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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 57-60

Fracture-subluxation of the shoulder in children: A case series and literature review


Department of Orthopedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission20-Apr-2020
Date of Acceptance11-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
Department of Orthopedics, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_25_20

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  Abstract 


Glenohumeral dislocation in pediatric age is a rare injury. The proximal humerus fractures, on the other hand, are relatively common with the management ranging from conservative to operative fixation. Concomitant proximal humeral fracture and subluxation or dislocation of ipsilateral glenohumeral joint are the rarer events with very few reports available in the literature. We present a series of four pediatric cases (2 males and 2 females) of fracture dislocation of the shoulder with relevant details. All the cases suffered injuries following fall from tree and were managed by operative means in two while two were managed conservatively. Good functional outcome was noted in the mean follow-up of 10 months.

Keywords: Child, open reduction, pediatric, proximal humerus fracture, shoulder fracture dislocation, shoulder injury


How to cite this article:
Dharmshaktu GS, Adhikari N, Mourya P. Fracture-subluxation of the shoulder in children: A case series and literature review. J Orthop Traumatol Rehabil 2021;13:57-60

How to cite this URL:
Dharmshaktu GS, Adhikari N, Mourya P. Fracture-subluxation of the shoulder in children: A case series and literature review. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 4];13:57-60. Available from: https://www.jotr.in/text.asp?2021/13/1/57/318402




  Introduction Top


Proximal humerus fractures are described in <5% of all pediatric fractures.[1] Most of these are metaphyseal and rest are epiphyseal separations in 70:30 ratio.[2] The conservative care is the mainstay of treatment as most of the injuries are physeal (Salter–Harris type 2) and heal or remodel well.[3] Shoulder dislocation, on the other hand, is a rare injury in children as the inherent anatomy makes dislocation less likely than fractures or epiphyseal separation. In a recent series of 220 pediatric proximal humeral fractures, no case of dislocation was reported.[4] Similarly, in a recent large series of proximal humeral fractures, no description of concomitant subluxation or dislocation was reported.[5] The combination of proximal humerus fractures and the shoulder dislocation is thus a rarity.


  Case Reports Top


Case 1

A 10-year-old female presented to us following fall from a tree while playing and injuring her right shoulder and difficulty in movement. There were no open or other associated injuries. The right arm was strapped in her dupatta (stole). The radiograph showed extra-articular fracture of the proximal humerus. A mild subluxation of the glenohumeral joint was also noted [Figure 1]a and [Figure 1]b. The girl chose operative treatment following informed consent and was operatively treated with open reduction and multiple Kirschner wire (K-wire) fixation followed by plaster U slab for 3 weeks [Figure 1]c and [Figure 1]d. The perioperative period was uneventful, and gentle shoulder physiotherapy started after 3 weeks and wires removed after 8 weeks. There were bone union and regain of shoulder movement and function noted in the follow-up of 10 months.
Figure 1: The radiograph showing fracture proximal humerus and inferior subluxation of glenohumeral joint (a and b). The postoperative radiograph showing fracture fixed with crossed K-wires and subluxation improved (c and d)

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Case 2

An 11-year-old male following fall from tree presented to us with his injured left upper extremity supported by right one and without other concomitant injuries. He was diagnosed with fracture dislocation of the left shoulder [Figure 2]a and [Figure 2]b. Closed reduction and percutaneous K-wire fixation under anesthesia were done [Figure 2c] along with plaster support for 4 weeks. Gradual union of fracture and good outcome were noted at the follow up of 9 months [Figure 2]d and [Figure 2]e.
Figure 2: The radiograph showing proximal humerus fracture with severe subluxation of head of humerus (a and b). The radiograph showing immediate postoperative (c), at 2 weeks (d), and 5 weeks (e) showing gradual union

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Case 3

A 12-year-old male patient presented with a history of fall from tree and injury to his left shoulder region along with head injury without altered level of consciousness. The head injury was cleared from a neurosurgeon, and the radiograph showed left fracture subluxation with severe proximal displacement of the distal fragment of the humerus [Figure 3]a. There was skin puckering without open wound noted at the site of corresponding bony prominence. The closed reduction was attempted as the patient refused operative treatment. The plaster U slab was kept for 6 weeks and fracture united. There was bony overlap and lateral bony overhang noted on radiographs but clinically there was no problem and the radiological abnormality remodeled well with time to normalcy [Figure 3]b and [Figure 3]c. The patient had good shoulder recovery with painless activities of daily living in the follow-up of 11 months.
Figure 3: The radiograph showing highly displaced fracture of proximal humerus with proximal migration of the distal shaft. There is subluxation noted of glenohumeral joint (a, above and below radiograph). The united fracture with cortical overhang (b) that improved on follow up (c)

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Case 4

A 14-year-old female presented with a left shoulder injury following fall from tree 3 days back. There was no other injury except left leg abrasions. The radiograph noted fracture subluxation of the left shoulder with displaced fracture [Figure 4]a and [Figure 4]b. The patient chose conservative management and was managed by closed reduction under image intensifier guidance and plaster U case application for 6 weeks. The course of treatment was uneventful, and fracture united in 6 weeks following which gradual physiotherapy was initiated for excellent outcome in the follow-up of 10 months [Figure 4]c and [Figure 4]d.
Figure 4: The radiograph showing marked inferior subluxation of the glenohumeral joint with displaced proximal humerus fracture (a and b). The conservative management resulted in sound union with acceptable alignment (c and d)

