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C2 Dens Fracture with Closed Cervical Migration of a 6Cm Humeral Fragment

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C2 Dens Fracture with Closed Cervical Migration of a 6Cm Humeral Fragment International Journal of Orthopaedics Sciences 2018; 4(1): 517-521 ISSN: 2395-1958 IJOS 2018; 4(1): 517-521 © 2018 IJOS C2 dens fracture with closed cervical migration of a www.orthopaper.com Received: 24-11-2017 6cm humeral fragment Accepted: 25-12-2017 Afonso Cevadinha Caetano Afonso Cevadinha Caetano, Pedro Xavier Fernandes, Raquel Teixeira, Department of Orthopaedic Surgery, Hospital de São Francisco Andreia Mercier Nunes, José Miguel Sousa, Clara Azevedo and José Xavier - Centro Hospitalar de Guimarães Consciência Lisboa Ocidental, Lisboa, Portugal Pedro Xavier Fernandes DOI: https://doi.org/10.22271/ortho.2018.v4.i1h.74 Department of Orthopaedic Surgery, Hospital de São Francisco Abstract Xavier - Centro Hospitalar de Case: A 39-year-old woman, with bipolar disorder, suffered an eight-meter fall, resulting in dens and Lisboa Ocidental, Lisboa, Portugal proximal and distal humeral fractures associated with migration of a 6cm humerus fragment to the left Raquel Teixeira cervical region. Department of Orthopaedic There were no skin breaches on admission. Surgery, Hospital de São Francisco Posterior instrumented C1-C2 fusion was performed along with proximal humerus stabilization through Xavier - Centro Hospitalar de anterograde static nailing after removal and repositioning of the cervical migrated fragment. Lisboa Ocidental, Lisboa, Portugal Conclusion: High-energy trauma significantly increases treatment complexity. Understanding injury Andreia Mercier Nunes mechanism is crucial to adequately diagnose undisclosed lesions that otherwise might go unnoticed. In Department of Orthopaedic cases of bone migration, a thorough debridement is advised to prevent heterotopic calcifications. Surgery, Hospital de São Francisco Xavier - Centro Hospitalar de Keywords: Odontoid process, humeral fracture, trauma, complication, neurologic deficit Lisboa Ocidental, Lisboa, Portugal José Miguel Sousa Introduction Department of Orthopaedic Trauma lesions are influenced by the magnitude and direction of the applied force as well as Surgery, Hospital de São Francisco the orientation of the axial / appendicular skeleton at the exact moment of injury [1]. Xavier - Centro Hospitalar de The range of damage is usually a reflection of direct and indirect effects [1]. Lisboa Ocidental, Lisboa, Portugal Trauma is known to be a major cause of death and disability worldwide, with 10 to 20% of the Clara Azevedo patients sustaining multiple injuries [2-6]. While cervical spine fractures are estimated to occur Department of Orthopaedic in 2% to 3% of all patients who sustained a blunt trauma [6, 7], odontoid fractures account up to Surgery, Hospital de São Francisco [7] Xavier - Centro Hospitalar de 10-20% of all cervical fractures and proximal humeral fractures represent approximately 7% [5, 8-10] Lisboa Ocidental, Lisboa, Portugal of all injuries to the appendicular skeleton . The majority of odontoid fractures are consequence of a flexion loading, while only a minority José Guimarães Consciência of cases result from an extension load [6]. Proximal humeral fractures usually result from a (1) Department of Orthopaedic Surgery, Hospital de São Francisco lower-energy indirect injury to the shoulder during a fall on outstretched hand, even though it [8, 9, 11] Xavier - Centro Hospitalar de may also occur due to high-impact direct trauma to the shoulder . Brachial plexus Lisboa Ocidental, Lisboa, Portugal injuries in adults are mainly associated with motor-vehicle accidents however other traumatic (2) NOVA Medical School – Lisbon events like falls, gunshot or stab wounds might also be blamed [12]. NOVA University [8-14] Even though these injuries have been fairly studied and characterized , the association of cervical fracture, proximal and distal humeral fracture as well as brachial plexus injury is a rare event. Even more, and to the best of the authors’ knowledge, there is no mention in the literature to the closed migration of a 6cm humeral fragment to the cervical region without evident external signs of the injury. This case report intends to raise awareness to the complexity and underline complications that may arise from a high-energy trauma. Correspondence Afonso Cevadinha Caetano Case report Department of Orthopaedic A 39-year-old woman, with past medical history relevant for HIV positive and bipolar Surgery, Hospital de São Francisco Xavier - Centro Hospitalar de affective disorder, suffered a self-inflicted fall from an eight-meters height. After stabilization Lisboa Ocidental, E.P.E. Estrada at the scene, she was transferred to a central emergency trauma unit. Primary and secondary do Forte do Alto do Duque, Lisboa, survey were performed