A 62-year-old woman presents with 3 months of left shoulder pain. She had a displaced proximal humerus fracture on the left a few years ago that was treated nonoperatively and had recovered well until recently. Anteroposterior X-ray (Figure 1) and coronal MRI image (Figure 2) of the left shoulder show osteonecrosis of the humeral head with advanced arthritis in the glenohumeral joint.
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Traumatic osteonecrosis of the humeral head is a complication that may arise after a proximal humerus fracture. Displaced fractures can disrupt the blood supply to the humeral head resulting in osteonecrosis. Proximal humerus fractures are often described by how many parts or pieces that the proximal humerus breaks in. Two-, three-, or four-part fractures occur when displacement and angulation occur between parts. As the number of fractured parts increases, the outcome worsens in terms of the fracture healing successfully. Osteonecrosis of the proximal humerus approaches 100% with a four-part fracture dislocation, up to 45% for a displaced four-part (without dislocation), and 14% with a displaced three-part.1,2
Symptoms of osteonecrosis of the humeral head include a gradual onset of shoulder pain. The patient may have progressive loss of shoulder motion and strength. Early X-ray findings may be normal. As the disease progresses, X-ray may show sclerosis, subchondral fracture (crescent sign), flattening and collapse of the humeral surface, and arthritis. MRI is the study of choice to diagnose osteonecrosis and is usually ordered when the diagnosis is suspected. This particular patient has advanced disease and arthritic changes on both the glenoid and humeral head. The only choice that addresses the patient’s glenohumeral arthritis and osteonecrosis is a total shoulder arthroplasty.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Patel S, Colaco HB, Elvey ME, Lee MH. Post-traumatic osteonecrosis of the proximal humerus. Injury. 2015;46:1878-1884.
- Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg. 1998;7:586-590.