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Learning Point for the Article:
It is important to distinguish between bone bruise and osteonecrosis by suspecting and serially performing radiographs and magnetic
resonance imaging after shoulder dislocation.
Atypical Osteonecrosis of Humeral Head FollowingAnterior Shoulder
Dislocation
Anoop Chandrashekhar Dhamangaonkar¹,Arvind B. Goregaonkar¹
Introduction: Osteonecrosis of the humeral head is not a very common entity. It is usually associated with comminuted proximal humerus
fractures. We report a rare case of osteonecrosis of humeral head after anterior shoulder dislocation without any fracture of the proximal
humerus.
Case Report: We report a case of a 24-year-old male who sustained a left-sided anterior subcoracoid shoulder dislocation following a road
traffic accident. The shoulder was closed reduced, and a post-reduction radiograph was taken to confirm concentric reduction. At 6-month and
2-year follow-up, the radiographs showed sclerotic changes and magnetic resonance imaging (MRI) confirmed the occurrence of
osteonecrosis. This is the first such report in contemporary literature.
Conclusion: Osteonecrosis of the humerus head can occur after an anterior shoulder dislocation. It is important to distinguish between the
bone bruise and osteonecrosis. This can be done by serially reviewing the patient’s radiographs and MRI.
Keywords: Humerus, osteonecrosis, dislocation.
Abstract
Case Report
Introduction:
Osteonecrosis of the humeral head is not a common entity. It is
usually seen in cases of traumatic 3 or 4 part fractures of the
proximal humerus. We report a rare case of traumatic
osteonecrosis of the humeral head after an anterior shoulder
dislocation.
Case Report:
We report a case of a 24-year-old male with a left-sided anterior
subcoracoid shoulder dislocation (Fig.1a) following a road
traffic accident. This was the first episode of dislocation. The
shoulder was closed reduced by the Kocher’s technique within 3
hours of trauma, and a post-reduction radiograph was taken to
confirm concentric reduction. The shoulder was immobilized
for 3 weeks (Fig.1b and c), following which rotator cuff
strengthening exercises were initiated. The patient was followed
up, after the shoulder was reduced at 3 weeks, 3 months, and 6
months, and then, the patient reported after 2 years. This
patient was a non-alcoholic healthy college-going student who
was not on any medications. At 6-month follow-up, the left
shoulder radiograph showed a sclerotic sector of the head with
cortical erosions near the greater tuberosity (Fig. 2a and b). A
magnetic resonance imaging (MRI) was done which revealed a
geographic area of the anterior part of humeral head with an
altered marrow signal, which was iso- to hyper-intense on short
tau inversion recovery sequence, with a hypointense rim on T1
sequence. The differential diagnosis was a bone bruise or
osteonecrosis of the humeral head. However, due to the
sclerotic changes on the radiographs, po ssib ility of
osteonecrosis could not be ruled out and this required
Journal of Orthopaedic Case Reports 2018 May-June : 8(3):Page 61-64
Author’s Photo Gallery
¹Departmentof Orthopaedics, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal GeneralHospital,Mumbai, Maharashtra. India.
Address of Correspondence:
Dr. Anoop Chandrashekhar Dhamangaonkar,
Dept. of Orthopaedics, Suite No. 115, First Floor, College Building, LTMMC & GH, Sion, Mumbai- 400022.
E-mail: anoopd_7@yahoo.com
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Website:
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DOI:
2250-0685.1110
Journal of Orthopaedic Case Reports | pISSN 2250-0685 | eISSN 2321-3817 | Available on www.jocr.co.in | doi:10.13107/jocr.2250-0685.1110
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which
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61
Dr. Anoop C Dhamangaonkar Dr. Arvind B. Goregaonkar
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sequential imaging. The long head of biceps tendon was
displaced medially, outside the bicipital groove (Fig. 2c and d),
and the rotator cuff was normal. The patient had a stable
shoulder with mild pain at the extremes of motion. A radiograph
of the pelvis with both hips was normal, without any sclerotic
changes of the femoral head. The patient was treated with cuff
strengthening exercises, and he resumed all routine activities
including leisure sporting activities. Bisphosphonate was not
administered. At the end of 2 years, the patient had no
functional restriction and had an excellent UCLA score. The
shoulder radiograph revealed a mixed sclerotic and lytic lesion
in the humeral head without any cortical defect and a
maintained a congruent articular surface. The greater
tuberosity erosions seen on the earlier radiographs became
sclerotic without any further undermining (Fig. 3a and b). A
repeat MRI of the shoulder at 2 years revealed a 19 mm3×17
mm3×12mm3serpiginous, geographic area, larger in size than
the previous MRI, which was consistent with osteonecrosis of
the humeral head without any deformation of the articular
surface. There was a partial thickness tear with medial retraction
of the subscapularis. The long head of biceps tendon was torn
and retracted. The rest of the rotator cuff and glenoid labrum
was normal (Fig. 3c and d). An MR angiography of the shoulder
was performed to know the status of the circumflex vessels (Fig.
