse humeralligament 3.Some proximal humerus fractures are irreducible, but there are onlya few reports in the literature of tissue interposition into the fracture site,with the majority of cases cited being pediatric patients 3, 5 and 6. Smithcited a case study of a 12-year-old with a severely displaced fracture with aclinical diagnosis of biceps tendon interposition into the fracture site. Thepatient was followed nonoperatively and at 8 weeks could actively abduct hisarm 160°, externally rotate 60°, and internally rotate 70°. By 6 months he had regainedtotal use of the arm and shoulder,without pain.

He concluded that although theinjury appears serious, full recovery of the arm and shoulder occurs and theoriginal angular deformity remodels over time 5.Bahrs et al discussed 43 case of proximal humeral fractures inchildren and adolescents concluding that a failed closed reduction should beinterpreted as a possible soft tissue entrapment most likely because of thelong head of the biceps 11.Visser and Rietberg presented three case studies of fractureseparation of the proximal humerus in children (all Salter-Harris type II) thatfailed efforts at closed reduction and underwent open reduction and internalfixation due to the extreme displacement of the fracture fragments, along withinterposition of both the long head of the biceps and periosteum 6.

Lucas, Mehlam and Laor reported three cases from the pediatric agegroup with proximal humerus fracture post fall on outstretched arm withevidence of LHB tendon or other soft tissue interposition into the fracturesite. All three cases were treated non-operatively with closed reduction andimmobilization and followed with progressive regain of their shoulder range ofmotion to normal with significant radiographic bone remodeling. They alsounderwent a cadaveric study to investigate the possible LHB tendon impingementby a simulated proximal humeral fracture. An osteotome and mallet were used tocreate a simulated fracture (transversely oriented) at the level of thesurgical neck of the humerus, immediately above the insertion of the pectoralismajor muscle. After manipulating the fracture in multiple directions,the LHBtendon did not become interposed into the fracture site at any point of thewide range of humeral motionabduction, flexion, internal and external rotation3.

Henderson described a case of a thirty year old male diagnosed withinterposition of the LHB after sustaining a subcoracoid fracture-dislocation ofhis shoulder post electroconvulsive therapy for depressive disorder 8.In the literature, there are cases of axillary artery entrapment,associated with proximal humeral fracture but none described any entity of LHBentrapment. Palm and colleagues cited a case of a 38 year old woman that wasdiagnosed with a proximal humeral fracture post trauma. She was also diagnosedwith a concomitant axillary artery entrapment in the fracture site and abrachial plexus injury 9. Keser and colleagues also described a case of a 51year old male patient diagnosed with axillary artery entrapment following aproximal humeral fracture 10.

 ConclusionShoulder injuries can be very simple injuries to deal with in theED but sometimes they could be challenging especially in patients presentingfor regular check up post trauma in patients  with minimal pain and normal shoulder range ofmotion. Standard radiographs of the shoulder joint should always be done aftermoderate or high energy trauma in young adults because sometimes the clinicalexam may be surprisingly misleading and proximal humeral fractures could beeasily missed. On the other hand, entrapment of the long head of the bicepsshould be considered in any uunsuccessful attempt of reduction in proximalhumeral fractures. Tenotomy and subsequent tenodesis ofthe LHB could be necessary in severly comminuted intraarticular humeral head fractureswhere anatomic reduction is primarly impossible.

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