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Acute Shoulder Posterior Dislocation with Impression Fracture of the Humeral Head
assistant to check for a good stability level. The window is covered
Figure 3: Specific Tools
with the previous cortical bone using a press-fit technique. The
posterior capsule is not surgically addressed. The shoulder is
positioned in 20º of external rotation, 10º of abduction and 10º of
extension. The patient wears the cast for five weeks, and additional
radiographs are performed to confirm the humeral head reduction.
The post-operative programme is two weeks of pendulum exercise and
passive assistant motion, and at five weeks the brace is removed and
full active and passive motion is allowed.
Critical Concepts
The indications for the use of this technique are an acute (assessed
within three to four weeks) impression defect, without displaced
osteochondral fragment, involving up to 50% of the articular surface
of the humerus (see Figure 5). Obviously, good bone quality and a
A hollow trephine cutter (top) to create a bone carrot and a bone tapper (bottom) that allows optimal running
young, active patient increase the chances of a successful procedure.
into the hollow trephine (10mm diameter).
An absolute contraindication is to perform this procedure in patients
over 70 years of age with osteoporotic bone. A relative contraindication
Figure 4: A 9x30mm Interference Biabsorbable Screw
Inserted Through the Window Perpendicularly in the
is the treatment of patients in whom a very large articular surface is
Same Direction as the Depression
involved (more than 50–60%).
In the authors’ experience, the opening of the rotator interval cuff is
enough to evaluate the depression fracture of the articular surface and
to control the reduction obtained. Should the visualisation be insufficient,
the surgeon can extend the interval split more medially. However,
detaching the proximal subscapularis tendon from the lesser tuberosity
should be the surgeon’s last option as it will have a negative impact on
the patient’s recovery time. The aim of the interference screw is to fill the
cancellous bone gap left by the tapper. The screw must not reduce the
Figure 5: Pre-operative Computed Tomography (CT) Scan
fracture, but is used only to prevent the collapse of the surface. To date, Showing the Anterior Humeral Head Impression Fracture (A) and
the authors have performed two of these surgical procedures, obtaining
Post-operative CT Scan View (B)
good anatomical reduction of the impression defect, and after more than
24 months there have been no signs of osteoarthritis, collapse or other
AB
late complications. The range of motion is normal without limits in
internal rotation. The authors’ anatomical technique therefore represents
a safe and easy anatomical alternative to subscapularis transfer in acute
humeral head defects involving up to 40–50% of the humeral shape.
19
The McLaughlin impression fracture is a rare but clinically and
radiologically well-defined lesion. Even though there is no evidence-based
treatment protocol in case of an acute, medium-sized impression defect in results, especially when performed acutely. The authors’ technique can be
a fit patient, the operation is mandatory. Among all the techniques, the a viable alternative in this case as it is safe and easy. Once again, this
non-anatomical approach is still widely used due to the reproducible good report underlines the need for early diagnosis and treatment. ■
1. McLaughlin HL, Posterior dislocation of the shoulder, J Bone 7. Connor PM, Boatright RJ, D’Alessandro DF, Posterior fracture- 14. Krackhardt T, Schewe B, Albrecht D, Weise K, Arthroscopic
Joint Surg Am, 1952;34:584–90. dislocation of the shoulder: treatment with acute osteochondral fixation of the subscapularis tendon in the reverse Hill-Sachs
2. Ovesen J, Sojbjerg JO, Posterior shoulder dislocation: muscle grafting, J Shoulder Elbow Surg, 1997;6:480–85. lesion for traumatic unidirectional posterior dislocation of the
and capsular lesion in cadaver experiments, Acta Orthop Scand, 8. Robinson CM, Aderinto J, Posterior shoulder dislocation and shoulder, Arthroscopy, 2006;22:227.e1–227.e6.
1986;57:535–6. fracture-dislocation, J Bone Joint Surg Am, 2005;83(3):639–50. 15. Keppler P, Holz U, Thielemann FW, Meinig R, Locked posterior
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posterior dislocation of the shoulder, J Bone Joint Surg Am, postoperative rehabilitation, Phys Ther, 1975;55:850–58. osteotomy of the humerus, J Orthop Trauma, 1994;8:286–92.
1987;69:9–18. 10. Cicak N, Posterior dislocation of the shoulder, J Bone Joint Surg 16. Dubousset J, Posterior dislocations of the shoulder, Rev Chir
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posterior fracture-dislocation of the shoulder by total shoulder 11. Walch G, Boileau P, Martin B, Dejour H, Luxations et fractures- 17. Gerber C, Chronic, locked anterior and posterior dislocation. In:
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EUROPEAN MUSCULOSKELETAL REVIEW 2007 65
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