4a, b, c, d). It showed attenuation of the some of the branches of
anterior circumflex humeral artery, but all the vessels around
the humeral neck were patent, but their course was not clearly
defined. To enable a better visualization of the arteries around
the neck of the humerus and to localize the site of obstruction of
the artery, if any, a computerized tomography angiography of
the left shoulder was performed at 2 years (Fig. 5a, b, c, and d).
This study reported that the origin and proximal part of the
anterior circumflex humeral artery was not opacified while the
distal part of the artery was seen filling with the dye through the
collaterals. The posterior circumflex humeral artery was
normal. On clinical examination, the patient was able to
perform 170° shoulder abduction , with a n or ma l
scapulothoracic rhythm. The power of internal rotation of the
shoulder was 4/5 as per the Medical Research Council grading
on the left side, and the power of the rest of the shoulder
movements such as external rotation, abduction, forward
flexion, and extension was 5/5. The patient was advised biceps
tenodesis with subscapularis repair. However, the patient was
not willing for the same.
Discussion:
The osteonecrosis of humeral head is an entity that is
commonly seen in 3 or 4 part fractures of the proximal humerus.
The incidence of osteonecrosis of humeral head after a shoulder
dislocation is not very common. There is only one report of
aseptic osteonecrosis of humeral head after anterior shoulder
dislocation [1]. Despite the paucity of literature, the
osteonecrosis of the humeral head is only second in incidence
after the fem oral head [2]. Howev er, sig nifican tly
differentpathomechanics warrant osteonecrosis of the humeral
head to be considered as a distinct entity [2]. The humeral head
is not subjected to the same weight bearing stresses as the hip
joint. The glenohumeral joint is lesser restraint than the hip
joint. This enables a greater range of motion even in advanced
stages of osteonecrosis. The scapulothoracic movement can
compensate, to an extent, for the restriction of glenohumeral
range of motion. Therefore, the time to intervene for the
different stages of osteonecrosis is different for osteonecrosis of
the head of femur and humerus. To explain the pathogenesis of
osteonecrosis of the humeral head, it is important to understand
the vascular supply of the humeral head. It is known, through
previous injection studies, that the humeral head has a very rich
anastomotic arterial supply [3]. The anterior and posterior
circumflex arteries, branches from the axillary artery, supply the
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Journal of Orthopaedic Case Reports Volume 8Issue 3 May-June 2018Page 61-64 | | | |
Dhamangaonkar A C & Goregaonkar A B
Figure 1: Radiographs at presentation: (a) Anterior subcoracoid dislocation, (b and c) check
radiographs of the shoulder confirming a concentric shoulder relocation.
Figure 2: Imaging at 6 months post-trauma: (a and b) Radiograph of the left shoulder showing a
sclerotic sector of humeral head with cortical erosions near the greater tuberosity, (c) short tau
inversion recovery coronal magnetic resonance imaging image, and (d) T2-weighted gradient
echo axial image showing the avascular necrosis of the humeral head with a subluxed long head of
biceps tendon.
Figure 3: Imaging at 2 years post-trauma: (a and b) Radiograph showing a mixed sclerotic and
lytic lesion in the humeral head with a congruent articular surface, (c) short tau inversion recovery
coronal magnetic resonance imaging (MRI) image, and (d) T2-weighted gradient echo axial MRI
image showing aser piginous, geographic lesion in the humeral head with a normal contour of
articular surface with a partial tear of subscapularis and a torn and retracted long head of biceps
tendon.
cd
b
humeral head. Between them, the contribution of the anterior
circumflex humeral artery is more important. The artery
courses laterally under the tendon of the long head of the biceps
and terminates by ramifying over the greater trochanter.
