ANATOMICAL CHANGES ASSOCIATED WITH UNTREATED PROXIMAL HUMERAL FRACTURE

Jamali M, Guffey JS, Winters R, Hubbard L, Blackwell B. College of Nursing and Health Professions, Arkansas State University, Jonesboro, AR, [...]
PURPOSE: To describe the anatomical changes associated with a non-reduced proximal humeral fracture and discuss implications for physical therapy practice. DESCRIPTION: Cadaver dissection of a 53-year-old male with diagnosis of lung cancer. Radiologic imaging and detailed anatomical dissection were used to analyze the case. Comparison to the non-involved extremity was included. OBSERVATION: External inspection of the cadaver revealed an unusual prominence on the proximal left humerus. No medical records explaining this anomaly were available. Radiologic imaging was undertaken prior to dissection. X-rays revealed an old, well-healed, mal-aligned fracture of the proximal humerus. This cadaver was known to have died from lung cancer, however, radiologists who viewed the films reported no evidence of pathological fracture secondary to lung cancer. Internal inspection via dissection began with inspection of the normal anatomy of the non-involved side (right). Dissection of the involved side revealed that the proximal end of the fracture was deviated forward by the pectoralis major muscle. The distal end of the fracture was deviated proximally and posteriorly by the deltoid muscle. The involved side demonstrated a significant re-organization of the deltoid muscle attachment. The attachment had moved proximally and was now similar to the attachment of pectoralis major. The deltoid attachment had also become much broader (60 mm). This two-fold increase in attachment breadth was present to fill a gap formed by the two mal-aligned ends of the fracture. An adventitious ligament was noted to have formed at the fracture site to support the distal attachment of the deltoid. The posterior fibers of the deltoid attachment demonstrated an unusually long attachment (100 mm) to the proximal partner of the fracture. This posterior attachment also extended to attach to the lateral head of the triceps muscle. CONCLUSION: Practitioners can overlook the actual origin of shoulder impairment/dysfunction, especially in cases with less obvious external features, if thorough examination does not include the patient's past history. When access to past medical records is not available, it is the responsibility of the physical therapist to pursue a complete medical assessment of the patient. The assumption that all past fractures have been appropriately treated may be erroneous. This presentation demonstrates how long term effects of humeral fracture can alter the anatomy and biomechanics of the shoulder complex.