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European Journal of Orthopaedic Surgery & Traumatologyhttps://doi.org/10.1007/s00590-018-2128-8
ORIGINAL ARTICLE • SHOULDER - FRAC TUR ES
Biceps tendon interposition in two‑part fracture of the humeral
surgical neck
Selim Şanel1 · Yalçın Turhan2 · Nurullah Ermiş1 · Korhan Özkan3 · Ender Uğutmen1
Received: 31 October 2017 / Accepted: 17 January 2018 © Springer-Verlag France SAS, part of Springer Nature 2018
Abstract
Objectives Long head of the biceps tendon (LHB) is an obstacle to closed reduction in two-part fracture of the humeral surgical neck if the distal humeral shaft is displaced into the axilla in anteroposterior X-ray examination.
Methods and material Among 36 proximal humeral fractures, 10 two-part humeral surgical neck fractures which were displaced into the axilla in anteroposterior X-ray views and classified as 11-A3.2 were included in this study. In all of these fractures, closed reduction attempts were unsuccessful. All of the cases were treated surgically.
Results In all of the cases, the humeral shaft was in the axilla in anteroposterior X-ray examination. It was found intraopera-tively that the humeral shaft was also displaced more than 100% anteriorly and the LHB was interposed in the fracture site. Traction applied to the shaft of humerus enhanced the ‘bowstringing’ effect of the LHB making closed reduction impos-sible. The fracture could only be reduced by open reduction. The LHB entrapment is released by pushing the humeral head upwards by a periosteal elevator.
Conclusion LHB entrapment in the fracture site should be strongly suspected in two-part fracture of the humeral surgical neck if the humeral shaft is displaced into the axilla in AP X-ray examination and more than 100% anteriorly in the sagittal plane. The classic closed reduction maneuver enhances the strangulation of the LHB and reduction could only be achieved by surgery.
Keywords Proximal humerus · Biceps tendon · Shoulder · Fracture dislocation
Introduction
Long head of biceps (LHB) originates from supraglenoid tubercle and extends all the way through the humerus and inserts into radial tuberosity, which is one of the primary flexor of the elbow joint and shoulder depressor. Interposi-tion of the tendon of the LHB as an obstrucInterposi-tion to reducInterposi-tion is reported in fracture-separation of the proximal humeral epiphysis in children and anterior/posterior dislocations of the shoulder [1–13]. The fracture pattern leading LHB inter-position has not been questioned yet. The aim of this study is to report the radiological and operative findings of biceps tendon interposition in proximal humeral two-part collum chirurgicum fractures. The mechanism of injury, muscle deforming forces that could either contribute to the patho-anatomy or hinder fracture reduction and fracture reduction maneuver are discussed.
* Yalçın Turhan yturhan_2000@yahoo.com Selim Şanel selim.sanel@maltepe.edu.tr Nurullah Ermiş nurullah.ermis@maltepe.edu.tr Korhan Özkan korhanozkan76@gmail.com Ender Uğutmen ender.ugutmen@maltepe.edu.tr
1 Orthopedics and Traumatology Department, Medical
Faculty, Maltepe University, İstanbul, Turkey
2 Orthopedics and Traumatology Department, Medical Faculty,
Duzce University, Duzce, Turkey
3 Orthopedics and Traumatology Department, Medical Faculty,
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Materials and methods
A retrospective evaluation was done among 36 proximal humeral fractures treated between the years 1999 and 2007. There were 15 two-part, 7 three-part, 11 four-part fractures and 3 fracture dislocations. Among 15 two-part fracture, 10 cases were included in the present study according to the radiological and operative findings. These cases were all 11-A3.2 fractures according to AO clas-sification. Five patients were male and five were female. There were one eight-year-old boy, 4 adolescents and 5 adults. The median age was 25 (8–61) years. Anteropos-terior (AP) X-ray examination was done in the emer-gency unit. The humeral shaft was in the axilla in all of the selected 10 cases (Figs. 1, 2). They were all classi-fied as 11-A3.2, that is, extraarticular unifocal fracture and simple with translation. In all of the cases, closed reduction attempt was unsuccessful and open reduction was performed.
It was found intraoperatively that the displacement of the humeral shaft was not only into the axilla in the frontal plane but also more than 100% anteriorly in the sagittal plane as well. Moreover, the long head of the biceps ten-don was strangulated between the fracture sites (Fig. 3). The clavipectoral fascia was incised, the biceps tendon was freed and removed from the fracture site. The fracture was reduced by pushing the humeral head upwards through the fracture site by a periosteal elevator (Fig. 4).
Fig. 1 AP X-ray examination which shows humeral shaft in the axilla in a 50-year-old male patient
Fig. 2 AP X-ray examination in a 70-year-old female patient;
simi-larly in Fig. 1, humeral shaft is in the axilla again
Fig. 3 Preoperative finding: anterior displacement of the humeral shaft and the strangulation of the long head of the biceps tendon between the fracture sites HS humeral shaft, HH humeral head, LBT long head of biceps tendon
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Results
X-ray examination can be a clue for biceps tendon interpo-sition in two-part collum chirurgicum factures. If the distal fragment is displaced more than 100% both into the axilla in AP view and anteriorly in the sagittal plane, it should be strongly suspected that the biceps tendon is strangulated in the fracture site and open reduction in the fracture is needed.