Another important branch of the anterior circumflex humeral
artery is the anterolateral arcuate artery, which ascends
proximally into the humeral head. It is the main intraosseous
supply and also supplies the lesser trochanter [3]. Obstruction
of the anterior circumflex humeral artery could occur due to an
intraluminal pathology (as in the non-traumatic causes) or due
to extraluminal pathology such asarterial compression. The risk
of osteonecrosis increases after an open reduction and internal
fixation of proximal humerus fractures due to the iatrogenic
damage to the supplying blood vessels during the dissection
around the long head of biceps tendon [4]. A case of bicipital
tendinitis causing osteonecrosis of the humeral head has also
been reported [5]. There has been another instance of
osteonecrosis occurring after an arthroscopic cuff repair [5]. In
our case, the damage to the anterior circumflex humeral artery
could have led to osteonecrosis of the humeral head,
considering the anterosuperior region of the humeral head
being affected. However, further evaluation is needed to probe
into the possible etiology for the vascular compromise in cases
of shou lde r dis loc ations. The treatment opti ons for
osteonecrosis of the humeral head vary widely from a
conservative non-operative treatment to core decompression to
total shoulder or reverse total shoulder arthroplasty [6]. Non-
operative treatment, to enhance the range of motion and to
strengthen the shoulder musculature, is recommended for all
patients. The patients in the early stages of osteonecrosis (Stage
1 or 2) respond very well to non-operative treatment. The
pa tients who continue to worsen cl inic ally, de spite
physiotherapy, should undergo a core decompression surgery. It
is preferred in Stages1 or 2 of disease. In late Stages (3, 4, or 5),
shoulder arthroplasty is the preferred treatment option. In our
case, the patient was put on non-operative treatment and he
responded well with decrease in pain, improved range of
motion, and muscle strength. The other important aspect that is
highlighted by this report is that it is difficult, but important, to
distinguish between bone bruise and osteonecrosis. If the
radiographs are normal with MRI suggesting altered marrow
signal, it could be only a bone bruise. However, if the
radiographs show mixed sclerotic or lytic lesions in addition to
the MRI showing altered marrow signals, there is a possibility of
osteonecrosis. The only method to differentiate between the
two is sequential evaluation. If serial radiographs show
progressive changes and so do the MRI sequences, then it is
more likely to be a case of osteonecrosis, rather than a bone
bruise. This radiological evaluation is more so important
because patients with osteonecrosis humeral head do not
clinically present early as compared to patients with
osteonecrosis of the hip.
Conclusion:
To summarize, though uncommon, osteonecrosis of the
humerus head can occur after an anterior shoulder dislocation.
It is important to distinguish between the bone bruise and
osteonecrosis. This can be done by serially reviewing the
patient’s radiographs and MRI. In a case of osteonecrosis of the
humeral head, non-operative conservative treatment does give
good results, especially in the early stages. However, in active
patients, we do recommend treatment of associated injuries like
performing a biceps tenodesis or rotator cuff repair.
Journal of Orthopaedic Case Reports Volume 8 Issue 3 May-June 2018Page 61-64 | | | |
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www.jocr.co.in
Dhamangaonkar A C & Goregaonkar A B
Figure 4: Magnetic resonance angiography of the left shoulder: (a, b, c) T1-weighted spectral pre-
saturation by inversion recovery (SPIR) coronal phase-contrast image and (d) proton density-
weighted SPIR sagittal image showing patent anterior and posterior circumflex humeral vessels
with mild attenuation of the anterior circumflex humeral artery.
Figure 5: Computed tomography angiography of the left shoulder: (a) Transverse and (b)
longitudinal sections showing the distal part of the anterior circumflex humeral artery filling with
the dye through collaterals w hile the prox imal part was not opacified. (c) Transverse and (d)
longitudinal sections showing posterior circumflex humeral artery filling normally with the dye.
Clinical Message
Osteonecrosis of the humeral head can occur, though rarely,
after anterior shoulder dislocations. On MRI imaging, it is
important to distinguish between the bone bruise and
osteonecrosis. This can be done by suspecting and serially
performing radiographs and MRI.
www.jocr.co.in
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Dhamangaonkar A C & Goregaonkar A B
Journal of Orthopaedic Case Reports Volume 8 Issue 3 May-June 2018Page 61-64 | | | |
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How to Cite this Article
Dhamangaonkar A C, Goregaonkar A B. Atypical Osteonecrosis of
Humeral Head Following Anterior Shoulder Dislocation. Journal of
Orthopaedic Case Reports 2018. May- June; 8(3): 61-64
Conflict of Interest: Nil
Source of Support: Nil
______________________________________________
Consent: The authors confirm that Informed consent of the patient
is taken for publication of this case report