and the main injuries identified were a type III (Anderson-D’Alonzo Portugal ~ 517 ~ International Journal of Orthopaedics Sciences classification [15]) dens fracture (Fig. 1), along with a 6 cm It is also noteworthy to state that the cervico-brachial bone fragment lodged in the left postero-lateral cervical heterotopic calcification present at six months follow-up, region (Fig. 2); a left comminute proximal humerus fracture actually resembling an omo-vertebral bone usually observed (Fig. 3); a left distal humerus fracture; and a brachial plexus in patients with congenital deformities such as the one injury. described by Sprengel [17], is further evidence of the bone No neck or shoulder skin breaches were identified. trajectory across the soft tissues. This probably results from Two days later after the adequate patient`s clinical the remaining periosteum or bone debris that kept stabilization a C1-C2 posterior autologous bone grafting osteoinductive/osteogenic properties and weren’t completely arthrodesis was performed, implemented by a hook, bar and removed during the previous surgical procedure, and it’s cross-linking device (Fig. 4). At the same time the humeral interaction with the injured/necrotic muscle [18]. fragment located in the cervical region was recovered and After identification of the different injuries, and its dimension, used for the proximal humerus reconstruction stabilized each one of them was given what we believe was the through anterograde nailing (Fig. 5). The distal humeral indicated treatment. fracture was treated with a two anatomic parallel plate and We realize that the selected C1-2 laminar hook construct with screws construct. As for the brachial plexus injury it was cross-linkage and bone grafting was only controlling rotation evaluated by MRI and electromyography, and considered not and flexion movements but not extension. However, it was suitable for surgery by the microsurgery team. our choice once we realised that extension movement was C2 fracture consolidation was confirmed within two months. blocked by the contact between C1 posterior arch and C2 However and as expected, at six months follow up thumb spinous process as required by the reduction position and abduction and extension deficits still persisted, along with a consider the risks of different procedures. Additionally, it was partial wrist and remaining fingers extension decrease range a type III dens fracture, usually treated in a nonsurgical way of motion. A 40º elbow extension deficit was still present at in our spinal unit. that time point while interestingly a heterotopic calcification As for the humeral proximal nailing, even if it was stabilizing was also identified at cervical area, in what appeared to be the the humerus, the subsequent shoulder ankylosis wasn’t in our trajectory of the previously migrated humerus bone fragment first plan. However, at the end of the day and considering the (Fig. 4). patient neurologic status, it was probably the most effective The proximal humeral fracture evolved into a gleno-humeral treatment for the clinical situation being that is the reason why ankylosis (Fig. 6 and 7) and a bone fusion was uneventfully we accept it [19]. The distal plating evolution was as planned, achieved at the distal humerus fracture. providing the necessary stabilization for the bone healing, At 3 years down the line the patient still referred no pain in actually fully achieved in all three main fractures. the cervical region. Even so, and despite progression of the The removal of the fragment wasn’t enough to prevent the heterotopic calcification and a noticeable cervical scoliotic heterotopic calcification, as noticed 6 months down the line. deformity she refused further surgery. A thorough debridement of the fragment`s pathway and anti- In spite of a confirmed shoulder ankylosis, the left upper limb inflammatory medications might probably be the best option gradually recovered its function actually presenting an active in future similar cases [20], specifically after considering the elbow range of motion of 80º flexion and 10º extensions, no impact of these medications on fracture union [20]. As for the pronosupination deficits, and sustained global wrist and traumatic heterotopic calcification and whenever detected, it fingers flexion-extension (Fig. 8 and 9). can generally be resected in between six to nine months [20]. At 3 years follow-up, the heterotopic calcification was Discussion actually more evident than at 6 months follow up. There was a To fully understand the complexity of a trauma mechanism is clear cervical scoliotic attitude probably partially related to of the utmost importance while evaluating a patient. Most of the plexus lesion. However the patient refused further surgery, the time, it can lead the surgeon to identify and diagnose has no neck nor shoulder and elbow pain,
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