Discussion
Biceps interposition is reported in anterior and posterior dislocations of the shoulder joint [1, 4–7, 9, 11]. Besides dislocations with and without fractures, there are a few studies about humeral proximal fractures resulting in biceps tendon interposition. These all involve children who had epiphyseal separations [2, 3, 8, 10, 12, 13]. Vis-ser and Rietberg [12] reported three cases of interposition of the tendon of the long head of biceps and anterior peri-osteum occurring in fracture separating in the proximal humeral epiphyseal cartilage plate. Curtis reported that interposition of periosteum and biceps tendon can lead to difficulty in fracture reduction in children [3]. Baxter and Wiley reported 57 epiphyseal separations of which 7 underwent open reduction and only one case had soft tissue interposition [2]. It was also reported that most of
the fractures of the proximal humeral epiphysis displace so that the distal fragment usually lies anterior and lateral to the proximal fragment, leading to anterior and varus angulation [2, 8, 10]. In the current study, there was an eight-year-old boy who had a proximal humeral fracture below the epiphysis, two 16-year-old and two 17-year-old adolescent whose epiphysis were nearly closed. These fractures can be interpreted as extraordinary fractures of the proximal humerus of the childhood as they were dis-placed medially toward axilla leading biceps interposition. Williams proposed the mechanisms producing fracture-separation of the proximal humeral epiphysis which are, namely, lateral rotation and extension, medial rotation and flexion, medial rotation and extension and pure extension types [13]. The fracture type in the current study resem-bles Williams’ lateral rotation and extension type. Although the case who had a lateral rotation–extension-type fracture in the Williams’ study had a successful closed reduction, closed reduction attempts were unsuccessful in the cases of the current study.
Lucas proposed that there is no biceps tendon interpo-sition in displaced proximal fractures of the humeral neck [14]. In the cadaveric study he performed, it was found that the LHB tendon did not become interposed into the fracture site in any displacement pattern. The only displacement pat-tern that resulted even in fracture fragment contact with the LHB was with the shaft fragment displaced 100% anteriorly. If the cases in his study are examined one by one, humeral shaft displacement was lateral in two, purely medial in one (no displacement in the sagittal plane and the humeral shaft was not in the axilla) and no information about displacement was given in the other. In the cadaveric study he performed, the examination was made in four directions, namely ante-rior, posteante-rior, medial and lateral. He did not combine the sagittal and frontal plane displacements. In the current study, it is found that LHB is entrapped in the fracture site in more than 100% displacement of humeral shaft in both frontal (medially to the axilla) and sagittal (anteriorly) planes at the same time.
The classic reduction maneuver for proximal humeral fractures is to apply longitudinal traction to the arm while positioning it in abduction and flexion [15]. It was found in this study that if LHB tendon interposition in a proximal humeral fracture is suspected this maneuver should be pro-hibited. As the biceps tendon is interposed in the fracture site, it prevents closed reduction and the closed reduction attempt, that is, traction and abduction of the distal fragment proximally, enhanced the ‘bowstringing’ effect and lock-ing of the biceps tendon on the fracture site maklock-ing closed reduction impossible. The fracture can only be reduced by open reduction by pushing the humeral head upwards by an elevator (not by traction of the distal fragment) and bringing the humeral shaft under it.
Fig. 4 The fracture was reduced by pushing the humeral head upwards and bringing the humeral shaft under it HS humeral shaft,
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The muscle deforming forces acting on proximal humerus are deltoid, pectoralis major, rotator cuff, biceps and triceps [15]. These forces act according to the fracture line, that is, above, between and below deltoid and pectoralis major insertion [15]. The fracture line of the cases in this study is all above deltoid and pectoralis major insertion. The humeral head is abducted, flexed and externally rotated by rotator cuff while the distal shaft displaced proximally by deltoid and medially and anteriorly by pectoralis major. As the dis-placement of the distal shaft increases and passes 100% in both sagittal and frontal planes, LHB entrapment is likely to occur.
Conclusion
LHB entrapment in the fracture site should be strongly sus-pected in two-part fracture of the humeral surgical neck if the humeral shaft is displaced medially and anteriorly more than 100%. The impingement of LHB tendon between the fractured fragments may predispose to insufficient reduction and it should be kept in mind that this important structure may be the primary restraint to fracture reduction during surgery. These fractures are 11-A3.2 according to AO clas-sification, and the fracture line is above the deltoid and pec-toralis major insertion. The classic closed reduction maneu-ver is unsuccessful as the strangulation of the LHB tendon increases and reduction could only be achieved by surgery.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicting interests.
Informed consent Written informed consent was taken from each
patient.
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