Abstract 3

Isolated Traumatic Shoulder Disarticulation

Authors: Zachary Lum DO, Jesua Law DO, John Casey MD
Doctor’s Medical Center
Modesto, CA

Introduction
Upper extremity amputations commonly occur in young, healthy individuals as a result of a high-energy trauma. This in contrast with lower extremity amputations, which commonly occur in the elderly with medical comorbidities such as diabetes and peripheral vascular disease.

Case Presentation
22 year-old male was an intoxicated restrained driver in a motor vehicle collision with a semi-truck. He sustained a near complete amputation of the left upper extremity, but remained hemodynamically stable and later was intubated after an initial ER evaluation was done. X-rays demonstrated an open proximal humerus fracture with significant comminution of the humeral neck and shaft with 40% bone loss of the proximal humerus . CT of the chest/abdomen/pelvis revealed a small pneumothorax, and chest tube was subsequently placed. Axillary, radial, and ulnar arteries were palpated, but the status of the brachial plexus was unknown. The patient had decreased sensation to his fingers and thumb but spontaneous purposeful movement of some fingers.

Fig 1Prior to surgical exploration in the operating room, several physicians including vascular and general surgery were consulted to determine limb viability. After a discussion with our surgical colleagues, as well as calling a tertiary replant center in our area, the decision was made to proceed with amputation.

In the operating room, there was extensive soft tissue injury to the entire shoulder with the comminuted proximal humerus exposed. During exploration of the wound, the deltoid branch of the thoracoacromial artery was found to be severed. All non-viable muscle was debrided, which included the anterior and medial deltoid as well as the biceps and brachialis muscles. The axillary nerve and the medial and lateral cords of the brachial plexus appeared to be intact.

Figure 2However, amputation at the level of the glenohumeral joint was done due to the massive soft tissue and bone loss. A posterior flap was defined using a portion of the triceps muscle, and the wound was loosely closed. Two subsequent debriedments were performed, then the wound was primarily closed with the posterior soft tissue flap. The patient had a rather uncomplicated recovery. His chest tube was removed on post-op day 5, and later discharged to law enforcement services on post-op day 7.

Discussion
Isolated traumatic shoulder amputations are rare because upper extremity amputations are usually the result of high energy trauma such as a motor vehicle accident and the associated injuries are usually fatal. Consequently, there is significant incidence of associated intracranial, thoracic, and abdominal injuries.

Figure 3An epidemiological study by Barmparas et al showed that only two of the 9000 patients with traumatic amputations had an isolated upper extremity amputation. This case is exceeding rare because unlike most isolated traumatic shoulder disarticulations, this amputation was not performed as an emergent, life-saving procedure. What made this case even more unique was the deviation from the normal flap used for closure. Due to the excess damage of the deltoid muscle this could not be used for closure and after several debriedments the inferior skin flap using the triceps was able to close the wound.

In comparison to the lower extremity, the anatomy and function of the upper extremity provide significantly different limb salvage considerations. There is a considerable difference between normal hand and prosthetic function due to the dexterity and sensory feedback of the arm, which cannot be replicated with current technology. The upper extremity may also be more amenable to limb salvage because it is not used for walking, which makes limb-length equality less important. Increased collateral circulation allows for increased time to reperfusion when vascular injury is present. However, loss of muscle needed to cover bone and provide limb function is the single largest factor in the decision making process of amputation versus limb salvage. This was paramount in the decision to perform a shoulder disarticulation in this case.

References

  1. Dowden, J., & Maxweel, R. (2012). Traumatic Shoulder Disarticulation After Motor Vehicle Colision. The American Surgeon, 78, E318- E319
  2. Tintle SM, Baechler MF, Nanos GP III, et al. Traumatic and trauma-related amputations: part II: upper extremity and future directions. J Bone Joint Surg Am 2010;92:2934–45.

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