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  Discussion Top


In the recent literature, the youngest case was reported in a 2-year-old child with anterior dislocation and Salter–Harris type 1 fracture.[6] There is description of similar injuries in a 3- and a 7-year-old children in separate reports.[7],[8] Another child of 6 years of age was reported with anterior dislocation and extraphyseal proximal humeral fracture and managed by open reduction.[9] A recent report described physeal separation along with dislocation of the proximal humeral epiphysis in a 3-year-old child managed by closed reduction and pinning to an excellent outcome.[10] Most reported dislocations are anterior. Posterior dislocation along with proximal humerus fracture is also described in a 9-year-old child.[11] The case was managed by closed reduction and percutaneous pinning. Another case of posterior dislocation with the said fracture was managed by titanium elastic nails.[12] Another recent report of a 6-year-old girl with similar injury with was managed by open reduction and fixation with elastic stable intramedullary nails, and authors advocate this technique in cases with severe fracture displacement.[13] The authors also stated that only 17 such cases are reported in the literature. The choice of treatment (conservative or operative) in our cases was based largely on parental preference following the informed consent and on surgeon's discretion in one case. There is no attempt to prove superiority of one method over the other.

Pseudodislocation of the shoulder in inferior direction has been described following fracture of proximal humerus and has been attributed to reflex inhibition of shoulder musculature. Spontaneous correction of the subluxation has been noted in the follow up as the normal shoulder tone was regained.[14] Large joint effusion, axillary neuropraxia, and temporary deltoid atony are other reasons cited for inferior shoulder luxation following trauma or surgery with 10%–60% reported incidence in adults. Another case of transitory shoulder dislocation following proximal humerus fracture was described in a 14-year-old girl.[15] Whether the subluxation in the settings of fractures of proximal humerus is pseudosubluxations or true ones should require further studies to clarify and more cases or large series is required to better comprehend these uncommon injuries and to form consensus on management.


  Conclusion Top


The fracture subluxation or dislocation of the shoulder in pediatric age is extremely rare injury. No consensus on diagnosis, classification or treatment exists for this injury. Large multicentric study of these rare cases is warranted for better understanding and treatment recommendations. The literature is scarce on this topic. The conservative management has not been attempted in any previous work in our opinion. This article should pave way for further work on this subject.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rose SH, Melton LJ, Morrey BF. Epidemiologic features of humeral fractures. Clin Orthop Relat Res 1982;168:24-30.  Back to cited text no. 1
    
2.
Lefèvre Y, Journeau P, Angelliaume A, Bouty A, Dobremez E. Proximal humerus fractures in children and adolescents. Orthop Traumatol Surg Res 2014;100:S149-56.  Back to cited text no. 2
    
3.
Salter RB. Injuries of the epiphyseal plate. Instr Course Lect 1992;41:351-9.  Back to cited text no. 3
    
4.
Nelson G, Brown C, Liu RW. No incidence of glenohumeral joint dislocation in a review of 220 paediatric proximal humerus fractures. J Child Orthop 2018;12:493-6.  Back to cited text no. 4
    
5.
Gennaro GL, Spina M, Lampasi M, Libri R, Donzelli O. Fractures of the proximal humerus in children. Chir Organi Mov 2008;92:89.  Back to cited text no. 5
    
6.
Winmoon C, Sathira-Angkura V, Kunakornsawat S, Prasartritha T. Fracture-dislocation of the glenohumeral joint in a 2-year-old child: Case report. J Trauma 2003;54:372-5.  Back to cited text no. 6
    
7.
Nugpok O, Menon J, Satyanarayana P. Fracture dislocation shulder in 3-year-old. Eur J Orthop Surg Traumatol 2010;20:333-4.  Back to cited text no. 7
    
8.
Isik M, Subasi M, Cebesoy O, Koca I, Pamukcu U. Traumatic shoulder fracture-dislocation in a 7-year-old child: A case report. J Med Case Rep 2013;7:156.  Back to cited text no. 8
    
9.
Azevedo J, Maia B, Correia J. Fracture-dislocation of the proximal humerus in a 6-year-old child: Case report. J Shoulder Elbow Surg 2013;22:e16-9.  Back to cited text no. 9
    
10.
Gupta R, Singh A, Singh KK, Vohra R. Fracture of proximal humerus with dislocation of glenohumeral joint in a 3 year old child: A case report. J Orthop Case Rep 2013;3:26-8.  Back to cited text no. 10
    
11.
Hong S, Nho JH, Lee CJ, Kim JB, Kim B, Choi HS. Posterior shoulder dislocation with ipsilateral proximal humerus type 2 physeal fracture: Case report. J Pediatr Orthop B 2015;24:215-8.  Back to cited text no. 11
    
12.
Fannouch G, Al Khalife YI, Al Turki AS, Jawadi AH. Traumatic pediatric shoulder fracture dislocation treated with closed reduction and intramedullary nailing: A case report. Trauma Case Rep 2017;9:22-6.  Back to cited text no. 12
    
13.
Jin S, Cai H, Xu Y. Shoulder dislocation combined with proximal humerus fracture in children: A case report and literature review. Medicine (Baltimore) 2017;96:e8977.  Back to cited text no. 13
    
14.
Michael SP, Banerjee A. Pseudo-dislocation of the shoulder in a child. Arch Emerg Med 1993;10:289-92.  Back to cited text no. 14
    
15.
Do T, Kellar K. Transitory inferior dislocation of the shoulder in a child after shoulder injury: A case report and treatment results. Iowa Orthop J 2004;24:119-22.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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