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Entrapment of the long head of the biceps tendon in proximal
humeral fractures is an uncommon pathology described in the literature in rare
cases especially in the pediatric population. Clinical presentation may be
misleading, and the diagnosis of proximal humeral shoulder fractures with or
without biceps tendon entrapment could be missed on plane radiographs and even
on 3D reconstruction CT scan. Interposition of the long head of the biceps in
complex proximal humeral fractures may be a challenge for proper anatomical
percutaneous or open reduction of these fractures. The following case report
describes a case of a patient involved in a ski accident falling on an
outstretched arm with an atypical presentation of long head of the biceps LHB
tendon entrapment in a multi-fragmentary depressed intra-articular proximal
humeral fracture. The patient underwent prompt surgical intervention.

Proximal humerus fractures account for 5% of all fractures and are
the third most common fractures occurring in the adult population over the age
of 65. Most of these fractures are relatively non-displaced and can be
successfully managed non-operatively 1. In ad­dition
to conservative treatment, many surgical interventions are at hand, including
open reduction and internal fixation (ORIF) with a variety of devices,
hemiarthroplasty, and percutane­ous fixation 2.Some authors discussed
the concern about interposed soft tissue, such as the long head of the bicep
tendon, in proximal humeral fractures in the pediatric population. These same
authors have offered this fear of tissue entrapment as the main reason for
recommending open reduction3, 10 and 11. 
We discuss an atypical presentation of a case of an adult patient
diagnosed with entrapment of the LHB in a complex proximal humeral fracture
after a ski injury.

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This is the case of a 43 year old male patient that presented to
our emergency department complaining of minimal pain and tenderness in his left
shoulder after sustaining a fall during skiing. The patient noted a high speed
down slope injury and falling on an outstretched hand with the shoulder
abducted in 90 degrees on direct impact with the snow. The incident took place
around 6 hours prior to his presentation and he continued his day skiing
normaly with intermitent minimal stabbing pain over the lateral aspect of the
affected shoulder. He presented for assessment and management of severe
shoulder pain.

Upon inspection he had no swelling, edema, erythema or any ecchymosis
over his left shoulder. Upon physical examination the patient had a full normal
slightly painful range of motion of his left shoulder joint with moderate
tenderness upon palpation of his left proximal humerus. No neurovascular
deficits were associated with his injury. In the ED a standard Antero-Posterior
and lateral radiographs of the affected shoulder joint were done and
surprisingly showed a multi-fragmentary displaced humeral head fracture (Figure
1).CT-Scan with 3D reconstruction was ordered for further evaluation and pre-operative
planning. The scan showed an acute comminuted, markedly displaced, vertically
oriented fracture of the proximal humerus, extending from the most superior
aspect of the articular surface of the humeral head at its mid aspect and the
lateral two thirds. The fracture lines also extended to involve the greater
tuberosity which was laterally displaced, the proximal humerus metadiaphyseal
junction at the humeral surgical neck and the floor of the bicipital tendon groove
(Figures 2,3).

The patient was transferred to the operating room at once for
planned percutaneous fixation of his left proximal humerus fracture with
Kischner wires and cannulated screws. With the patient placed in the beach
chair position, and after multiple failed trials of proper anatomic reduction
and fixation the decision was taken to switch to an open technique. A mini
deltopectoral incision approach to the proximal humerus was made. After
multiple unsatisfactory extraarticular attempts of reduction of the fracture
and anatomical realignment of the articular surface, a decision was taken to
enter the joint and reduce the fracture fragments under direct vision. Proper
dissection and entry into the shouder joint was done through the rotator cuff
interval with proper retraction,while taking care not to breach the integrity
of the cuff insertions. Surprisingly the LHB was found to be entrapped in the
longitudinal split  banana shaped
fracture of the superior articular surface of the humeral head, extending from
the bicipital groove anteriorly all the way posteriorly at the cartilage  bone interface (Figure 4). Anatomical
realignment of the articular surface and freeing the entrapped LHB tendon was
impossible, so the decision was taken to do a LHB tenotomy( Figure 5). After
the tenotomy was done, anatomical reduction of the fracture and the articular
surface was achieved and fixed with screws. Subsequently subpectoral tenodesis
to restore the biceps function was done (Figure 6).

His shoulder was immobilized for the first 3 weeks post operatively
with a proximal humerus shoulder immobilizer. After 3 weeks physical therapy
was initiated starting with passive range of motion for 2 weeks and then
progressing to active range of motion as tolerated without any biceps
strengthening for the first 6 weeks.  The
patient presented 3 months after the surgery with full active and passive range
of motion and near normal biceps muscle strength (Figure 7).

