The occurence of an intrathoracic fracture dislocation of the proximal humerus represents a true emergency despite the initial clinical presentation being benign.
Subtle clinical indicators of an intrathoracic dislocation include subcutaneous emphysema and the absence of a palpable radial head in the anterior shoulder or axilla.
Definitive Management should include concurrent orthopaedic and thoracic surgical consultation. Orthopaedic management would generally consist of hemiarthroplasty, although internal fixation may be attempted in a young patient. The indications for thoracotomy and extraction of the humeral head include progressive cardiopulmonary compromise.
Most importantly, awareness of this entity is important as it can be easily overlooked as it was by our trauma service.
“It is difficult to understand how a condition so clear cut and with such outstanding symptoms can be overlooked”
–in reference to chronic shoulder dislocations but the sentiment still applies
Cubbins WR, Callahan JJ, Scuderi CS. The reduction of old or irreducible dislocations of the shoulder joint. Surg Gynecol Obstet 1934; 58:129-35