Intraosseous capture of the long bicipital tendon after fracture-dislocation of the shoulder: A spontaneous Nicola procedure

Abstract

A case of recurrent traumatic anterior dislocation of the shoulder occurring 12 years after an initial fracture-dislocation is presented. Both dislocations were difficult to reduce. Radiographic abnormalities indicated that at the time of the primary injury, the long bicipital tendon had been captured between the fractured greater tuberosity and the humeral head, creating a spontaneous lesion mimicking a Nicola procedure. The patient did not notice any impaired function or instability after rehabilitation of the first injury. Entrapment of the tendon in the fracture could have contributed to stability during the intervening 12 years. Together with scar tissue formation from the healing of the anterior soft tissues, it also gives a stabilizing effect by a loss in external rotation, limiting the risk of redislocation by preventing the large Hill-Sachs defect from reaching the anterior margin of the glenoid in external rotation. We discuss the role of the long bicipital tendon and other causes for irreducibility associated with fractures of the greater tuberosity. Traumatic anterior shoulder dislocations are sometimes complicated by fracture of the greater tuberosity. If the tuberosity fragment remains in contact with the humeral shaft by periosteum, a closed reduction of the glenohumeral dislocation usually will result in an anatomic repositioning of the greater tuberosity as well. This is due to the balance of the periosteum and the supraspinatus and infraspinatus tendons. The fractured cases are even considered to have a better prognosis 15 concerning the risk of recurrent instability, perhaps attributable to the greater age of these patients. The anterior stabilizing structures might also be less damaged and, if they are not disrupted, instead could act as a hinge during the dislocation. 11 On the other hand, if the fracture involves the bottom of the intertubercular groove, a fracture-dislocation could result in a concomitant dislocation of the long bicipital tendon (LBT) through the fracture to a posterior intra-articular position, rendering the dislocation impossible to amend by closed reduction.7,11