Proximal humerus fractures typically
involve the humeral head and neck. Because of the importance of the proximal
humerus which serves as the insertion and origin for multiple muscles, the
attachment of several ligaments, and shoulder articulation, the precision of
management of these fractures is highly importance in order to decrease
morbidity and optimize functional outcomes 7.The majority of PHFs are the result of low energy falls, are
minimally displaced, and may be treated with sling immobilization and physical
therapy. However, in around 20% of fractures, surgery should be taken into
consideration. The treating surgeon must have a well structured idea of the
fracture itself, the patient’s bone quality, other patient-related factors, and
the different reconstructive surgical options 4. In most cases standard plain
radiographs are enough to define the fracture pattern. Computed tomography CT
can be used to evaluate for a head-splitting component, better visualize bone
quality and extent of comminution, and to further delineate the fracture
configuration. The fracture pattern is of great importance when it comes to
making the choice for treatment options and predicting the risk of
osteonecrosis after proximal humeral fractures 4.Some of these fractures are irreducible, but there are only few
reports in the literature of tissue interposition into the fracture site 5 and

The LHB tendon resides within a groove separating the greater and
lesser tuberosities. The long head of the biceps tendon originates from the
supraglenoid tubercle of the scapula and crosses the head of the humerus within
the shoulder joint’s capsule, exiting along the intertubercular sulcus joining
with the short head. The transverse humeral ligament retains the tendon in the
bicipital groove 3.

Only a few reports in the literature of tissue interposition into
the fracture site are reported, with the majority of cases cited being
pediatric patients 3, 5 and 6. Smith cited a case study of a 12-year-old with
a severely displaced fracture with a clinical diagnosis of biceps tendon
interposition into the fracture site. The patient was followed nonoperatively
and at 8 weeks could actively abduct his arm 160°, externally rotate 60°, and
internally rotate 70°. By 6 months he had regained total use of the arm and
shoulder,without pain. He concluded that although the injury appears serious,
full recovery of the arm and shoulder occurs and the original angular deformity
remodels over time 5.

Bahrs et al discussed 43 case of proximal humeral fractures in
children and adolescents concluding that a failed closed reduction should be
interpreted as a possible soft tissue entrapment most likely because of the
long head of the biceps 11.

Visser and Rietberg presented three case studies of fracture
separation of the proximal humerus in children (all Salter-Harris type II) that
failed efforts at closed reduction and underwent open reduction and internal
fixation due to the extreme displacement of the fracture fragments, along with
interposition of both the long head of the biceps and periosteum 6.

Lucas, Mehlam and Laor reported three cases from the pediatric age
group with proximal humerus fracture post fall on outstretched arm with
evidence of LHB tendon or other soft tissue interposition into the fracture
site. All three cases were treated non-operatively with closed reduction and
immobilization and followed with progressive regain of their shoulder range of
motion to normal with significant radiographic bone remodeling. They also
underwent a cadaveric study to investigate the possible LHB tendon impingement
by a simulated proximal humeral fracture. An osteotome and mallet were used to
create a simulated fracture (transversely oriented) at the level of the
surgical neck of the humerus, immediately above the insertion of the pectoralis
major muscle. After manipulating the fracture in multiple directions,the LHB
tendon did not become interposed into the fracture site at any point of the
wide range of humeral motionabduction, flexion, internal and external rotation3.

Henderson described a case of a thirty year old male diagnosed with
interposition of the LHB after sustaining a subcoracoid fracture-dislocation of
his shoulder post electroconvulsive therapy for depressive disorder 8.

In the literature, there are cases of axillary artery entrapment,
associated with proximal humeral fracture but none described any entity of LHB
entrapment. Palm and colleagues cited a case of a 38 year old woman that was
diagnosed with a proximal humeral fracture post trauma. She was also diagnosed
with a concomitant axillary artery entrapment in the fracture site and a
brachial plexus injury 9. Keser and colleagues also described a case of a 51
year old male patient diagnosed with axillary artery entrapment following a
proximal humeral fracture 10.

Shoulder injuries can be very simple injuries to deal with in the
ED but sometimes they could be challenging especially in patients presenting
for regular check up post trauma and in those with minimal pain and normal
shoulder range of motion. Standard radiographs of the shoulder joint should
always be done after moderate or high energy trauma in young adults because
sometimes the clinical exam may be misleading and proximal humeral fractures
could be easily missed. On the other hand, entrapment of the long head of the
biceps should be considered in any uunsuccessful attempt of reduction in
proximal humeral fractures.
Tenotomy and subsequent
tenodesis of the LHB could be necessary in severely comminuted intraarticular humeral
head fractures where anatomic reduction is primarily impossible.